Hi, I'm Dr.Tracey Marks, a psychiatrist,
and I make mental health education videos.
Today, I'm talking to you about
what you need to be aware of
if you're gonna take benzodiazepines
like Xanax, Klonopin, or Ativan.
I've gotten several requests for this topic
with most of them centering around the issue
of benzodiazepine withdrawal and what that looks like.
Benzodiazepines, or benzos for short,
is the class of drug that works at the GABA receptors
in your brain to produce a relaxing or sedative effect.
We use benzodiazepines to treat
short-term anxiety and sleep.
Some doctors will use them as a muscle relaxer
and Valium is pretty typical for this.
They can also be used to stop a seizure.
You may get Valium or Ativan prior to a procedure
such as a colonoscopy.
The most common benzodiazepines are
Ativan, Klonopin, Xanax and Valium.
Benzodiazepines are habit-forming
and it's easy to become addicted to them and here's why.
Benzos cause a tolerance effect
and this means that if you take them regularly
like daily or several times a week,
over time the effect can wear off
and you'll need to take more to get the same effect.
So now, instead of say taking a half of a pill
and having that work now you notice
that you need to take two pills to get the same effect.
And this is a medication tolerance effect
it can happen to anyone
and it's not the same as an addiction.
If this happens to you,
it doesn't mean that you've been misusing the medication
or have an addiction.
Addiction involves developing
a psychological dependence on it where you need to take it.
Now you may say how's that different
from taking it for anxiety
after all, anxiety is psychological?
Let me illustrate this.
Phil has anxiety and sees his primary care doctor
because he's not sleeping well.
He has a lot going on at work
and can't afford to go without sleep.
He tells his doctor that he can't
get his brain to shut down at night
and he's been having some panic attacks at work.
His doctor gives him Xanax and tells him
to take it as needed.
Phil takes it and he notices
that he falls asleep as soon as his head hits the pillow.
Then, he takes it at work
and he doesn't feel anxiety for several hours.
It doesn't make him sleepy
and he's able to get a lot more work done
because now he can calmly focus.
It's like magic.
The directions on the bottle say
to take up to four times a day as needed.
Now it says this because Xanax
is a very short acting benzodiazepine.
It works quickly and it doesn't hang around very long.
But a huge downside to it
is that when it wears off
you can get rebound anxiety.
And this is anxiety that can feel worse
than the anxiety that you started with.
So what happens?
You take more to make that feeling go away.
So this is eventually what happens to Phil.
He takes it at work but he and his wife
aren't getting along very well.
So when he gets home and she starts criticizing him,
he takes another Xanax to deal with her.
So he ends up taking the medicine four times a day
and a month later he tells his doctor
that things are much better for him
but he needs a refill on the Xanax.
His doctor says okay
but he tells him that now the Fluoxetine
that he also prescribes should be doing its job
so he shouldn't need to take the Xanax as often.
But Phil has a really tough month at work
and took a little more Xanax to help him through that.
When he asked for another refill
his doctor said that you need to see a psychiatrist.
He comes to me and I give him my
this is why I hate Xanax speech
and switch him from Xanax to Klonopin
with the intention to wean him off of the daily use.
Klonopin, like all of the benzos,
is habit-forming especially when you get to where
you're taking it everyday.
But Klonopin, and the generic name is Clonazepam,
is a longer acting medication
and longer acting medications have a smoother transition
off when it wears off and you get less rebound anxiety.
Now, Phil has two things going on here.
He's got the physical dependence
because he needs to take the Xanax around the clock
to control his anxiety.
But he also has a psychological dependence
and this is how it looks for him.
Since Klonopin is a longer acting medication,
it's prescribed a maximum of two to three times a day.
Less than the Xanax frequency of four times a day.
Many people can get by with it just once a day.
So, I instruct him to take it twice a day,
three only if he feels he has to.
Phil comes back early for his next appointment
because he ran out of Klonopin.
He admitted that it was his year end at work
and he had a lot more anxiety
so he would take the Klonopin every two to three hours.
Sometimes he'd only take half of the pill
because he noticed that it did seem to work
or to be a little stronger than the Xanax.
Now Klonopin lasts much longer than two hours.
He shouldn't need to take it that frequently.
But the problem was that Phil wasn't taking the pill
because he needed it for his unmanageable anxiety,
he was relying on the pill
to deal with any kind of emotional distress.
So when something bad would happen,
his reaction would be to take a pill
and that's where he shifted from taking the benzo
to treat anxiety to using it
to take away any negative experience.
So what happened to Phil?
He said he just wanted to get through
this busy period at work
and then he would stop taking the Klonopin.
And he promised though that he would
not take it multiple times a day.
After things slowed down at work,
he and his wife went on a long weekend trip
but Phil forgot to pack his Klonopin.
But he figured since he was planning to stop it anyway,
then this would be the time on his vacation.
On day two of the trip,
he woke up in a panic and spent the entire day
feeling as though his whole body was shaking.
He'd tried to tough it out
thinking that maybe he was just reacting to something
that he drank the night before.
On the third day, his wife found him
on the floor unconscious and jerking.
She called 911 and he was treated
at the hospital for benzodiazepine withdrawal.
Now this is an extreme example
just to illustrate what can happen.
Most medication withdrawals like what you can get
from the antidepressants are uncomfortable
but they're not dangerous.
I did a video of brain shocks and antidepressants
that you'll see in the corner
and I'll link to it in the description.
Benzodiazepine withdrawal can be dangerous
in that in extreme cases it can cause a seizure
and this tends to be in people
who have taken it longer than three months
and take high doses.
Which what's a high dose?
It'd be a step or two higher than the starting dose.
There's lots of withdrawal symptoms
that you can get but it usually looks like
increased anxiety, tremors,
poor sleep, irritability or sweating.
You can also get elevated blood pressure and heart rate.
So is it ever okay to take benzodiazepines daily?
The proper treatment for daily anxiety is an antidepressant.
We also use medications like Propranolol and Buspirone.
These medications are not habit-forming and,
except for Propranolol,
they don't work immediately.
The onboarding process can take a month
to six weeks before you can feel some relief.
So to help you feel better sooner than that,
it's a common practice to also prescribe
a benzodiazepine as needed for anxiety
on a short-term basis.
Short-term is generally considered three months or less.
So, this is what I'll tell someone in a similar situation.
I'll say this medication is to help your anxiety
until the antidepressant kicks in.
I would rather you not take it everyday
but if you need to, it's okay for now.
We'll keep our eye on it and I'll help you wean off of it
starting around three months.
Now things are a little different
if you don't take it everyday.
There are people who get a bottle of 30 pills
that last them six months or more
because they only take it when they fly
and they fly four or five times a year.
Or they take it on average of once every couple of weeks.
And that would be irregular use.
I consider regular but infrequent use as weekly.
I think twice a week is on the cusp of becoming frequent.
And in my experience,
once a person starts taking it three times a week,
three becomes four and four becomes daily.
Daily long-term use is associated with cognitive changes
like not being as mentally sharp.
It can also create balance problems in some people
where you just aren't quite solid on your feet.
And this can be a big problem with elderly people
by increasing their risk of falls.
If you've been taking the medication
for more than three months and you're taking it daily,
you definitely need to have your doctor
taper you off slowly when you
get to the point of discontinuing it.
You don't want to just stop taking it suddenly.
This is the kind of medication that you have to keep up with
and not let it run out because you're leaving town
and you notice that you only have two pills left.
If you travel a lot or you just have a very busy life,
these mediations can create a tether to your pharmacy
which can feel very confining.
The longer you've been taking it daily,
the slower your taper should be.
And there's not a set protocol for this,
your doctor would use his or her clinical judgment
on a case-by-case basis.
But how long it takes also depends
on how high your dose is.
I've had people where it's taken a couple of years
to slowly wean off.
We just keep chipping away at the pill size over months.
It's like tricking your body into realizing
that it's getting less and less medication.
One of the ways I help patients avoid this problem
is I tell them to think of the medication
as a break the glass pill
that you take to keep from going to the hospital
because you feel like you're having a heart attack.
It should not be a take the edge off of a crappy day pill.
When you start to think of it that way
and take it that way,
it very easily becomes something
that goes from infrequent to daily.
And once you enter daily use
you become tethered to the medicine
and need to take it daily just to feel well.
Now I have to emphasize that everyone is different
and there are people who are able to take
one benzodiazepine a day for years
and never need to increase their dose.
My thought about that person is that it may be
that they no longer have the problem
that they originally took it for
whether that be sleep or anxiety.
But they think they still need it because
if they stop taking it,
they have terrible anxiety or don't sleep.
But probably what they're experiencing is withdrawal
and not a return of their original problem.
If you want to see more on medication withdrawal
from antidepressants, watch this video
that I have on antidepressant withdrawal and brain shocks.
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on mental health education.
See you next time.