Benzo long term maintenance therapy (like Methadone-Suboxone therapies for opiates)

[Charles Ferdinand]

Hi!
The way I understand it some people consume low doses of a very powerful opiate for an undefinite amount of time, to avoid withdrawals and given that relapses are very common among us, addicts.
So why can we apply the same principle here for benzos, using a highly powerful (Brotizolam doses are in the micrograms: .25 mcg equivalent to 10mg of Diazepam Valium).
The drug is already in the market (for sale here in Mexico), the only drawback being it's short half-life (4~5 hrs)
Plus, benzo withdrawal can last for up to 6 months (or years if you have PAWS), it can kill you, and makes opiate withdrawal look like spank.

Regards!

 

[Coolwhip]

I think you already answered yourself.

 

[ebola?]

Non "as needed" prescriptions to benzos are, in practice, programs of long-term maintenance. I don't know why you think that highly potent benzodiazepines are better than less potent benzos--even Valium is sufficiently potent to effectively maintain addicts with high levels of tolerance. What's most desirable is a long duration of action, which facilitates achievement of maintenance-proper rather than escalating abuse and makes the eventual taper smoother and more viable overall. In this respect, Valium is near ideal, its main weakness being the high level of sedation it induces.

ebola

 

[ebola?]

Actually, now that I think about it, the advantage you are thinking of with respect to high potency compounds is the prevention of dosing with one's drug of choice. One achieves such using compounds with a very high receptor affinity and occupancy but comparatively low efficacy (the latter concern making partial agonist/antagonists more suitable). This is one reason why suboxone maintenance is preferable over fentanyl maintenance; it is pretty much an accident that suboxone is very potent at sub-ceiling levels. But at the end of the day, this goal is political rather than medical (why would we want to externally compel addicts to use one drug of a particular class over another?), and thus in my opinion largely invalid.

ebola

 

[negrogesic]

Not really a great idea, at least in the sense of an opioid for the purposes of NRT. Once the process of withdrawal has begun (or has occurred in the past) benzodiazapines can often precipitate what the addict perceives as 'withdrawal', even in cases where doses remain static over time or appear to be relatively consistent in regards to blood levels.

And while severe and of great duration, after permanent discontinuation/eventual recovery from most withdrawal symptoms (obvious, this is clouded by comorbid anxiety or psychiatric disorders), benzodiazepines are somewhat unlike opioids in the sense that the addict generally does not 'crave' or 'fantasize' abuse for an untold amount of time (assuming a rather 'pure' addiction/abuse pattern; ie, when abuse differs from a habituation<--->addiction relationship, which is actually quite unrealistic).

I recommend high dose neurontin as an aid to allow for safe, 'more' comfortable, and ultimately more successful discontinuation of benzodiazapines. Pregabalin appears to hold promise as well, although there is not much data on its use for this purpose (pregabalin, while more potent than neurontin, is also significantly more expensive, of greater abuse potential and may not be readily available in Mexico).

This is spoken having experienced the horrors of massive dose benzodiazapine withdrawal (the better part of a decade ago), a secondary 'relapse' of sorts from an ill-conceived attempt to use benzodiazepines therapeutically (much lower doses involved, but the withdrawal was not substantially less horrific), and having had a past addiction to opioids (treated quite successfully with mega-dose methadone maintenance).

I emphasize the word 'past' when I refer to addiction (in contrast to the popular 'perpetual addict' notion), because these matters can in some cases (for example, I am fortunate in that I do not suffer from a psychiatric or pain disorder that requires the use of benzodiazapines or opioids). However, while brief therapeutic use of opioids does not make me crave additional opioids (ex; a two week use of hydrocodone following shingles), a similarly brief use of benzodiazapines can in my case, result in the distinct and unpleasant symptoms of dependence and discontinuation. There is a physiological basis for this that is well-documented (others can explain; time constraints have already been exceeded), and is not exclusive to my case. Note; there does exist a sort of 'terminal' opioid-addict, that will abuse until death from overdose or complication; however it is rare that the same exist when the drug of abuse is predominately benzodiazapines (yes, benzodiazapines can result in death from discontinuation, but such occurrences are rare relative to fatal opioid overdoses).

Summarize; the nature of benzodiazapine addiction differs substantially from that of an opioid addiction, and by virtue of this difference the same pharmacological approaches cannot be used. Safely discontinue benzodiazapine use by all means necessary, and do not use it again (obviously, it can be administered if needed in an inpatient setting). Carefully use drugs like neurtonin to facilitate this process. Understand that any unnecessary prolongation of a taper is only effectively prolonging the withdrawal. Seek CBT or other non-pharmacological means to treat comorbid disorders that may require the future use of benzodiazapines.

 

[laCster]

exercise, diet, and a healthy-sex life work much better than benzos for long-term treatment of anxiety. low doses of DXM, lyrica, and marijuana also work wonders for me; marijuana being the only drug i ingest daily...

 

[Hammilton]

an issue I see is that these drugs aren't agonists per se, they're allosteric modulators. Does anyone know if the high affinity less recreational lower affinity more enjoyable drug apply here?

 

[Charles Ferdinand]

Ok, so Brotizolam has a really short half-life also (5.5 ~ 6 hrs)
I kicked benzos in New Year's Eve, but after withdrawal I just went to my old self: anxious and visceral, antisocial and hypochondriac. Among many other things.
Tried excercise and diet (3rd time in 5 years since I was diagnosed), Tried psychologists and therapy ( 6th time since diagnose, 5 years ago), tried a new psychiatrist (5th since diagnose) and he prescribed lithium, valproic acid, olanzapine and lorazepam for a new diagnosis: Schizoaffective disorder. I plainly refused and left without paying him, when he complained I threatened to go to the National Comission of Medicine (CONAMED in Mexico).
So that's where my problem is.
Sometimes peoples are just anxious, sometimes we're just cursed.

 

[Psychedelic Jay]

It is simply unethical. You will eventually desensitize so many GABA-A receptor sites, that you will gain very high levels of epileptic activity after a "little" slip-up.

That's like giving an alcoholic more alcohol. It will fend away WD symptoms and save his/her life at the moment, but will not warrant "real" safety in a true treatment... Which will be a habituation.

 

[negrogesic]

Ok, so Brotizolam has a really short half-life also (5.5 ~ 6 hrs)
I kicked benzos in New Year's Eve, but after withdrawal I just went to my old self: anxious and visceral, antisocial and hypochondriac. Among many other things.
Tried excercise and diet (3rd time in 5 years since I was diagnosed), Tried psychologists and therapy ( 6th time since diagnose, 5 years ago), tried a new psychiatrist (5th since diagnose) and he prescribed lithium, valproic acid, olanzapine and lorazepam for a new diagnosis: Schizoaffective disorder. I plainly refused and left without paying him, when he complained I threatened to go to the National Comission of Medicine (CONAMED in Mexico).
So that's where my problem is.
Sometimes peoples are just anxious, sometimes we're just cursed.

Few quick observations and questions:

- How long after your complete discontinuation of BZD's did you wait before continuing their use again (assuming you have)?

- After the withdrawal period had apparently ended, did you feel significantly 'worse' than you did in the years or months prior to your initial abuse/regular use of BZD's (ie, "old self" comment)

- Prior to any BZD use, did you experience any form of psychosis (particularly, auditory or visual hallucinations), reoccurring delusions or paranoi(those which were NOT associated with overt manifestations of an acute anxiety disorder or mood disorder mania)?

- What were you past psychiatric diagnoses that you feel were (and still are) more or less accurate, such as a GAD-variant etc

- Why did you so strongly disagree with the recent Dx of schizoaffective?

Note: Not to discredit a potentially legitamite Dx, but I have seen a number of cases where it is seemingly employed by psychiatrists as a 'save face' blanketing-term for what is in reality 'various psychiatric disorder(s)-NOS' (some may have been deemed too time-consuming/complex to properly unravel and treat in a less formulaic manner).

- I lost my train of thought with that side note........Uh, don't do drugs, stay in school and so forth

 

[themdyaunome]

I didn't read every response to this question so I'm not sure if I am repeating anyone here, but as Ebola stated, almost all benzo's are prescribed "as needed." Whether it be for anxiety, panic disorder, sleep or muscle relaxation. However most people do not follow that advice, and take it daily instead of when needed.
I did the same 5 years ago and have been on alprazolam ever since. Benzo's are not supposed to be used for a long period of time, it is supposed to help you out until you find a proper anti-depressant/mood stabilizer, along with counseling sessions to diagnose the root of the problem. Anyways, usually when a doctor does use a taper method to wean someone off their benzo, they use one with a longer half-life, such as clonazepam or valium, rather than xanax or ativan.
This is exactly how it is done with opiates as well, using suboxone or methadone, which both have a much longer half-life than other opiates such as heroin/morphine. These are also supposed to be temporary solutions as well, but it usually doesn't end up that way, as I said before.

EDIT: Just wanted to state that it is not always replaced with an anti-depressant or mood-stabilizer, though it usually is. Many times they are used in conjuction with each other, but many SSRI's out there now are supposed to have anti-anxiolytic properties. Sometimes all it takes are good therapy sessions to rid people of their problems. Not myself, unfortunately.

 

[themdyaunome]

It is simply unethical. You will eventually desensitize so many GABA-A receptor sites, that you will gain very high levels of epileptic activity after a "little" slip-up.

That's like giving an alcoholic more alcohol. It will fend away WD symptoms and save his/her life at the moment, but will not warrant "real" safety in a true treatment... Which will be a habituation.

This is also true. I have been on 4mg of xanax for the last six years, and some days when I work 14-16 hours, I have to take more, due to the short duration/half-life of the xanax. This may leave me with a day or two without my medicine, in which I am constantly shaking, panicking and have experienced the "brain-shocks." It just isn't safe. I am trying desperately to get put on clonazepam at the moment, because with the longer half-life, I feel like I can take it just twice a day and not have to worry about taking too many. However, I definitely wish I had never gotten on them in the first place.

I'm envious when I see a buddy of mine take 1mg and be on the verge of nodding out, where I need to take at least 8-10mg to feel anything more than my "normal" self.

 

[RobotRipping]

benzo maintenance just doesn't work; although we're finding ways to shed tolerance. If you could maintain a steady efficacious dose then there's hardly ever other SOLID evidence from cognitive impairment to memory deficits, when used as an anxiolytic. I find benzos boring now (effective for their purpose), guess it was the MXE, dillies and ethylphenidate that changed me. Perhaps research into etizolam and it's family of drugs could be promising

 

[MagickalKat777]

benzo maintenance just doesn't work; although we're finding ways to shed tolerance. If you could maintain a steady efficacious dose then there's hardly ever other SOLID evidence from cognitive impairment to memory deficits, when used as an anxiolytic. I find benzos boring now (effective for their purpose), guess it was the MXE, dillies and ethylphenidate that changed me. Perhaps research into etizolam and it's family of drugs could be promising

Agreed with all of the above. I actually noticed that the Non-BZD olanzapine had a strikingly similar effect on my anxiety like alprazolam did but it was long lasting and had many side effects. I have not personally tried etizolam but I have yet to hear one real complaint about it versus the other BZD medications.

I have been on BZD medications since 2004 and honestly, you start on an "as-needed" basis and then next thing you know you're taking it daily, then twice a day, then three times, then needing multiple pills, then switching benzos, all the while your doctor just keeps writing out the scripts. If I had actually researched alprazolam before I ever took it, I never would have taken it. It seems that etizolam doesn't have the extremely strong addiction potential of alprazolam and clonazepam (these are more addictive than diazepam IMO) but it appears to be close to equi-potent to the two and has an "effective" life that lies somewhere in the middle. I think that they need to research more BZDs based off of etizolam as well. I will be getting some soon for myself to see how I do with it. This clonazepam is crap compared to diazepam which I can't get any doctor to prescribe and alprazolam on an as-needed basis actually makes me panic MORE when it hits me before it calms me down.

BZDs are extremely tricky drugs. Among other things, BZDs down-regulate GABA which is part of what causes the tolerance (the rest being mostly related to NMDA up-regulation in response and an increase in AMPA activity that isn't completely understood at this point) and the withdrawals are worse than alcohol. The problem is that a doctor is much more likely to give you a prescription for a BZD medication than he is to give you an opioid medication despite the fact that BZDs are actually more dangerous when used properly than *most* opiates when abused.

I wish someone would have given me a permission slip before I took alprazolam the first time or I think my life would be quite different from where it is right now!

As stated before, it is completely impossible to do long term BZD maintenance unless you want a long term addiction with nasty withdrawals with it. I had to kick alprazolam before clonazepam started working. Those first five days were so much hell that I quite literally do not remember them other than bits and pieces where I was shaking on my bed. You have to realize that you are fucking with two vital systems in the human body and they both happen to be quite sensitive - GABA and NMDA. The former being simplified as the "calm" and the latter as the "stimulated." When those are out of balance, one overthrows the other in an attempt to achieve balance in the brain and generally speaking, GABA loses to NMDA every time.

 

[Charles Ferdinand]

Few quick observations and questions:

- How long after your complete discontinuation of BZD's did you wait before continuing their use again (assuming you have)?

- After the withdrawal period had apparently ended, did you feel significantly 'worse' than you did in the years or months prior to your initial abuse/regular use of BZD's (ie, "old self" comment)

- Prior to any BZD use, did you experience any form of psychosis (particularly, auditory or visual hallucinations), reoccurring delusions or paranoi(those which were NOT associated with overt manifestations of an acute anxiety disorder or mood disorder mania)?

- What were you past psychiatric diagnoses that you feel were (and still are) more or less accurate, such as a GAD-variant etc

- Why did you so strongly disagree with the recent Dx of schizoaffective?

Note: Not to discredit a potentially legitamite Dx, but I have seen a number of cases where it is seemingly employed by psychiatrists as a 'save face' blanketing-term for what is in reality 'various psychiatric disorder(s)-NOS' (some may have been deemed too time-consuming/complex to properly unravel and treat in a less formulaic manner).

- I lost my train of thought with that side note........Uh, don't do drugs, stay in school and so forth

I used lorazepam (along with lithium, valproic acid and olanzapine) for as long as the treatment was prescribed (15 days) and haven't go back to that doctor since. He gave me lorazepam for I asked for something for anxiety (not a benzo specifically): muscle pains, insomnia, and social anxiety, and basically been introverted and thinking the same things over and over again, for example: as when saying hi to someone on college, imagining it over and over but in different scenarios (what if I had say this instead of that, etc).
I don't agree with the diagnose because drugs had no effect whatsoever on me, none, plus, I don't have any mood changes.
I did developed psychosis for a few days when withdrawing from a 8mg clonazepam/day habit for the first time, I lasted 8 days and gave up, I finally kicked benzos on january tapering and using carisoprodol ocassionally.
I've always been diagnosed with an anxiety disorder, be it social anxiety or avoidant personality, that was the first time someone gave me an "diagnostic impression" of schizoaffective disorder, after 20 mins of consult.
Never experienced any other sign of psychiatric symptom prior to my first visit to the psychiatrist, just sheer anxiety, and I feel kinda the same right now.
And after quitting I felt worse at the begininning but with my taper plan and soma I eventually felt good again (that being my old anxious self).
So I quit in march completely, and took the ativan for 15 days in october. Haven't use them again as they have no effect on me whatsoever, and feel no compulsion to try them again.

 

[negrogesic]

I will admit, I have been convinced (in time) that long-term treatment of BZD's can be warranted in certain cases. This being said, when I learned that my sister had been written a BZD as a long-term means to treat anxiety that was largely a product of circumstance (ie, "life"), I gave the physician (a middle-age female) such a tongue-lashing that she literally began crying (the physician).

Yet, I think we've all been guilty of spiking a patient with ativan out of frustration.....

 

[MagickalKat777]

negrogesic - tell me of an instance where you *know* that long term BZD is warranted. I have seen people on up to 16mg of Klonopin a day make a full recovery back to a normal life, free of anxiety, yet while they were ON THE MEDS, they couldn't leave their house. You can't downplay the significance of GABA down-regulation. Nobody can. Anybody that has been marked as "long-term BZD" just has fallen too much into modern medicine. There are numerous papers on the efficacy of BZDs after the 6 month period, in some cases even just 3, that show a complete lack of efficacy and even with escalated dosage the receptors have become tolerant to that BZD causing a need to switch to another BZD. When that one stops working, the brain has forgotten about the other one and becomes receptive to it again. BZDs are like a virus attacking the system after someone removed the antibodies for that virus.

 

[themdyaunome]

Questionable

negrogesic - tell me of an instance where you *know* that long term BZD is warranted. I have seen people on up to 16mg of Klonopin a day make a full recovery back to a normal life, free of anxiety, yet while they were ON THE MEDS, they couldn't leave their house.

I can somewhat answer that question. While there are no physical symptoms that may warrant long-term use of benzo's, which shouldn't occur often, there would be one or two circumstances in which I and a couple people I know have talked to their doctor and decided that for now, that was the best choice. If the quality of that person's life has risen and continues to stay in that mental state of well-being, self-confidence and anxiety/panic free, then long-term use could be argued, as long as certain requirements are met. I.E. the person is not abusing his or her prescription, nor abusing other drugs or the people around them. This can be monitored by simple therapy sessions and random, perhaps once a month, drug tests. While you say you have seen people make a full-recovery, that is great for them. But once I stopped with my xanax, because I thought it would be best to get off of it, for the next two months I was even more depressed, anxious and had more panic attacks that I could count. And I even made it two months, then I decided it was time to get back on them, because they are right for me, and help me in my everyday life. I know this is true for a lot of people out there.

Btw, don't get me wrong. If long-term use can be avoided, by all means AVOID IT!

 

[MagickalKat777]

I should have clarified. Long term usage being favorable over a *clinically supervised (comfort maintained)* withdrawal and reintroduction to life. I'm afraid I may end up being a benzo lifer because I've sunk so low on them, like EVERYBODY eventually does, that I don't like to leave the house. Alcohol abuse is pretty much almost a definite if you're taking clonazepam (read online - something about clonazepam, just like certain SSRIs, greatly increases the need for alcohol), which does nothing but make things worse and its pretty much unavoidable to have a dose escalation unless you're taking an NMDA antagonist (DXM, memantine, ketamine, PCP, curcumin) - how can life-long benzos be "managed" when you add in the natural, non-abused (I never abused my benzos but still ended up going from as-needed .5mg Xanax to daily .5mg to 3 times daily .5mg to daily 1mg Xanax XR to three times a day 1mg Xanax XR within a year until I ended up being switched to Klonopin after I hit 8mg mixed XR and IR in a *YEAR*) BZD tolerance? I just don't see how its manageable. I have yet to meet a single person who was totally stable on "managed" BZD treatment - I've met more on SSRI treatment that were stable and they've pretty much proven those to be placebo drugs. I don't think it is sustainable by any stretch of the imagination. The goal of BZD treatment should be as a short term stop-gap and other forms of treatment should be incorporated but doctors are all too ready to hand out that Xanax prescription (by and large most would probably agree that it is the biggest "problem" benzo) over sending their patient to a therapist to work through the minor issues that they have. By the time someone is done with BZD treatment, over the long term, they tend to be no better off (in most cases they are worse) than when they started them!

 

[themdyaunome]

I myself went through a 3 month taper, along with my doctor and counseling sessions to get off of my xanax. However, I just went back to my old self, always worrying about something, constant panic attacks and the fear of strangers. Many times I couldn't even drive to the store to get groceries or gas because I was afraid to speak to anyone. I hopped back on the Xanax and it has helped me cope with it, although not completely overcome it, quite well. Btw, I have been prescribed it for 6, almost 7 years now. Yes tolerance does come into effect, where I am from, I believe it is for the entire U.S., you cannot be prescribed more than 4mg/day, which is what I take. Yes, I could easily take 10mg and barely feel any difference, yet 5mg could floor the average person with no tolerance. However, I still benefit from the drug today as I did when I was first put on it. I have a much better social-life, I can hold a job AND I can go buy milk when I need to. However, if I go through a day with anything less than say 2.5-3mg, I can definitely feel some not too welcoming side-effects. To each their own, it works for me. I am currently trying to get on klonopin however, as the half-life is longer so I wont feel I have to dose as often as I do with xanax. I have been prescribed ativan, diazepam and xanax, and have taken klonopin regularly, as well as a couple other types here and there. Xanax and Klonopin seem to be the only ones that work for my condition.

EDIT: Didnt see the part about not being able to leave the house. It is the opposite for me. Take my xanax and Im ready to start my day, don't take it, and I shelter myself up for a couple days straight. Sounds to me like it just isnt the cure you or your doctor were searching for. Many people benefit just from regular counseling. There's a lot of things you can try, and should. Don't give up, life is much harder to deal with when you stop caring about it.

Also concerning your post, I have been on five different types of SSRIs, they do not work for me. In fact, they make me feel worse than before. Xanax has greatly improved my depression, anxiety and even my bipolarism. I cant say 'cured' because I know I will live with it the rest of my life. Too many negative situations occurred, plus I realized I have always been a little bit "mentally unstable", even as a child.