Tag Archives: dependence

Benzodiazepines: Disempowering and Dangerous

I recently read an article by Fredric Neuman, MD, Director of the Anxiety and Phobia Center at White Plains Hospital, NY.  The article is titled The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium, and was published in June 2012 by Psychology Today.  Thanks to Medicalskeptic for the link.

Dr. Neuman opens by telling us that benzodiazepines are “…very commonly prescribed for any sort of discomfort.”

“They are called anxiolytics, and they are prescribed for any level of anxiety and more or less to anyone who asks for them.”

Dr. Neuman has been working at the Anxiety and Phobia Center for 41 years, first as Associate Director and then as Director.  So when he says that benzos are routinely given to “anyone who asks for them,” it’s probably safe to say that he’s being accurate.

He tells us that the benzos have a “modest tranquilizing effect” in the doses at which they are “usually prescribed.”  But –

“…I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills.”

and

“…I think these individuals suffer a loss of self-confidence. Their ability to rely on themselves has been undermined by their reliance on these drugs.”

Dr. Neuman asserts that benzos

“…are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.”

He provides a list of those adverse effects that concern him most.

  1. They are addicting.
  2. They effect coordination, particularly in the elderly.
  3. They compound the effect of other drugs and alcohol.
  4. They interfere to some extent with memory. 

And to this list he adds the dangers of abrupt discontinuation and

“…the fact that I think something is lost, as I indicated above, when someone relies on something make-believe to get through the day.”

Dr. Neuman concludes:

“…these drugs are sometimes helpful a little, and in some ways hurtful a little.  But I don’t wish to give the impression that they are really bad. If a patient demands them, I will usually acquiesce, assuming the dose is small. I always encourage patients to take less as time goes on.  If they won’t, I don’t usually argue with them.”

and

“I know most doctors give these drugs much more readily than I do.”

 DISCUSSION

In the article Dr. Neuman comes across as a reasonable and helpful person.  He prescribes benzos, but he recognizes and articulates the disempowering aspect of relying on drugs, and I think it is reasonable to assume that in his practice he encourages people to pursue genuine resolution of fears and anxieties rather than chemical masking.  But what struck me most forcibly in the article was the sentence:

“If a patient demands them, I will usually acquiesce, assuming the dose is small.”

Dr. Neuman is to be commended for his honesty, but it is a truly amazing admission – particularly his use of the word “demand.”  It has long been my contention that there is very little essential difference between psychiatric “prescribing” of psychoactive drugs and the illegal selling of drugs on the street.  Dr. Neuman’s use of the word “demand,” his admission that he usually acquiesces, and his credible assertion that most doctors prescribe these drugs more readily than he does, lends support to this contention, at least as far as benzos are concerned.  It is difficult to reconcile his statements with the notion that these drugs, when used in a psychiatric context, are medications being prescribed to treat illnesses.

MORTALITY HAZARD

The same day that I read Dr. Neuman’s piece, I also read an article in the BMJ:  Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study, by Weich et al.  Here are the conclusions:

“In this large cohort of patients [34,727 participants and 69,418 matched controls]  attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality [hazard ratio: 3.3] over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.”

The increased risk for those participants who had taken only benzodiazepines was slightly higher at 3.68.  Risk ratios were adjusted for age, gender, and the following health problems:  “arthritis, asthma, cancer, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, gastrointestinal disorders, hypertension, musculoskeletal disorders, anxiety disorders, sleep disorders, other (non-anxiety), psychiatric disorders, and prescriptions for non-study drugs.”  The association followed a dose-response pattern.  Participants who had taken benzos at the highest doses had a hazard ratio of 5.1.

Even allowing for the standard disclaimer, the study raises serious doubts as to the oft-claimed safety of these products, especially as other studies have produced similar findings.  It should also prompt us to question Dr. Neuman’s somewhat cavalier approach to these products – an approach which in my experience is widespread in psychiatry.  A three-fold increase in mortality rate over seven years is not a trivial matter.

Withdrawal from Benzodiazepines

Important updates on this subject can be found at the posts listed at the bottom of the post.

. . . . . . . . . . . . . . . .

I’ve recently come across an article by Matt Samet called Social Vacuum.  It’s dated March 2013, and was published on Robert Whitaker’s website Mad in America.

Matt had been taking a benzodiazepine for some time, and while on a tapering withdrawal, he experienced some distressing symptoms, including some acute social discomfort.  (For a full account of benzo withdrawal – click here.)

He describes the withdrawal symptoms in detail, and also outlines some of the strategies he used to cope with these.  I think the article would be helpful for people who are going through these kinds of withdrawals, and also for counselors, etc., who are helping/supporting clients through this.

When benzodiazepines were initially launched in the early 1960’s, the psychiatrists and the manufacturers stated categorically that they were non-addictive.  Eventually it became impossible to maintain this fiction, and the addictive potential of these products is now recognized.  Some people manage to come off these products, but large numbers of people worldwide continue to use these drugs as an integral part of their daily routine.  Benzos are sedatives and are sometimes called minor tranquilizers.

Withdrawal from these drugs is potentially dangerous, incidentally, and medical supervision is a good idea, especially if the dependence is marked.  Try to find a physician other than the one who got you hooked on them in the first place.  In severe cases, hospitalization is required.

The following drugs are in the benzodiazepine category:  Valium; Librium; Xanax; Ativan; and Klonopin.  For a more comprehensive list of brand names, see this site on Wikipedia.

. . . . . . . . . . . . . . . .

Important updates on this subject can be found at the following subsequent posts:

More on Benzodiazepine Withdrawal

Benzodiazepine Withdrawal

Benzodiazepine Withdrawal: A Dilemma

Drugs and Alcohol (Part 3)

This post was edited and updated on June 29 2014, to include additional thoughts.

. . . . . . . . . . . . . . . .

A Rational Policy on Drugs and Alcohol

In my last post I argued against government prohibitions against drugs and alcohol.  My position is that substances such as cocaine, heroin, methamphetamines, etc., should be legal in the same way that alcohol and tobacco are today.  I believe, however, that the distribution and marketing of these substances should be brought under direct government control.  All of the commonly abused addictive substances are dangerous, and they have taken – and continue to take – an enormous toll on society.  This cost includes lives, health, lost opportunities, money and general suffering and anguish.  But it’s difficult to put old heads on young shoulders, and it seems that each generation – indeed each individual – has to learn these lessons anew.  I don’t believe we can ever eradicate substance abuse entirely.

What seems especially wrong to me, however, is that we allow individuals and groups to prosper and thrive by actively marketing these products – an endeavor in which they have been extraordinarily successful. So we have various government agencies trying to reduce the incidence of alcohol and nicotine abuse while huge corporations are working towards the opposite end.  I realize, of course, that most of the major alcohol producers say that they abhor alcohol abuse, and that they only encourage “responsible” drinking.  These kinds of statements, however, always remind me of Hitler insisting that he had no expansionist agenda.  The fact is that alcohol and tobacco manufacturers spend millions (billions?) of dollars promoting their products and linking their products with sexiness and success in the minds of potential consumers.  To my way of thinking, this is simply wrong.

Here’s the system I would like to see in place.  The manufacturers of these substances could continue to operate, but could sell their products only to the government.  The government (federal, state, or county) would wholesale the products and would also have a retail outlet in each county.  In heavily populated areas, there could be more than one per county.  These outlets would be similar to the state-run stores in Virginia, Pennsylvania, and Vermont, except that they wouldn’t just sell liquor.  They would sell all alcohol and tobacco products as well as heroin, cocaine, methamphetamines, etc…  All the addictive drugs would be available for adults to purchase through the government outlet, but nowhere else.  Customers would be required to show an ID, and each purchase would be registered in a database.  Customers whose consumption seemed excessive would be required to talk briefly to a counselor.  The counselor would encourage them to think about their consumption of addictive substances – but if they wanted to pursue the purchase, they would not be prevented from doing so.  People who came to the store in a state of intoxication would be taken involuntarily to a detox center where they would be detained until it was safe to let them go; i.e. that it was medically safe to discharge them.

All profits generated from the sale of addictive substances would be used to fuel preventive efforts and to support the detox centers.  Prices of products would be set as high as practicable, but not so high as to encourage bootlegging and black markets.

Of course there are many who will decry the notion of government interference in the free market.  But under the free market system, we have 450,000 tobacco-related deaths, and 85,000 alcohol-related deaths, and 17,000 illegal drug-related deaths each year in the United States.

Others will say that the government couldn’t run such an operation successfully.  But the stores in Pennsylvania have operated successfully since 1933.  Anyway, there it is:  my humble suggestion for a more rational way for our society to deal with these dangerous substances, which we, as a species, seem to find so attractive.

Next Post:  More exciting stuff.

Drugs and Alcohol (Part 2)

In my previous post on this subject, I discussed addiction to alcohol and other drugs.  I made the point that addiction to these substances is not an illness, but rather an extremely strong habit.

Treatment Programs

The notion that alcoholism is a disease gained popularity in the 50’s and 60’s.  At about the same time, employers were beginning the practice of offering medical insurance to their staff, and insurance companies routinely included 30 days of treatment per year for alcoholism and/or drug addiction.  At the time, there were very few treatment units for these problems, and little use was made of the drug and alcohol provisions in the insurance policies.

America, however, is nothing if not entrepreneurial, and soon private treatment units began to appear, fuelled by insurance dollars.  At the same time, a quasi-religious group named Alcoholics Anonymous was thriving, and the commercial treatment units forged a symbiotic alliance with this organization.  The treatment units hired senior members of AA as counselors, and “patients” were required to attend AA meetings as part of their treatment.  In fact, for most of the units, treatment consisted of induction into the AA fellowship.  Group therapy, individual therapy, lectures, films, etc., were all aimed towards encouraging and fostering membership of AA (and, of course, Narcotics Anonymous for people addicted to other drugs).  Because alcoholism and drug addiction were conceptualized as illnesses, these programs were technically under the direction of a physician director, but his/her role seldom extended beyond the physical issues of detox, alcohol-induced tissue damage, etc…  The actual running of the unit was in the hands of a counselor director (usually a recovered alcoholic and a member of AA).

By the late 80’s, chemical dependency treatment had become one of the fastest-growing (possibly the fastest-growing) industries in the United States.  Around 1990, however, the insurance companies decided to pull the plug. And just as the treatment unit boom had been fuelled by insurance dollars, so its demise occurred when these dollars stopped flowing.  I was involved in the chemical dependency treatment arena when these changes were occurring, and there was undoubtedly a good deal of hardship on the individuals who lost their employment.  But in hindsight, I find myself on the side of the insurance companies.  Their position was (and still is, I presume) that alcohol and drug addiction are not in themselves medical problems.  So they would pay for detoxification, where this was medically necessary, but not for the 30 days of group therapy and induction into AA.  Sometimes they would pay for these kinds of psycho-social interventions in an outpatient setting – but the days of the 30-day-residential (inpatient) programs were over.

There are still a small number of units serving individuals who can foot the bill from their own resources.  And of course, there is still a publicly funded system.  Most (perhaps all) states provide an involuntary commitment procedure for alcohol and drug addicts who have become dangerous to themselves or others.  These individuals are committed to treatment units, sometime at the state hospital, sometimes free-standing.  These programs are usually operated on the same general lines as the private units mentioned earlier, and are often described as “revolving doors”.  This is because the “clients” routinely return – sometimes two and three times a year -for further “treatment”.

War on Drugs

The war on drugs has been around since the 60’s, but gained enormous momentum in the early 80’s under the Reagan administration.  This so-called war which the United States government (along with the governments of many other nations) is waging against its own citizens, has to date cost the tax payer an estimated one trillion dollars (thirty-nine billion dollars so far this year).   In addition, it has criminalized literally thousand (millions?) of ordinary people, has filled our prisons to overcrowding and beyond, has fuelled the biggest prison-building program in our nation’s history, has destroyed quality of life in many of our urban areas, and has turned the Mexico-US border area into a war zone.

And all for what?  All for the US government’s claim that it has the right to tell people what they may and may not ingest.

First, let me clarify my position.  The only drug I have ever used is alcohol.  I have had a great deal of illness in recent years, and have occasionally received morphine and dilaudid for pain during inpatient stays at hospitals.  I do not advocate the use of drugs for recreation, self-medication, or coping with life’s difficulties.  Alcohol, nicotine, cocaine, heroin, etc., are all drugs, and they are all bad for you.  And the more you ingest, the worse it gets.  And some of the damage is permanent.

However, it is also my position that governments have not the right to tell people what they may or may not put into their bodies.  In a democratic republic, political power ultimately resides in the people.  And we surrender some of this power to an elected government in the interests of mutual safety, organization of services, etc.. But the notion that the government has the right to determine what an individual may or may not ingest is a throwback to a monarchical type of tyranny that should have no place in a country such as the United States.  And as the War on Drugs has clearly demonstrated, they aren’t able to enforce their prohibitions.

So my position is legalize everything.  But I would have certain safeguards and protections in place, which I will outline in my next post.  Stay tuned.

Next Post:  Drugs and Alcohol (Part 3)

Drugs and Alcohol (Part 1)

The APA’s DSM lists two broad categories of diagnoses in this area: dependence and abuse. So we have alcohol dependence and alcohol abuse; amphetamines dependence and amphetamines abuse; cocaine dependence and cocaine abuse. And so on.

Dependence is defined by the presence of three or more of the following criteria:

  1. tolerance, as defined by either of the following:
    1. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
    2. markedly diminished effect with continued use of the same amount of the substance
  2. withdrawal, as manifested by either of the following:
    1. the characteristic withdrawal syndrome for the substance …
    2. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. the substance is often taken in larger amounts or over a longer period than was
    intended
  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. a great deal of time is spent in activities necessary to obtain the substance… use the
    substance … or recovery from its effects
  6. important social, occupational, or recreational activities are given up or reduced
    because of substance use
  7. the substance use is continued despite knowledge of having a persistent or recurrent
    physical or psychological problem that is likely to have been caused or exacerbated by
    the substance …

Abuse is defined as one or more of the following:

  1. recurrent substance use resulting in a failure to fulfill major role obligations at work,
    school, or home …
  2. recurrent substance use in situations in which it is physically hazardous …
  3. recurrent substance-related legal problems …
  4. continued substance use despite having persistent or recurrent social or interpersonal
    problems caused or exacerbated by the effect of the substance …

Let’s consider alcohol dependence, which to all intents and purposes is what most people would refer to as alcoholism. A person who drinks, say, half a bottle of whisky every day, who never appears particularly drunk, who becomes extremely sick if he stops drinking, who has made numerous unsuccessful efforts to quit, who has incurred some liver damage, and whose social life has been severely curtailed because of drinking, would normally be called an alcoholic. Some people prefer the term addicted and would describe him as addicted to alcohol. DSM would say that he has a mental disorder called alcohol dependence. The problem with all three terminologies is that they encourage us to blur the distinction between a description and an explanation. This distinction is the central theme of this blog.

The term “alcoholic” for instance, looks like an explanation, is constantly presented as an explanation, and is widely accepted as an explanation, but in fact it is purely descriptive. In the example cited above, imagine the man’s wife confiding in a friend about the problem. She ends by asking: “Why won’t he stop – why can’t he see that he’s killing himself?” And the friend replies: “Because he’s an alcoholic.” But “alcoholic” means a person who continues drinking large quantities of alcohol despite adverse consequences. So all that the friend has said is that the husband is drinking large quantities of alcohol despite adverse consequences because he is drinking large quantities of alcohol despite adverse consequences. Nothing has been added in the way of an explanation. And yet the words themselves often have a measure of comfort for the listener.

Let’s consider another example – a battered woman. She asks a friend: “Why does he beat me all the time? Why is he so mean to me?” The friend replies: “Because he is a jerk!”

Here again, it looks like an explanation. It looks and feels as if the “why” question was adequately answered. But when we remember that a “jerk” is someone who routinely hurts people, we see that the substance of the reply is: he hurts you because he hurts you.

This practice – of presenting descriptions and labels as if they were explanations and their being accepted as such – is deeply embedded in our language and in our communications generally.

Staying with the battered woman – imagine another friend commenting on the situation, saying: “Why does she keep going back to him when he mistreats her so?” And receiving the reply: “Because she is co-dependent.” Here again, it looks as if the “why” question has been answered. But co-dependent means being excessively dependent on the approval of others. So the reply essentially means: she goes back to him because she goes back to him. Co-dependency is simply a label for this kind of self-destructive, overly dependent behavior. Putting a name on a problem can be emotionally soothing, and is perfectly acceptable in ordinary interactive speech. But what the APA has done is take this naming process and presented it as if it were a scientifically validated explanatory system, which DSM most emphatically is NOT.

In addition, it needs to be pointed out that even as a labeling system, the DSM falls short. A person who meets criteria 1, 3 and 5, for instance, receives the same “diagnosis” as a person who meets criteria 2, 4 and 6, even though their history, presentation, and general circumstances may be entirely different.

As with the other human problems addressed in these posts, genuine explanations of alcoholism and drug addiction require a detailed knowledge of the history and circumstances of the individual, coupled with an understanding of the principles underlying behavior acquisition. The general principles are as follows:

1. Alcohol and other drugs of abuse (nicotine, cocaine, heroin, amphetamines, etc.) act on the brains of most individuals in a way that induces a feeling of pleasure.

2. When an activity is followed by a feeling of pleasure, there is an increased probability that the behavior will be repeated. This is the fundamental principle underlying habit formation.

What’s commonly called addiction to alcohol and others drugs is in fact an extremely strong habit. So the question arises: why do some people become addicted (in other words, form this very strong habit), while others do not? In my view, the fundamental issue here is critical self-scrutiny. It is important that as children, we acquire the habit of critical self-scrutiny: the habit of reviewing our actions and deciding from day to day what needs to be changed. One of the realities of life is that if you start drinking large quantities of alcohol, you will begin (quite soon) to incur negative consequences. Hangovers, wasted time, wasted money, painful indiscretions, broken relationships, and lost opportunities are the routine lot of the heavy drinker. Now most people, when faced with this reality, eventually look at themselves in the mirror and say something to the effect: “This is just ridiculous. I have to make some changes.” And they do. The person who has not developed the habit of critical self-appraisal, however, can always find another way of looking at things. A dishonest way – a way that somehow lets him off the hook for the excessive drinking. Examples of this kind of distorted thinking are:

You’d drink too if you had a wife like mine, …troubles like mine, … a job like mine, … children like mine, etc..

I don’t drink as much as _________.

Winston Churchill drank a fifth of whisky a day – it didn’t do him any harm.

These other people are just uptight. They don’t know how to have fun.

I’d be ok if people would stop nagging me.

Etc., etc., etc.

The fact is, there is only one appropriate response to heavy drinking, and it goes something like this:

I’m drinking too much. It’s causing problems in my life. It’s common knowledge that these problems just get worse as long as the drinking continues. I need to cut down drastically or stop altogether.

But the further question arises: Why do some people make this kind of critical self-appraisal and follow through – while others don’t? And this is where we get down to individual cases. How do children acquire the habit of critical self-appraisal? Why is it that some children acquire this habit, while others don’t?

Next post:

Alcohol and other drugs (cont)
Treatment programs
War on drugs