Misc Are beta-blockers safer than benzos for anxiety relief, sedation, and combination with stimulants?

[ninjapirateroberts]

I'd be careful mixing beta blockers with stimulants. They are contraindicated in treatment of stimulant overdose.

Beta2 adrenergic receptors help increase the heart rate when norepinephrine binds, but they also dilate veins, lowering blood pressure.

This opposes alpha 1 adrenergic receptors, which also bind norepinephrine, and cause vasoconstriction and raise blood pressure.

When on stimulants that produce norepinephrine release, I would worry about the unopposed alpha agonism causing a dangerous blood pressure spike.

Clonidine is a much better choice, as it decreases the release of norepinephrine rather than by changing the balance of its binding sites.

Evidence for "unopposed alpha stimulation" is really lacking though.

Avoidance of β-blockers in patients who use stimulants is not supported by good evidence - PMC

www.ncbi.nlm.nih.gov

"Many clinicians are hesitant to prescribe β-blockers in the setting of active stimulant use owing to a perceived risk of 'unopposed α-receptor stimulation.' Evidence does not support a high risk of harms from the combination of β-blockers and stimulants, and the best available evidence suggests long-term β-blockers are safe in the context of stimulant use. Until there is clear evidence of harm, patients with stimulant use disorder and concurrent cardiac comorbidities deserve to be offered the standard of care, including discussion on the risks and benefits of β-blocker therapy."

Also: https://litfl.com/beta-blockers-for-cocaine-and-other-stimulant-toxicity/

 

[ChemicallyEnhanced]

I read that beta-blockers are sometimes used as "performance-enabling drugs" which help reduce anxiety since they block epinephrine and norepinephrine on adrenergic beta receptors in the heart.

Beta-blockers for anxiety: Uses, benefits, and side effects

Beta-blockers are a type of medication that can treat heart conditions. Some doctors also prescribe them to ease the symptoms of anxiety. Learn more in this article.

www.medicalnewstoday.com

How Are Beta-Blockers Different Than Other Anxiety Medications?

Beta-blockers act differently than many other anxiety medications by relieving the physiological symptoms of performance anxiety like a racing heart.

www.gokick.com

The effect of propranolol versus placebo on resident surgical performance - PMC

PURPOSE: To determine whether propranolol can decrease surgical tremor and anxiety in residents performing ocular microsurgery without impairing patient or physician safety. METHODS: In this randomized, double-masked, crossover study, 5 third-year ...

www.ncbi.nlm.nih.gov

Propranolol For Anxiety: How To Ease Performance Nerves

Primarily used to treat blood pressure and heart conditions, beta-blockers are known to lessen the physical effects of anxiety conditions and social phobias.

www.gokick.com

I found a study that reports that beta blockers are safer in combination with active stimulant use:

Avoidance of β-blockers in patients who use stimulants is not supported by good evidence - PMC

www.ncbi.nlm.nih.gov

Has anyone had experience with beta blockers (Propranolol, or other drugs) for anxiety relief, sedation, or combination with stimulants as opposed to benzos? (I know benzos are indicated for all of those symptoms including insomnia but I don't know if doctors recommend benzos in combination with stimulants as they do with beta blockers). I've never tried beta blockers, and some sources state beta blockers may cause insomnia (so they can't be used like benzos or Z-drugs).

Since beta blockers are not psychoactive and only act on the sympathetic nervous system, is it a safer alternative to benzos? (given benzo's notorious withdrawals, dependence, etc.)

Beta blockers only reduce PHYSICAL symptoms when it comes to anxiety. They are not psychoactive so they will not take away any of the mental part of anxiety.
Since stimulants increase heart rate and beta blockers decrease heart rate, I wouldn't mix them. It sounds like it could become cardiotoxic, the same way taking amphetamines and anti-psychotics together causes very uncomfortable effects.
I take beta blockers during opioid or gabapentin withdrawal and they so a pretty good job for withdrawal symptoms like trembling, tachycardia, nausea etc

 

[ninjapirateroberts]

Beta blockers only reduce PHYSICAL symptoms when it comes to anxiety. They are not psychoactive so they will not take away any of the mental part of anxiety.
Since stimulants increase heart rate and beta blockers decrease heart rate, I wouldn't mix them. It sounds like it could become cardiotoxic, the same way taking amphetamines and anti-psychotics together causes very uncomfortable effects.
I take beta blockers during opioid or gabapentin withdrawal and they so a pretty good job for withdrawal symptoms like trembling, tachycardia, nausea etc

I only ever get physical anxiety -- mental anxiety was never really an issue for me (my mental anxiety only starts when I feel my heart rate is high and that I'm about to get a heart attack, faint, or something).

 

[4meSM]

Not too long ago I consulted a cardiologist because I was experiencing palpitations. However, after conducting numerous tests, they concluded that anxiety was the most likely cause. I've experienced similar symptoms to what you're describing when taking stimulants, worrying about my heart rate and the vicious cycle that comes with it...

The cardiologist told me he was hesitant to prescribe beta blockers to younger individuals without a cardiovascular condition. This is because these drugs essentially act as a temporary fix, only masking symptoms and often requiring continuous (indefinite) use, which could potentially lead to withdrawal issues. Instead, he suggested investing in a portable heart rate monitor like an Apple Watch or a similar, potentially cheaper, device. This would allow for constant assurance that your heart rhythm is normal and there's no cause for concern. An elevated heart rate is a common psychological response in these situations, a persistently high blood pressure is a more serious concern though. But unfortunately that's not as easy to monitor.

 

[ChemicallyEnhanced]

I only ever get physical anxiety -- mental anxiety was never really an issue for me (my mental anxiety only starts when I feel my heart rate is high and that I'm about to get a heart attack, faint, or something).

In that case, they'll definitely help! If it's Propranolol you're having, don't take more than 80mg in a day.

 

[ninjapirateroberts]

Not too long ago I consulted a cardiologist because I was experiencing palpitations. However, after conducting numerous tests, they concluded that anxiety was the most likely cause. I've experienced similar symptoms to what you're describing when taking stimulants, worrying about my heart rate and the vicious cycle that comes with it...

The cardiologist told me he was hesitant to prescribe beta blockers to younger individuals without a cardiovascular condition. This is because these drugs essentially act as a temporary fix, only masking symptoms and often requiring continuous (indefinite) use, which could potentially lead to withdrawal issues. Instead, he suggested investing in a portable heart rate monitor like an Apple Watch or a similar, potentially cheaper, device. This would allow for constant assurance that your heart rhythm is normal and there's no cause for concern. An elevated heart rate is a common psychological response in these situations, a persistently high blood pressure is a more serious concern though. But unfortunately that's not as easy to monitor.

I've been wearing Apple watch for like 2 years now, and I wear them 24/7 -- I only remove them when I take a shower (and that's when I also charge the watch).

I get "increased heart rate" alerts when my HR is 120+ (or "decreased HR" alert when it's below 40 BPM) for more than 10 minutes (it happens when I eat my dinner and my HR would be 120+ for a few hours, I don't know why this happens).

Other than that, my resting HR during sleep is average (45-50 BPM) and my resting daytime HR would be 85-100 BPM.

I check my BP twice a week (actually required to due to my ADHD doc needing the data for profile and monitoring), and it's always average (around 110/75 range).

 

[ninjapirateroberts]

In that case, they'll definitely help! If it's Propranolol you're having, don't take more than 80mg in a day.

My current dose is 20mg a day and I don't plan on taking more than 20mg anytime. If I develop tolerance to 20mg, I guess I'd withdraw and continue after a while once it reaches baseline. I know these heart medications are to be taken carefully but the main reason I'm taking is that from what I've read (and from others in here), it's safer in comparison to benzos at least and doesn't make me physically dependent on it (since I'm only taking a smallest dose and not for heart condition and do not have inborn cardiac abnormalities). The main reason I'm taking propranolol is because I believe it's safer when compared to benzos for physical anxiety and especially for my condition in which my anxiety is mostly physical due to HR and I don't have abnormal brain activities which would require psychoactive drugs like benzos to calm me down (I think taking psychoactive drugs for my case fucks up with my ADHD-psychostimulant pharmacotherapy so I'm just trying to find the safest yet least physically dependent drug and I've only ever found propranolol for that as of now).

 

[Mycophile]

I've been taking propranolol 20mg after about 3-4 hours into my daily Vyvanse stimulant dose for several days and it's been really great. It takes the edge off and makes me more "calm" due to reduced heart rate (most of my anxiety is due to me noticing my heart is going little fast, or that I could literally "hear" my heart, like when you sip coffee for example). It doesn't seem to cause any mental effects (I got drowsiness only the first day, but it's gone after the 2nd time).

Tbh, stimulants use to raise my HR when I'm about to go out, talk to someone on phone, need to give a presentation (or ask a question in class), take an exam, etc. but this beta-blocker takes away the physical anxiety part, in result making me calm. I'd say it's definitely better than benzos (at least for me) especially when combined with a stimulant (meaning not to take the edge off during stimulant comedown, rather during drug effect). I also don't feel any anxiety or heart palpitation during Vyvanse comedown (I always get heart palpitation after eating dinner, but when I'm on propranolol, I get zero heart palpitation or comedown anxiety).

I found this really, really helpful for anxiety, in combination with the stimulant (without messing up with the mental alertness/ADHD-suppressant effects of stimulants). I guess even if propranolol is mostly physically (heart) active, I'd developed tolerance... but I guess since I'm taking a small dose (20mg a day) compared to what a heart patient would take, I guess I can still withdraw and not have life-threatening or really fucked up side effects unlike benzos (which btw I'm CURRENTLY withdrawing from).

So do you take it every day?

I mean, I'm glad it's working for you, and of course no psychiatrist or doctor is God or right all the time, but mine told me that it's not generally healthy or advised to take a beta blocker every single day because of its effects on the heart, so I have to side with him in terms of my own personal safety over people on the internet.

But on the other hand, I certainly would like to try it. My brother's friend is a lawyer and said propanolol works great for him when he gets up there, but I'm not sure how often he takes it.

I'm also VERY slowly weaning off Klonopin, but I don't know whether or not I'll ever fully get off it, or if I do then I will probably have to drink very little caffeine to do so, which is a problem for me as I am so dependent on it.

My goal would be to either quit or get down to a very low amount of coffee and with it I wouldn't probably need my Klonopin at all, but it's a real struggle. Today was the first day I tried paraxanthine instead of coffee, but I still ended up drinking 1 cup of coffee and 1 cup of tea cause I didn't feel quite right. Not sure how it will work overall as a substitute, but I will say that I never needed Klonopin till I started drinking more than 3 cups of coffee a day. Now I still have generalized anxiety disorder and OCD and all that, but it's nowhere near as bad without all the caffeine.

 

[CFC]

I get "increased heart rate" alerts when my HR is 120+ (or "decreased HR" alert when it's below 40 BPM) for more than 10 minutes (it happens when I eat my dinner and my HR would be 120+ for a few hours, I don't know why this happens).

It's pretty normal to experience increased HR after eating for a number of reasons [blood redirecting to digestion, blood pressure falling/heart rate increasing to balance and maintain steady CO2 exchange etc] but not tachycardia for hours.

You should probably look to get that investigated - could be a food intolerance, could be underlying arrhythmia, could be nothing...

 

[ninjapirateroberts]

It's pretty normal to experience increased HR after eating for a number of reasons [blood redirecting to digestion, blood pressure falling/heart rate increasing to balance and maintain steady CO2 exchange etc] but not tachycardia for hours.

You should probably look to get that investigated - could be a food intolerance, could be underlying arrhythmia, could be nothing...

I eat one meal a day (I eat dinner), and for breakfast I usually eat an apple, pistachio, and nutella (yeah, just raw nutella without bread or anything). I don't eat anything in between (maybe some peanuts, broccoli or seeds in the evening). And I eat bean burrito, eggs, or something like that for the dinner (I mostly get increased HR or sometimes heart palpitation when I eat stomach full -- a decent meal).

 

[ninjapirateroberts]

So do you take it every day?

I've been taking it daily for a week now. But planning to cut back and just take maybe 3 times a week (20mg) when I'm going out (meaning doing some physical activity) or something like that.

 

[soulwentmia]

I'd be careful mixing beta blockers with stimulants. They are contraindicated in treatment of stimulant overdose.

Beta2 adrenergic receptors help increase the heart rate when norepinephrine binds, but they also dilate veins, lowering blood pressure.

This opposes alpha 1 adrenergic receptors, which also bind norepinephrine, and cause vasoconstriction and raise blood pressure.

When on stimulants that produce norepinephrine release, I would worry about the unopposed alpha agonism causing a dangerous blood pressure spike.

Clonidine is a much better choice, as it decreases the release of norepinephrine rather than by changing the balance of its binding sites.

Beta-Blockers for Cocaine and other Stimulant Toxicity

The toxico-mythology of 'unopposed alpha stimulation' and the contra-indication of beta-blockers in the treatment of cocaine, amphetamine and other stimulant toxicity. Down with dogma!

litfl.com

Stimulants cause excessive catecholamines. Beta-blockers are the only class of medication that directly antagonizes this effect. Based on the results of our systematic reviews we determined alpha-blockers (phentolamine), nitric-oxide mediated vasodilators (nitroglycerin, nitroprusside), and calcium channel blockers treat hypertension, not heart rate. A beta-blocker like labetalol will do both effectively and safely.

Medicine is full of dogmas of the past, and ongoing research helps support, revise, or refute these for the benefit of patients and present-day and future clinicians. When we stop questioning these entrenched beliefs, especially when absolute, we have done a disservice to our patients and ourselves. Chris Nickson wrote in a recent email to me regarding this dogma, “I think few things in medicine are absolute,” which is the correct way to think about it. Toxicology is a field that is largely based on case reports of rarely-encountered situations, as it is impossible to do even moderately-sized randomized double-blinded prospective studies of potentially life-threatening conditions. The treatment of cocaine and amphetamine toxicity is a good example. The “unopposed alpha-stimulation” contraindication is based on medical lore and “toxicomythology,” a term coined by toxicologist Richard Dart who wrote,

We must remove entrenched but inaccurate beliefs in the medical literature and challenge new assertions to ensure that they are scientifically valid.

"evidence does not support a high risk of harms from the combination of β-blockers and stimulants, and the best available evidence suggests long-term β-blockers are safe in the context of stimulant use."

 

[Skorpio]

Beta-Blockers for Cocaine and other Stimulant Toxicity

The toxico-mythology of 'unopposed alpha stimulation' and the contra-indication of beta-blockers in the treatment of cocaine, amphetamine and other stimulant toxicity. Down with dogma!

litfl.com

Stimulants cause excessive catecholamines. Beta-blockers are the only class of medication that directly antagonizes this effect. Based on the results of our systematic reviews we determined alpha-blockers (phentolamine), nitric-oxide mediated vasodilators (nitroglycerin, nitroprusside), and calcium channel blockers treat hypertension, not heart rate. A beta-blocker like labetalol will do both effectively and safely.

Medicine is full of dogmas of the past, and ongoing research helps support, revise, or refute these for the benefit of patients and present-day and future clinicians. When we stop questioning these entrenched beliefs, especially when absolute, we have done a disservice to our patients and ourselves. Chris Nickson wrote in a recent email to me regarding this dogma, “I think few things in medicine are absolute,” which is the correct way to think about it. Toxicology is a field that is largely based on case reports of rarely-encountered situations, as it is impossible to do even moderately-sized randomized double-blinded prospective studies of potentially life-threatening conditions. The treatment of cocaine and amphetamine toxicity is a good example. The “unopposed alpha-stimulation” contraindication is based on medical lore and “toxicomythology,” a term coined by toxicologist Richard Dart who wrote,



"evidence does not support a high risk of harms from the combination of β-blockers and stimulants, and the best available evidence suggests long-term β-blockers are safe in the context of stimulant use."

Interesting, definately a useful change of paradigm.

 

[ecstacylover]

A beta-blocker like labetalol will do both effectively and safely.

But as he says in his article, labetalol is also an alpha blocker. There's an MDMA study where the nonselective beta blocker pindolol had no effect on MDMA's increase in mean arterial pressure, despite reducing MDMA's increase in heart rate. Another paper showed ketamine-mediated increase in heart rate and mean arterial pressure are catecholamine-mediated in dogs. Compared to ketamine alone, ketamine+propranolol induces nonsignificant increase of mean arterial pressure increase and nonsignificant reduction of heart rate increase, and also significant increase in preload (whereas ketamine alone has no effect on preload).

I've taken propranolol a handful of times with the ketamine analog PCE, as well as with the stimulant 4-Me-MPH, and every time they significantly helped the physical anxiety. But I always thought this was via a decrease in blood pressure when instead it seems to be due to decrease in heart rate, or maybe in my case just placebo.