Fighting Fear

Confronting phobias and other fears

The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium

The use and misuse of the minor tranquilizers

One day I was sitting in the hospital cafeteria when a surgeon was called to answer the telephone. I knew he was a surgeon because he was wearing surgical scrubs. I found myself listening to his conversation.

Surgeon:   Yeah?  (pause)   I see. (another pause) Well, you know what I think. You should come in and get this operation. (long pause) You’re not going to come in? …Well, what do you want?  You want some Xanax?

I found myself wondering, what sort of condition would require an operation but might possibly respond to Xanax.

The fact is, these drugs 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. Patients who are afraid of other drugs, such as the anti-depressants, usually feel comfortable taking and relying on these drugs. They are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.

A new patient complained to me that his previous psychiatrist had prescribed Xanax to him for insomnia, and that since then he had been unable to stop taking it. He told me he was thinking of killing the psychiatrist.  I told him I did not think that was justified. (I always take a strong stance against killing psychiatrists.) I would be able to help him. The dose the psychiatrist had prescribed turned out to be .5 mgm, a relatively small dose and one that I, myself, prescribe on those relatively uncommon occasions when I prescribe sleeping medicine. It was so low a dose that he could not have been addicted, or even dependent physiologically. But he had tried stopping on his own and could not do it. It was only a psychological dependence, but it was real. I had to convince him that he did not need the drug to go to sleep.

I asked him to start cutting down on the dose by shaving the pill, and then over time shaving it more and more.  After about a week, he was down to .25 mgm. Then it got hard. It took over an additional month before he was picking up what was left of the drug with a wet finger.  It was dust. He realized finally that he had withdrawn finally and safely from the Xanax.

One of the problems with these drugs is that people attribute powers to them they do not have. They have a real modest tranquilizing effect. In the doses they are usually prescribed they have about the same effect as a glass of wine or a beer. In fact, they work on the same neurological transmitters, the GABA system. But I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills. Long after they stop taking them, if there comes such a time, they may continue to carry them around in a pill box, “just in case.”  I have a colleague who agrees with me that very many, perhaps most, of the people who take the benzodiazepines do not need them. But “so what?” as he puts it. These are safe drugs used properly, and people can take them, it seems, over a lifetime without evidently hurting themselves. But 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. Is this a little thing?

There is only one distinction between the various benzodiazepines. Xanax (alprazolam) and Ativan (lorazepam) are short-acting. Klonopin (clonazepan) and Valium (diazepam) are longer-acting.

The beneficial effects of the benzodiazepines:

  1. They do, indeed, have a minor tranquilizing effect. For that reason they are called the minor tranquilizers.
  2. They are as effective as a sleep aid as any of the other drugs sold primarily for that purpose. In fact, they are used by neurologists to treat certain sleep disorders, such as sleep-walking or sleep-talking.
  3. They are muscle relaxants, although I think they are not usually prescribed for that purpose.
  4. They are anti-epileptic agents, but, again, are used less than other anti-convulsants.
  5. They are used for the treatment of panic disorder

Unless, there is some other reason to use these drugs, starting anti-depressants, for instance, or another drug which is likely to cause a temporary increase in anxiety, I do not use them in the treatment of panic disorder.  The single exception is the alleviation of anticipatory anxiety. If someone is going to take a dreaded airplane trip on Sunday, I don’t see why he/she should not take something the few days before to help make sleep possible. Also, on the day of the airplane trip, anything that will help the phobic person get on that plane is okay.  The cure of a panic disorder, however, and it certainly can be cured, rests on the patient’s coming to understand that the panic attack itself is self-limiting and not dangerous. In order to recover completely, the panicky person must remain in the phobic situation long enough for the panic attack to lessen on its own. Giving these drugs inevitably encourages the patient to think that the panic attack would not have resolved without them. This is the opposite of the truth. In any case, these drugs will not reliably prevent panic attacks.

Almost all the phobic patients we see in our clinic have come to us already on the benzodiazepines, without those medications alleviating their condition. After a while, the drugs take on a magical aura. Patients often feel better as soon as they swallow the pill, even though the pill takes a half-hour or more to work. Sometimes, if they forget their pills, they will anticipate an attack, and will be more likely to get one for that reason.

The disadvantageous effects of the benzodiazepines:

  1. They are addicting. I mention this first, because it is always mentioned first.  Although they are addicting in high enough doses, they are rarely prescribed in those amounts. Most patients take them without building up tolerance or increasing the dose to dangerous levels. Like other psychoactive drugs, they can be used to get high, or commit suicide, but the anxious patients we see do not usually fall into these groups.
  2. They affect coordination, particularly in the elderly. It became apparent that they were contributing to automobile accidents in the elderly, so New York State made it a controlled substance, which meant special prescriptions had to be used for them. These prescriptions cost the physician a quarter each. This was intended to discourage excessive usage.
  3. They compound the effect of other drugs and alcohol. One drink feels like two.
  4. They interfere to some extent with memory. Therefore, I will not prescribe them for college students. Some really high potency benzodiazepines can cause people to forget an entire evening.

Like every other drug, the manufacturer lists a dozen other side effects, but those mentioned above are what concern me most. That 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.

Summary: 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. As a psychotherapist, I am almost always encouraging patients to do something difficult or unpleasant.I don’t want to argue unnecessarily.

Caveat: What I have given above is my opinion. It is an educated opinion, but just my own. I know most doctors give these drugs much more readily than I do. Sometimes, I think they give them as an alternative to spending time with the patient. But often enough, experienced physicians believe in them strongly. I do not recommend that anyone change the way they use these drugs without first consulting his/her doctor. Even when the drug is otherwise unnecessary, being on them for a period of time makes it difficult to come off them without a resurgence of anxiety, and ,often, other, psychologically induced, symptoms.(c) Fredric neuman 2012

Follow Dr. Neuman's blog at fredricneumanmd.com/blog

 

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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