I’ve written about the dangers of Xanax (alprazolam), Klonopin (clonazepam), and other drugs in a class of drugs called ‘benzodiazepines’. The drugs are grossly over-used by patients, and over-prescribed by psychiatrists, usually for patient complaints of anxiety.
My primary concern over use of benzodiazepines is that when used to treat anxiety, they are more likely to aggravate than improve a patient’s symptoms, especially if taken regularly. Patients develop physical and psychological dependence to benzodiazepines very quickly. Once physically tolerant, patients experience withdrawal symptoms if doses are missed, and generally interpret the withdrawal symptoms as manifestations of their own anxiety disorder. The progression from taking alprazolam or clonazepam ‘as needed’ to taking them regularly is as predictable as any other biological process. And after physical tolerance has developed, symptoms that were once considered manageable become part of an unmanageable ‘anxiety disorder.’
I have learned over the years that the term ‘anxiety’ means different things to different people. The complaint shouldn’t cause doctors to automatically reach for the prescription pad. When asked to describe his ‘anxiety’ in detail, a patient said ‘I will pace around the house, looking for something to do. I will turn on the TV and change channels, but there is nothing interesting. I feel…. restless and bored. I need to get out of the house, but there is nothing for me to get outside to do. I’m like a caged animal. You know— anxiety!’
I responded, ‘you mean you were bored?’
‘No’, he said. ‘Boredom is when there is something to do that isn’t interesting. This …
Regular readers of my blog know that I believe buprenorphine is the most important development for treating addiction during my lifetime. At the same time, my own recovery from opioid dependence began over 20 years ago, long before the use of buprenorphine. I am grateful for the change in my perspective that occurred one desperate afternoon, when I first recognized the uselessness of ‘will power’ for stopping opioids. I was one of the lucky addicts who experienced a ‘spiritual awakening’— the realization that I could not recover through my own power, no matter my education or motivation.
I’ve searched, since then, for a scientific explanation of how acceptance of powerlessness and belief in a higher power removed, almost instantly, an obsession that I couldn’t control before that moment. I recognized the preciousness of my recovery as friends from treatment lost their sobriety. And I learned, at one point, that success in ‘traditional recovery’ requires lifelong attachment to meetings and step work.
Ten years later I was excited by the power of buprenorphine to induce remission of the same obsession. As patients on buprenorphine regained meaningful lives at a pace similar to those who practice traditional recovery, I realized that recovery from addiction and freedom from ‘character defects’ can stem from changes in thought, or from changes in neurochemistry. I realized that one approach isn’t more ‘natural’ than the other, and that both methods require lifelong efforts to prevent relapse to addictive behaviors. I wrote the following, several …
I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry. She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor. “Add a little of this, and if that doesn’t work, try adding some of that” she said. “Psych is all a gray area. You can be creative.”
Now THAT’S crazy. Her recommendations, sadly, will likely be followed in a number of actual patients. No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.
At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.
Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches. They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.
Evidence-based medicine encourages …
Newborn abstinence syndrome from buprenorphine provokes strong emotions. Expectant patients rightly anticipate harsh attitudes from doctors and nurses. They read in forums and chat rooms about experiences of women who say that CPS was called after delivery, or about babies who were kept on opioid tapers, in the hospital, for weeks or even months after mom’s discharge. And in the absence of appropriate support from the medical profession, they worry that their use of buprenorphine will cause the baby to suffer from withdrawal.
A member of SuboxForum recently wrote that the hospital where her doctor had privileges required that she sign a formal policy about babies born to mothers on buprenorphine. She was told that her baby must go to the NICU for at least 10 days after delivery, regardless of condition, and she was not allowed to refuse that level of treatment.
Meanwhile, one of my buprenorphine patients came to her appointment last week, five days after the birth of her baby. Mom and baby left the hospital together less than 48 hours after deliver, and she brought the baby to her appointment. I realize that hospitals discharge patients more quickly these days but her discharge seemed a bit fast, but not because of anything related to buprenorphine. I just believe that new moms, who are frequently anemic and sleep-deprived, should have a bit more rest before taking on an infant’s schedule.
How can the ‘standard of care’ vary so greatly? What role does insurance coverage …
With all the recent attention over the epidemic of opioid dependence, why do some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products? The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.
The shortage is caused by a number of factors. All doctors train in medical schools, which are primarily located in larger cities. So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts. As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views. Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.
Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine. The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor. But to become buprenorphine-certified, doctors must sign an agreement that allows …
In ‘Addiction Treatment with a Dark Side’, Deborah Sontag of the New York Times shared her observations of the clinical use of buprenorphine for treating opioid dependence, warts and all. Readers of the Talk Zone know my bias—that buprenorphine/Suboxone is one of the only effective treatments for opioid dependence, and many patients are best-served by long-term, perhaps life-long treatment with buprenorphine. But I read the article the article with interest because I know that Ms. Sontag ‘did her homework’, including visiting a number of practices, speaking with a number of patients, and reviewing hundreds of studies about buprenorphine and Suboxone over the course of many months.
From my perspective, the article overstates the diversion problem. In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment. I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.
With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion. Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone. The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year. The total number of deaths linked …
The forces of nature appear intent on reversing mankind’s progress toward better health. An example is the ever-increasing resistance of bacteria to antibiotics. A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans. In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.
Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’ Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases. There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.
Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts. The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic. As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that …
I’m always impressed by the power of our ‘unconscious.’ I realize that people have a range of models for conceptualizing how our minds work; my own combination of education, analysis, and observation has led to an understanding that ‘works for me.’
My conscious mind works in series, holding one or two thoughts at a time and proceeding in a somewhat-linear fashion. The unconscious, on the other hand, is an amalgam of countless processes that never end, epiphenomena of the constant barrage of sensations, emotions, and memories that are sorted, compared, associated, and recorded.
At least that’s how I see it.
The unconscious is not something that can be figured out, no matter how much insight a person may develop. During treatment for addiction I thought that if I could discover my unconscious motivations for using, my desire to use would cease. I don’t see it that way now. Even after more than a decade of sobriety, I am aware that my unconscious mind remains intertwined with the addictive parts of my personality, forever inseparable.
My unconscious mind protects me from unpleasant emotions. Some insights are deemed, by whatever determines my conscious experience, as too painful. But even when I’m not allowed to have a certain awareness, I can sometimes infer what is going on beneath the surface using the clues evident in my behavior.
For example, I’ve been struggling to write for several weeks now, since my dad’s death. I don’t know for certain what unconscious thought or emotion is getting in …
My dad passed away two days ago, one day after his 89th birthday. It doesn’t feel quite right to post something so personal. But it feels more wrong to write about anything else.
Writing was a source of tension between us in some ways. My perspectives on myself, my parents, and my upbringing have changed over the years, and I tried to share my observations with my dad in several short essays centered around memories from my childhood. The efforts were a mistake. I learned that insight develops in each of us at different rates and in different directions, and my ‘aha’ moments—realizations about how my dad shaped my development— felt to him like criticism. I don’t think he fully realized that I accepted him, loved him, and respected him.
As for my ‘aha moments’, I don’t assume that my realizations and insights are accurate. As my perceptions change over the years, I try to remain open to two alternate explanations for those changes—that with age I’ve learned, through wisdom, to see things more accurately, or that with age my thought process is becoming more rigid and any newfound ‘insight’ is an illusion, a product of that rigidity.
My dad was an intellectual, who read more books about philosophy and theology each year of his adult life than I’ve read in my lifetime. So when our understandings of the world differed, I had to at least consider that my own judgment was off, rather than assume that old age impacted …
I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.
My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin. Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.
I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication. As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap. They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.
But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment. I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges. To be blunt, young people don’t do as well on Suboxone or buprenorphine as their …