♪ Bob and Brad ♪
♪ The two most famous ♪
♪ Physical therapists ♪
♪ On the internet ♪
- Welcome my friends to the Bob and Brad podcast
produced by Bob and Brad,
the two most famous physical therapists on the internet,
in our opinion of course.
I am Bob, exactly one half of the Bob and Brad team,
and I'm gonna be your host today.
And I'm joined again by Chris the pharmacist.
One of the smartest guys I know.
That's my tagline with him.
And he's today gonna talk about
understanding the pharmacology of benzodiazepines.
Did I say that right? - Benzodiazepines, yup.
- And how to reduce anxiety,
and it also can help us sleep, correct?
- It sure can.
- All right, so let's get started.
What role does this drug play?
We had another video where we talked about the SSRIs.
- Yep. - You maybe wanna
tell what that is real quick,
and what the benzodi-
- Yeah, I mean, when we're dealing
with anxiety specifically,
anxiety is an awful, awful feeling.
And there are several different forms of anxiety,
but most commonly is general anxiety disorder.
But the reality of it is when people feel like garbage.
You're talking about one in five Americans.
So that is a lot of people,
upwards of 50 million Americans experience anxiety.
And it's horrible.
- And worse this year.
- Yup, it seems to be a lot worse
this year, 2020 has been - 2020
- a highly unique year for that.
And then at least my pharmacy,
I'm seeing more of these drugs going out left and right.
- Than ever, would you say?
- Yeah, I would say so.
I mean, in my, you know, it's not scientific,
but I mean, we've talked- - Sure, just anecdotally.
- My staff, we kinda talk and like, wow,
we're really kicking these out.
But the reality of it is, is you know,
when we have anxiety, the mainstay of therapy
is either talking with your doctor.
Well, first seeing your doctor,
because we need to know if there's
a physical underlying cause.
You know, certain medications can cause it,
thyroid condition can cause it, cardiac conditions.
There's a lot of things.
So once we established it's nothing physical
that's causing it and it is anxiety,
you know, and you're having these horrible thoughts,
what they say most days of the week for six months,
which again, in my opinion is way too long.
- Way too long, right.
You know, they would start you
on either cognitive behavioral therapy or the SSRIs,
which are the serotonin,
selective serotonin re-uptake inhibitors.
- Do they start the cognitive behavior therapy
right away, or do they wait
until the medication has started to kick in?
- No, I think, you know, a lot of times the doctor,
if the patient, you know, the patient drives the bus.
I mean the therapy is centered around
what the patient's willing to do.
And so if you're willing to go through therapy,
which I think is one of the best things out there,
'cause it's non-drug.
You know, cognitive behavioral therapy
basically teaches you,
and they have very skilled clinicians
that are gonna help you to teach you
to replace the negative, horrible thoughts
with positive ones, to help you
to kind of balance things out
and understand why those feelings occur
when you're having those negative thoughts,
so that we can kinda come to a better place
where you can kinda control it more naturally.
- I've seen the studies where
you take one, drugs, or you take the therapy
and, you know, they both can help,
but together that's what's, - they're far more effective.
- Far more effective. - And I think it's widely
underutilized aspect of our healthcare community.
And I think counselors have a lot to offer.
And I would hope that every, you know,
unfortunately there's been a stigma
with mental illness and people are like,
well, I don't need that kind of help.
Well, I think the- - Much less,
but it seems like yeah,
it's still there. - Yeah, and we
have to crash that door down.
I mean, it's something that,
that people need to take advantage of
because it's there for them and it's helpful.
And they leave lasting beneficial results
for the rest of your lives.
So whether it's- - what about like meditation?
Does that fall in that same category?
- Yep. Mindfulness and meditation
actually are all within that.
And you know, it's interesting
there's books about it.
There's, you know, you can go to,
you know, group talks about it.
Sometimes there's apps on your phone
that you can actually utilize.
And for some people, they're wonderful opportunities
to help you to help mitigate and manage anxiety.
But, you know, sometimes we just need the medications.
And so, and it's just, sometimes that's the easier choice.
Maybe you've got three small kids
that are running in five different directions,
although with COVID,
it's a little bit different these days.
But you know, it might not be optimal
for you to go in and see a counselor.
So medications certainly help.
And a lot of times they'll start you on the SSRIs
or even the SNRIs but that point,
those take time to work.
Like four to six weeks. - Take a long time to work.
- So that's where the benzodiazepines kick in.
And so those are the ones that work immediately,
but they have a strong, negative connotation.
They are addictive.
We have to be careful with them.
Tolerance develops, and there's lots of side effects
that are associated with them, so they're just
a small stopgap. - How quickly, typically,
could a dependence occur?
- Within a couple of weeks.
So it doesn't take long, usually most clinicians
only want- - So if you took it every day
for a couple of weeks, you mean?
- Yeah, I mean people can, if they need to,
and again, it's kind of intermittent you on it.
There's a phrase that doctors
put on prescriptions called PRN.
It stands for as needed.
It's actually just a derivative of Latin,
but you know, a lot of times these drugs,
depending upon which one,
whether it's lorazepam, clonazepam,
diazepam, you know, alprazolam,
those are the ones that are the most,
those are the four most commonly used ones.
And there are others, many others actually,
and they all have different potencies
and lengths of action.
So a doctor is gonna certainly listen to you
and make sure that there's something appropriate.
And if it's something that's like,
I am just so panicky, I'm about just explode.
I mean, I think sometimes clinicians will say,
you know, I think it is reasonable for you
to consider taking a benzo. - Make that bridge.
- And let's get you something
so that we can help you to relax,
get you the sleep, so that your brain can recover,
so that we can wait for the other drugs to kick in.
Or your therapy to begin to help you.
So it's a short term- - Yeah I have a family member,
I don't, not gonna mention her name,
but she had cancer and so they actually
let her be on the clonazepam the entire time.
- Sure. - And it's funny,
you know, she, she got off it fairly easy.
She did pretty well with it.
She said, "I really don't like
how I feel on it, so it was easy for me to get off",
but apparently she didn't get dependent upon her-
- Yeah, and you know, the things drive addiction,
are, you know, there's a genetic predisposition
to a lot of these things.
And so, and again, your clinician
is very skilled at looking for these cues.
And so they have to assess you every time you come in.
And so you're meeting with a doctor,
you know, in some cases monthly,
three months, six months,
depending upon the circumstances
that they deem appropriate for your particular situation.
And so they're gonna be looking for those cues
and seeing what's appropriate, what's not appropriate.
The generalized guidelines are,
you only want to take it for a couple, two to four weeks.
And actually if you take it for as long as four weeks,
then you have to actually taper off it
at about a rate 25% per week to step down safely,
because you could have withdrawal effects.
And that can be very, very serious
even to the point where a severe withdrawal with benzo
could actually create a cardiac type of emergency.
- Oh my gosh, yeah. - So it's things that
clinicians are very, very careful with-
- Very aware of. - When they're treating
their patients, and you know,
us as pharmacists in the community,
we're kind of looking at see refill patterns,
how they're doing, you know,
we wanna make sure that they're safe
with their medication of use,
making sure they're tolerating everything okay.
Not having problems with dizziness, drowsiness,
falling asleep at work.
You know, so there's, those are the mainstay.
That's why they work, is they make you tired,
but they can make you dizzy
and they can make you drowsy, so they're used-
- How long are they in your system?
- Well, and again, that kind of depends.
- On which one you use. - Yeah. So clonazepam,
much longer, diazepam even longer.
Things like lorazepam and alprazolam much shorter,
but the problem with the shorter acting potent benzos
is they can cause rebound anxiety.
So these things are not designed to be used,
they're just a stop gap
until hopefully other measures will take place
and really help to the patient
to safely manage their anxiety symptoms.
- Yeah, the same girl would use it
when she'd fly, because she had a fear of flying.
- Yep, very reasonable, fear.
That's a phobia, so that's an anxiety.
- And she would use it for that alone now,
and always worked quite well.
- Yeah. And so that's a one, I mean,
unless she's flying for a living,
I mean, obviously pilots don't get to take it.
But it's one of those things where yeah.
People that travel, some people
do not like sitting in a tube that's, you know,
44,000 feet in the air.
It's not a comfortable feeling for some people.
- Same storage advice with these, that you're-
- Yeah, any medication really,
it comes down to, unless we
tell you specifically, - Avoid the moisture.
- Yeah. So it's not in the kitchen,
not in the bathroom because those are the two
most moisture prevalent rooms in the house.
So you want it to be out of reach of children
and really somewhere that's cool and dry.
So usually it's a bedroom high up or, you know,
little kids and pets can't get at it.
- Sure. Now,
I saw, when I was doing some research,
I mean, yeah, there's people
that actually had to go to rehab for the addiction.
- Benzos are absolutely dangerous medications
when used inappropriately.
And so, and that's the key - And again, you talked
about the genetic portion of it
can really weigh heavily, - Yeah, I mean,
the science of addiction - the tendency towards it.
is really, it's fascinating and scary all at once.
And I mean there's books and books and programs
to help people to try and avoid those perils,
but it happens and it happens much more commonly.
And right now with COVID,
we're seeing even higher addiction rates,
with other drugs too.
And a lot of times benzos are mixed with other products
like alcohol or other drugs.
And that's where the real dangers can set in,
you know, an overdose on a benzo
can cause respiratory depression
and stop your heart from working,
and that's it. - I know she talked
about alcohol that you just don't wanna do that,
- No, it's exceedingly- - you don't even wanna
have a glass. - You don't wanna go
anywhere near mixing and matching
with these types of medications.
It can be devastating.
I mean, you may not wake up
depending upon how much you've imbibed.
So we have to be exceedingly careful.
And it's something that, you know, as pharmacists,
we're kind of looking for that too,
because you know, sometimes, you know,
we all wanna be safe
and sometimes it's an accident too.
I mean, and some of these drugs affect how you think.
And so when we're elderly, it's not something-
- Yeah, you're not even thinking right, correctly.
- Yeah. And so all of a sudden it's like, well,
I don't remember if I took one a couple hours ago,
I'm gonna take another one because I feel panicky.
Well, all of a sudden now we've taken three or four doses
and all of a sudden it can have
some devastating consequences.
You know, and so as we age, I mean,
it can definitely affect your memory and your cognition,
so it's certainly something that clinicians, again,
they look very, very carefully at their patients.
You know, sometimes some more than others,
it just kinda depends.
I mean, there's, we run into clinical inertia all the time.
We see, you know, an 80 year old lady
taking these medications,
and is this really the safest thing for you to do?
And so it's like, yeah,
and sometimes that's a very hard conversation to have
because these people have taken these medications
for a number of years,
which again, you heard me say earlier,
only a couple of weeks,
and you heard me just now say a couple of years.
And so, and again, it's the clinician's responsibility
to make sure that the patient's using it
in a responsible way without the side effects,
but sometimes, you know, doctors can be busy
and also, it's like a quick visit.
And it's like, you know, that one just got by the goalie.
- Oh yeah, you maybe have so many medical issues
to address, yeah. - There were seven
other things on the docket that you wanted to talk about.
And that one just got,
it just slid under the rug, so to speak.
- I was talking to a doctor friend
who has all these little old ladies
and they're on Ambien and they can't,
they don't want to be off.
- They don't wanna be off, nope.
- It gets them to sleep, they don't want to get off it.
- Exactly. And that's one of the hard, it's very hard.
I actually was reading an article last night about,
you know, a doctor is suggesting
how do people stop these things?
And it's like, you know, they try.
- It's difficult. - And it is, longterm,
it's just not a good solution.
And so we don't want people on them indefinitely.
- Do you have to take these with food or not?
- No, and a lot of cases, it's not,
the biggest thing, we don't want you to,
just stay away from alcohol
and some other substances while you're on it.
But you know, it can be with, without food.
Kind of depends on your stomach and you know,
what your GI tolerances are.
So if it's something
that you got a little bit of a touchy tummy,
you know, you have piece of toast,
some crackers with that.
And always, you know, full glass of water is ideal
from that regard.
But for the most part, there's not a lot of GI side effects.
The biggest things that we watch for are central.
So it's gonna be, you know, the dizziness,
the drowsiness, the impaired driving of an automobile.
I mean, and that's a big thing with benzos,
take it with a panic attack and let's say you're at work.
- And you gotta get home. - All of a sudden,
now you gotta get home, I mean, that's-
Taking these types of drugs,
if you got in a car accident and the doctor,
the police are like, were are you on any medications?
Well, I just had some little alprazolam at work.
That's now a DWI, or driving,
DUI at that point.
So driving under the influence.
- Somebody got hurt, you'd be-
- It's devastating. And I mean, just the,
their responses you know, I mean,
it can go on forever, depending on how bad the scenario is.
So it's, these are things
that you don't want to drive on
because they do affect your coordination.
I mean, you wouldn't go out
and play baseball or golf on these things
because you wouldn't be able to control,
you just don't have the coordination physically
because of how they work with the polarization
in your cells and why it relaxes you.
I mean, it's also why it works so effectively
is because it allows you,
it allows the communication in those nerves
to work a little bit more efficiently
so that they tell your, the cells to kind of calm down.
- These, I imagine there's over the counter meds
you don't wanna take with this, too.
- Correct, there's actually several,
a lot of the herbal products like kava, dangerous.
I mean, you need to be- - well maybe, some of,
that make you sleepy. - Antihistamines.
So, I mean, if you look at, let's say Benadryl.
Benadryl is kind of the granddaddy
of all antihistamines,
what is the number one side effect?
Well, it's sedation, because it binds
the histamine receptor and it makes you sleepy.
It's also why you don't itch or have allergy symptoms.
Well, when we take something
that makes you sedated by itself,
and then we add another ingredient that,
we'll just pick on alprazolam today, that makes you tired.
We take them both together, you see a synergistic response.
And so what would be maybe somewhat tolerable or okay,
now all of a sudden becomes, wow, I am really knocked out.
- So it's not one plus one equals two, it might be
one plus one equals three? - Six.
- Or six, wow. - Yeah. I mean, it just
depends on your metabolism
and the doses of what you've taken.
So there's a lot of factors, your genetics.
So there's a lot of factors that go into these things
and, you know, these are the things that pharmacists
talk to you about, your doctor talks to you about.
But you know, there's certain things that,
yeah, we can't just indiscriminately,
just medicate with other stuff
when we're on certain things.
And so that's why I like to think I have a job.
I, you know, I encourage everybody,
if there's a question, please call.
I spend, I am happy to take any phone call,
anytime, any place, anywhere.
- Yep, he does a great job. - If they have
a question on something.
So we're gonna try and minimize those effects,
just because we want to keep,
at the end of the day, we gotta keep you safe.
Number one. - Awesome.
Well, I think we'll wrap it up there.
If you got questions, put them in the comments below
and we'll maybe address them in a future video,
if we see the same one popping up a lot.
So that we know what people are thinking.
- All right. Sounds great, Bob.
- Thanks for watching. - Thanks a lot.