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From: Philip Peters on 14 Jun 2008 08:58
anon schreef:
> This is not a scientific study of a controlled population sample--it is more
> anecdotal evidence from one physician who overprescribes benzos--


Gotcha! You only read the first text which is an interview (I *knew*
this was going to happen, it's not the first time). You effectively fell
into your own trap.




of which
> there are, alas, far too many. In fact, Big Pharma has so corrupted the
> psychiatric profession in this country that SSRIs get handed out like candy
> even though carefully vetted studies show that that most of them are no more
> effective than--or only marginally more effective than--placebos.



The jury is still out on this, there are conflicting studies out there.
I totally agree that SRRI's are vastly overprescribed, as I said
earlier, and often at the expense of those lovely benzo's (which
actually were overprescribed in the seventies as well which gave them
their bad reputation instead of the doctors who prescribed them at
random without even a proper dagnosis). Nowadays Big Pharma has been
hyping up SSRI's just like benzos were hyped up thirty years ago so what
else is new? When properly prescribed after a serious diagnosis has been
established there is a place for both benzos and SSRI's etc. in the
treatment of Panic Disorder. As important, if not more, is to find a
good CBT or REBT-therapist; the results of CBT etc. are at least as good
if not better than those of medication and often it makes sense to
combine them, at least for a period of time.

>
> The documentation of the powerfully addictive properties of benzos is vast,
> along with an equally vast literature demonstrating the potentially
> life-damaging side effects that can come with long-term use, including
> short-term memory loss, cognitive deficits, depression, and horrific rebound
> anxiety and rebound insomnia during attempted withdrawal.


See the literature I posted and you refused to read.
>
> For a survey of the vast scientific literature on the horrors of benzo
> addiction withdrawal, see the references at the end of the following:
>
> http://en.wikipedia.org/wiki/Benzodiazepine_withdrawal


> All of those listings constitute SCIENTIFIC LITERATURE, not the comforting
> anecdotal bedtime stories proferred by this self-serving, ethically
> irresponsible megalomaniac, who universalizes from his microscopic corner of
> the universe.


Do you really think Wikipedia is *scientific*? It's totally unreliable
information brought together by whoever feels like it. In this case
Wikipedia's stance on benzos reflects the UK *Anti Benzo Squad*'s. It's
worth less than nothing.
I universalized nothing from my own personal experience, on the contrary
I presented a lot of *scientific* literature and opinions by leading
psychiatrists which you decided not to read. Maybe you could try again.

Oh, I was out of this thread.
Had to come back one more time to make it clear that I sent dozens of
peer reviewed studies accompaniet by a lot of anecdotal information and
the only thing you did is read the first entry.
Or you chose to ignore the rest because it doesn't help your agenda.

Philip (don't know why I joined this thread after years of bickering
with the anti benzo boys, but hey, I'm out of it -again ;-)


>
> "Philip Peters" <philip(a)p-peters.demon.nl> wrote in message
> news:4852fcbe$0$14344$e4fe514c(a)news.xs4all.nl...
>> anon schreef:
>>> "Some" this, "some" that--all without any documentation
>>> but with a lot of
>>> ad hominem sneering and name calling (the Anti-Benzo Squad), as though
>>> that compensates for documentation and rational argument. This poster's
>>> message consists entirely of personal testimony and anecdotal
>>> evidence--it's pure garbage. I've already posted the relevant scientific
>>> documentation from a variety of sources, none of which this snide smear
>>> artist has bothered to try to refute.
>>
>> See below.
>>
>>
>> The point is--proceed
>>> with caution, and try to use them only on a spot or short-term basis
>>> unless a trusted doctor absolutely feels you must rely on them for a
>>> longer period.
>>
>> Now here we agree. Never self-medicate, always have meds prescribed by a
>> trusted doctor.
>> And with this little bouquet of quotations below I gracefully bow out of
>> this thread on to greener pastures and let everyone judge the matter for
>> themselves. Enjoy!
>>
>> Philip
>>
>> ---------------------------------------------------------
>>
>>
>> A Conversation With a Colleague
>>
>> from Medscape General Medicine
>> http://www.medscape.com/viewarticle/457797?src=search
>>
>> Thomas A. M. Kramer, MD
>>
>>
>> The following is dialogue with a colleague who is a child psychiatrist
>> and who has recently expanded her practice to treat more adults.
>>
>> Dr K: When do you actually use benzodiazepines to treat anxiety? I
>> mean, how many other drugs will the patient actually have to fail
>> before you would prescribe them?
>>
>> Dr. F: Well, sometimes none. A lot of the time, I would use them right
>> away. First-line.
>>
>> Dr K: Really?
>>
>> Dr. F: Sure. It wasn't that long ago that benzos were used routinely
>> as first-line treatment for generalized anxiety. It's only fairly
>> recently that they've been supplanted by SSRIs and SNRIs.
>>
>> Dr K: And aren't those drugs better? Don't benzos tend to make
>> patients sleepy, stupid, and addicted? I mean, not using benzos as
>> first-line treatment is a step forward, right?
>>
>> Dr F: Certainly, SSRIs and SNRIs are important treatment options. But
>> benzos have their virtues, too. They work right away; antidepressants
>> in general take a few weeks to work. When dosed appropriately, they
>> don't make people sleepy or stupid. As far as addiction goes, that's
>> pretty controversial, but my feeling is that the risk of addiction for
>> benzos is grossly overstated. Certainly, in a vulnerable population,
>> like people with substance abuse history or strong family histories of
>> substance abuse, tolerance and dependence can be a problem. But that
>> is a very small percentage of patients who present for treatment for
>> anxiety. I've seen a lot of patients who have taken 10 mg a day of
>> Valium for years with good result. They don't escalate the dose, and
>> if they try to come off it or miss a few doses, all that happens is
>> that they get anxious again. Benzos don't really have very many side
>> effects besides the ones you mentioned, and since antidepressants have
>> side effects of their own, there are some patients who can tolerate
>> benzos who cannot tolerate antidepressants.
>>
>> Dr K: So why don't we use them any more?
>>
>> Dr F: I do. But the sense I get, in what little adult work I do, is
>> that they have really fallen out of favor.
>>
>> Dr K: You're right, but I don't think that's for good reason. I think
>> that's basically a function of marketing.
>>
>> Dr F: You mean, drug companies are trying to get us to write for their
>> SSRIs and SNRIs for anxiety as opposed to benzos?
>>
>> Dr K: Exactly. The other side of that coin is that nobody is marketing
>> benzos at the moment. That may change soon with the launch and
>> subsequent marketing of rapidly dissolving Klonopin and Xanax XR, but
>> for the time being, all of the marketing efforts of the pharmas for
>> anxiety treatments are focused on antidepressants.
>>
>> Dr F: So you are saying that we all are really controlled by the
>> pharmaceutical industry? That their marketing efforts really do
>> control our behavior?
>>
>> Dr K: Well, no. I do think that at least some of us are capable of
>> independent thought. The problem, I think, has more to do with sources
>> of information. So much research and educational programming is funded
>> by pharmas that they have an enormous amount of influence over what is
>> defined as the state of the art. While they may not have direct
>> control over the results of published research, or the content of
>> educational programs at meetings, or the information that is sent to
>> us in the mail, they have enough influence to determine a lot of what
>> it is you are going to see when you go to "read the literature." You
>> end up thinking that the treatments for which they choose to fund
>> research and programs are indeed the state of the art. After all, you
>> read all of these advantages of these new treatments. No one's putting
>> material in front of you telling you about the advantages of the older
>> treatments.
>>
>> Dr F: And no one is funding head-to-head studies between the new and
>> the old treatments, either.
>>
>> Dr K: Exactly. Why should they? The only people who fund clinical
>> trials these days are pharmas -- although that has changed a little
>> bit with some new NIMH studies that are actually comparing different
>> treatments without any pharma funding -- and pharmas are certainly not
>> going to fund such a study because it may not look so good for them.
>> Look, I have nothing against marketing. I think that the pharma
>> industry, like any other industry, is entitled to promote its
>> products. I am also sympathetic to the fact that is not easy for them
>> to do this. It is hard to get the attention of busy physicians. My
>> concern is that some things are marketing that aren't labeled as such.
>> I am tired of hearing the words "unrestricted educational grant."
>> There ain't no such animal. Simply deciding what it is you're going to
>> fund with such an unrestricted educational grant gives you a fair
>> amount of discretion as to what clinicians will hear about and know.
>> And as far as research is concerned, it seems to me that the results
>> of studies sponsored by pharmas seem to almost always be good news for
>> the company actually doing the sponsoring. I'm not saying that they
>> manipulate the data, but I am saying that they have a fair amount of
>> control over what data you see and what data never sees the light of
>> day.
>>
>> Dr F: I can see a little bit of this happening now with ADHD
>> treatments. While stimulants can have bad side effects, particularly
>> weight loss and insomnia, they do work for most kids, and as we start
>> to get alternatives to stimulant medications for ADHD, some materials
>> and programs I've seen are starting to imply that stimulants may
>> become obsolete. Immediate-release stimulants are a very good example
>> of what you're talking about. They're treated in current discussion as
>> if they're obsolete, but they can have a great deal of clinical
>> utility, particularly as augmenting medications.
>>
>> Dr K: I think the best example of this phenomenon is lithium. Lithium
>> is a fabulous drug. Unfortunately, nobody is marketing it presently,
>> and there's a lot of aggressive marketing of other medications for
>> bipolar disorder. As a result, I think a lot of clinicians are
>> becoming convinced that lithium is an inferior drug. There have even
>> been a few papers written by old-timer psychopharmacologists defending
>> lithium as a treatment of choice, particularly for classic, nonrapid
>> cycling bipolar I disorder. I have even seen things written saying
>> that lithium has become less effective over time. That's crazy.
>> Lithium may have been used less than successfully for bipolar subtypes
>> for which it is less effective, such as rapid cycling or mixed
>> dysphoric states, but for classic mania it really works, and these
>> days clinicians really need to be reminded of that fact. This kind of
>> marketing has almost relegated a useful medication to the status of
>> historical artifact.
>>
>> Dr F: Interesting.
>>
>> Dr K: Yeah, and you know what else? I think we just wrote my next
>> column.
>>
>>
>>
>> Thomas A. M. Kramer, MD, Associate Professor of Psychiatry, University
>> of Chicago, Chicago, Illinois
>>
>>
>>
>> Medscape General Medicine 5(3), 2003. � 2003 Medscape
>>
>>
>>
>> A study by Charles Medwar a member of the WHO's Advisory Panel on Drug
>> Policies and management suggests that benzodiazepine withdrawal is less
>> severe than that from some SSRIs.
>>
>> In particular Dr Medwar review of UK safety data shows that from 1963
>> to 1997, just over 230 million prescription for temazepam and diazepam
>> generated only 25 notifications of withdrawal reactions. In the 10
>> years to 1997, 5 million paroxetine (Paxil) prescription resulted in
>> 802 notifications. In the 10 years that SSRIs have been available in
>> Britain, 17,845 there have been official notifications of adverse
>> effects from GPs.
>>
>> (Source: The International Journal of Risk and Safety in Medicine, vol
>> 10, pge75.)
>>
>>
>>
>> >From Psychiatric Annals 25:3.March 1995 RE: Benzodiazepine Use:
>> David G.Benzer, DO; David E. Smith, MD; Norman S. Miller, MD
>>
>> Pharmacological dependence is not the same as addiction and is not a
>> reason for discontinuing therapy; it is an adaptation of the central
>> nervous system to the persistent presence of the sedative drug. It is
>> critical to slowly taper benzodiazepines in patients who are dependent;...
>>
>> Addiction refers to a preoccupation with acquiring a drug and the
>> compulsive use of that drug despite the recurrence of adverse
>> consequences. The loss of control over the use of the drug is the hallmark
>> of addiction, an illness to which there seems to be a biologic
>> predisposition. There is evidence that addiction-prone individuals
>> subjectively perceive the effects of benzodiazepines differently. A study
>> of alprazolam (1 mg "Xanax") in alcoholic and nonalcoholic men produced
>> positive mood changes in alcoholics *not* reported by the nonalcoholics.
>>
>> Patients who are dependent on benzodiazepines merely need to be safely
>> tapered off the drug when the course of therapy has ended. Addicts require
>> the same careful discontinuation as well as treatment addressing their
>> underlying addiction.
>>
>> ~~~~~~~~~~~~~~~~~
>>
>> >From Psychiatric Annals 25:3.March 1995 RE: Benzodiazepine Use:
>> David G.Benzer, DO; David E. Smith, MD; Norman S. Miller, MD
>>
>> Dependence often accompanies the use of benzodiazepines for panic
>> disorder. For example, alprazolam used at doses of 2mg or greater for more
>> than 6 weeks must be assumed to create dependence. This is not necessarily
>> a problem; it is neither a reason to not use benzodiazepines in these
>> conditions nor is it a justification for discontinuing the medication
>> prematurely. The patient and physician must mutually be aware to never
>> abruptly discontinue the benzodiazepines. Gradual tapering is the method
>> that will safely and efficaciously allow the patient to discontinue
>> benzodiazepine therapy when appropriate.
>>
>> ~~~~~~~~~~~~~~~~~
>>
>> Title: Addiction to benzodiazepines--how common?
>> Title Abreviation: Arch Fam Med Date of Pub: 1995 Nov
>> Author: Piper A Jr; Issue/Part/Supplement: 11 Volume Issue: 4
>> Pagination: 964-70 Journal Title Code: BX6 Publication Type: JOURNAL
>> ARTICLE
>> Date of Entry: 951228N Entry Month: 9602 Country: UNITED STATES
>> Index Priority: 1 Language: Eng Unique Identifier:96074207 ISSN:1063-3987
>>
>> Abstract: Benzodiazepines have compiled an impressive record of safety and
>> efficacy. Despite this record, however, physicians and laypersons
>> frequently worry about the drugs' addictive potential. Overemphasizing
>> these concerns may discourage prescription of benzodiazepines, thereby
>> impeding treatment of anxiety disorders. This review first defines the
>> term addiction. It then examines how frequently conditions meeting that
>> definition occur in patients without histories of substance abuse, who are
>> prescribed benzodiazepines under medical supervision. In such patients,
>> benzodiazepines almost never induce
>> behavior that satisfies any reasonable definition of addiction.
>> Abstract By: Author
>> Number of References: 111
>>
>>
>>
>> >From the APP Textbook of Psychopharmacology (Schatzberg & Nemeroff,
>> eds.), p.
>> 224 (chapter on benzodiazepines):
>>
>> "The controversy surrounding BZ administration and potential abuse or
>> addiction
>> in routine patient use is generally not supported by the available
>> scientific
>> evidence. (See Shader and Greenblatt 1993 for an excellent review of this
>> complex area.) In a large community study of long-term alprazolam users,
>> Romach and colleagues (1992) found that dosage did not escalate over
>> prolonged
>> use and that most patients used the BZs as prescribed. In fact, if
>> deviations
>> occurred, it was generally that a patient took less than the prescribed
>> dosage."
>>
>> and p. 710 (in the chapter on substance abuse):
>>
>> "Most patients who are in fact physiologically dependent on
>> benzodiazepines do
>> not increase the dose of medication above the physician's prescription or
>> in
>> any other way abuse the prescribed medication. However, if the
>> benzodiazepine
>> were to be abruptly discontinued, the patient would, in all probability,
>> go
>> through a withdrawal abstinence syndrome that could be extremely severe.
>> ...
>> The fact that patients become physiologically dependent on therapeutic
>> doses of
>> benzodiazepines has led some in the field to equate any use of
>> benzodiazepines,
>> in any patient for long-term treatment, with abuse of the drug. This is
>> undoubtedly an overstatement of the abuse of these agents. Significant
>> abuse
>> of benzodiazepines does in fact occur, but it is usually seen in patients
>> also
>> abusing other drugs, _not_ in the patient kept carefully monitored and
>> kept
>> stable on therapeutically indicated benzodiazepines."
>>
>>
>> Written by a psychiatris who is also an associate Professor at University
>> of Ky. The article was written on how to DC the Benzo Xanax, but in the
>> text of this paper it explains how this drug works and why it is often the
>> first choice for pure panic anxiety. Hope it helps you start to understand
>> what is happening and how to deal with your problems of this disorder. I
>> have lived with all the symptoms of PNE without medication for years. Thus
>> I have been through both methods of dealing with this problem. What I have
>> learned in all the years of PNE is stopping the symptoms will start you
>> into recovery sooner.
>> lori
>> For the layperson ---
>> Dr. Steve's Guidelines for Discontinuing Xanax (alprazolam)
>> Stephen Cox MD, Asst Clinical Professor of Psychiatry, UKMC
>> This article is written in lay terminology and with analogies to make
>> complicated medical science
>> understandable.
>> You've no doubt heard negative things about Xanax. We have all read
>> stories of some negative aspect of the use of Xanax. These stories are
>> surprising. I, personally, have seldom experienced difficulty in tapering
>> Xanax in patients with panic disorder. This may be a surprise to those who
>> are not experienced in prescribing psychoactive medicants for anxiety
>> disorders.
>> The fact is that Xanax works very well indeed in treating panic disorder.
>> Tolerance develops to the initial dose. Dose increases are necessary in
>> the first weeks of therapy. Why the tolerance? This is a very good
>> question and should be answered before you start taking Xanax. You can't
>> possibly know how to go off Xanax unless you understand what happens to
>> your body as you are going on it.
>> There is a neurotransmitter in your brain called GABA. It stands for gamma
>> amino butyric acid. GABA is your natural God-given tranquilizer. It is
>> present at 80% of the nerve connections in your brain. When you are too
>> nervous your brain cells release GABA which causes negatively charged
>> chlorine atoms to stream into your nerve cells. That's good because it
>> makes it harder for other stimulating neurotransmitters to trigger the
>> firing of that nerve. If your brain were a car, anxiety might be like the
>> car speeding down a hill toward a sharp curve. As it comes to a curve it
>> must slow down. The car brakes are applied so that the car can negotiate
>> the curve and not burst through the guard rail. The GABA molecules of your
>> brain are like the brakes in your car. If you don't have enough GABA, your
>> brain is going to be like the car speeding toward a curve with worn out
>> brakes! Xanax acts by making what little GABA you do have work more
>> strongly. This is sort of like applying stronger pressure on worn out
>> brakes so that your car will negotiate a curve safely.
>> When you take Xanax for a couple of weeks it usually works great for panic
>> disorder but then it does not seem to work as well as time goes on. This
>> is to be expected. Why? This could be for two reasons. One possibility is
>> that your brain cuts back on the release of GABA. It is sort of like your
>> brain says, "Gosh, things are a lot calmer in here. I don't think I need
>> to make as much GABA as I used to." Well, you likely didn't have enough
>> GABA to begin with. And now your brain makes even less than it did before
>> you started taking Xanax. Naturally, the Xanax wouldn't work as well once
>> GABA is reduced.
>> A second reason for tolerance may be down in your liver. Your liver gets
>> rid of Xanax ultimately by making enzymes which destroy Xanax. After you
>> are on Xanax for awhile it is as if your liver says, "Hey we sure are
>> getting a lot of Xanax these days. Let's make more Xanax-destoying
>> enzymes." And so it does. Let's say your dose that you started out on was
>> giving you a blood level of, say, 100 units. But after your liver makes
>> more of this destroying enzyme you have a level of, say, 55 units of
>> Xanax. No wonder you feel like the Xanax isn't working as well. It isn't!
>> Even though you're taking the same dose, your blood level dropped.
>> Remember, it does not really make any difference how many milligrams you
>> swallow. What really matters is how much is
>> running around in your bloodstream.
>> So, tolerance normally develops to Xanax and it may be due to either or
>> both of the above reasons. If you didn't understand those two things, go
>> back and read it again because what follows won't make much sense unless
>> you understand those two ideas.
>> Now, let's say we have a 26 year old woman, Monica, who has been on 6 mg
>> of Xanax for panic disorder for 3 years. She's doing great. She can drive
>> anywhere she wants and no panic attacks have occurred for 2 years. She
>> even flew from Cincinnati to Cancun Mexico without a problem. She asked
>> her psychiatrist if it would OK if she went off the Xanax now to see if
>> she still needed it. The psychiatrist said yes, 'but you must not do it
>> faster than I order'. The patient was relieved to hear her psychiatrist
>> was urging a gradual decline. You see, the patient's roommate, Suzy, had
>> taken herself off Xanax from 6 mg per day to 3mg a day suddenly. And after
>> only a week she stopped it completely. She thought she would die, she felt
>> so bad; and, she blamed it on 'the
>> addictive nature of Xanax'. Fortunately, Monica was told by her
>> psychiatrist to cut her daily dose from 6.0 mg per day to 5.75 mg per day
>> and to stay on that dose for two weeks. Then she was told to cut to 5.5 mg
>> a day for another 2 weeks, and so on by 0.25 mg off her daily dose every 2
>> weeks. Monica's psychaitrist explained that there was no way to tell if
>> she still had panic disorder or not and by going down that slowly, if
>> Monica should experience any anxiety symptoms, it would be due to the
>> reappearance of panic disorder symptoms that were inadequately treated by
>> her lower dose of medicine. This would mean that Monica still was
>> afflicted with panic disorder and needed continued treatment, at least for
>> the time being. If, on the other hand, she gradually
>> tapered the Xanax down to zero and had no panic attacks, she would
>> officially be either well or in remission.
>> So, if you want to go off Xanax, ask your doctor how to do it. If there is
>> a rush, it can be done faster than the above method. But usually there is
>> no rush. And it is usually best to go slowly.
>> Now, let's review. Why didn't our patient Monica have any withdrawal when
>> she tapered off Xanax, whereas her roommate, Suzy had severe withdrawal?
>> The answer is that both women had a very, very low level of GABA
>> production and a very high level of liver Xanax-destroying enzymes. When
>> Suzy cut herself off over a week's time, she thought she was tapering off
>> but it was actually much too fast. It takes a long time for the brain to
>> figure out that it needs to make more GABA and to do so. It also takes a
>> long time for the liver to quit making so much Xanax-destroying enzymes.
>> Monica's psychiatrist wisely told her to make these tiny cuts in the
>> Xanax dose that were barely perceptible to her as far as the way she felt.
>> And equally wisely she had her go 2 weeks on that dose to let her brain
>> GABA increase and liver enzymes decrease before cutting the dose further.
>> Dr. David Sheehan of the University of South Florida suggested this method
>> to me at a meeting in Tampa years ago. I cannot recall any of my patients
>> experiencing any bothersome withdrawal discomfort in going off Xanax by
>> the above method. Any difficulties I witnessed were relapses of a
>> clinically silent panic disorder that was previously adequately treated by
>> the Xanax at the pre-taper dose.
>> You should never, never, never decide to go off Xanax on your own without
>> your physician's counsel and guidance. Xanax is a remarkably safe medicine
>> except for two things: overdosing on it can be extremely hazardous to
>> driving safety. Sudden or rapid stopping Xanax at daily doses of 4 mg or
>> more can cause moderate to severe withdrawal and, in very rare instances,
>> a convulsion could occur.
>> You should carefully weigh the decision to go off Xanax with medical
>> counsel. Is this a good time to go off it? Is this a stressful time? If
>> so, you should wait until a calmer time. Are you being pressured into
>> going off Xanax prematurely by well-meaning, but uninformed family or
>> friends who value more your 'being off medicine' than they do the relief
>> of your suffering with panic attacks and avoidance behavior. Panic
>> disorder is not a trivial thing. It, untreated, is associated with the
>> highest suicide attempt rate of all medical disorders. It, untreated, also
>> has a higher mortality risk from cardiovascular cause than non-panic
>> disorder persons. The general principles we have discussed with Xanax also
>> holds true for other high potency benzodiazepines like
>> lorazepam (Ativan�) and clonazepam (Klonopin�). The dosages however are
>> all different and the mg reductions do not apply to these other medicants.
>> Despite popular beleif, it is my opinion that Xanax is under-utilized by
>> clinicians in their patients. Such medicines are remarkably safe. Panic
>> disorder patients seem rarely to abuse such medicine. Compliance problems
>> (patients not following doctors orders) with panic disorder patients on
>> Xanax are rare; and, when seen are most often a matter of the patient not
>> taking as much medicine as is prescribed rather than taking too much.
>> Dr. Stephen Cox
>> http://lexington-on-line.com/naf_xanax.html
>>
>>
>> To quote Dr Roy Baker, a board member of the American Society of
>> Addiction Medicine [2]:
>>
>> :: All drugs with the potential to cause addictions share certain common
>> :: neurobiological characteristics: they activate the mesolimbic system,
>> :: principally the nucleus accumbens, causing increased dopaminergic
>> :: activity in that area of the brain. This results in an increase in
>> hedonic
>> :: tone.
>> and
>> :: "It is important not to confuse physical dependence as evidenced by
>> :: benzodiazepine withdrawal syndromes with addiction or drug dependence
>> :: (DSM-IV). "
>>
>> Benzodiazepine not only don't excite the N accumbens but have been
>> shown to inhibit cocaine's affect on dopamine receptors in the N
>> accumbens. [3] They should have the same positive effect on other
>> recreational drugs, for the same physiological reason. Certainly,
>> there is much evidence that benzos do reduce the withdrawal effects of
>> most recreational drugs. Consequently, benzodiazepines are being
>> increasingly used to mediate drug withdrawal in detox centers. [4]
>>
>> Another common test used to determine whether a drug is addictive is
>> to apply the "3 C" test to its users. The term was coined by Dr David
>> Smith of the Haight Ashbury Free Clinic and San Francisco Medical
>> Center and is widely used by addiction specialists. To meet the
>> addiction criterion, the patient must exhibit all three of the
>> following:
>>
>> 1: Control: when the addicted person starts using their drug they
>> episodically lose control over their ingestion.
>> This is something that rarely happens to benzodiazepine users. To
>> quote Prof Heather Ashton:
>> :: "Given the number of people who are prescribed benzodiazepines,
>> :: relatively few patients increase their dosage...."
>> http://www.a1b2c3.com/drugs/benz02.htm
>>
>> The American Psychiatrists Association made the same point in their
>> "Benzodiazepine Dependence, Toxicity, and Abuse: A Task Force
>> Report" To quote:
>> :: "There are no data to suggest that long-term therapeutic use of
>> :: benzodiazepines by patients commonly leads to dose escalation or to
>> :: recreational abuse"
>>
>> This is re-enforced by the recommendations in their current Panic
>> Disorder III. Treatment Principles And Alternatives web page:
>> :: "However, benzodiazepines may still be underused because of an
>> :: inappropriate fear of addiction. The studies of long-term alprazolam
>> :: treatment for panic disorder show that the doses patients use at 32
>> :: weeks of treatment are similar to those used at 8 weeks, indicating
>> :: that, as a group, patients with panic disorder do not escalate
>> :: alprazolam doses or display tolerance to alprazolam's therapeutic
>> :: effects, at least in the first 8 months of treatment. However,
>> :: studies of dose escalation following longer periods of
>> :: benzodiazepine use are generally lacking."
>> http://www.psych.org/clin_res/pg_panic_3.cfm
>>
>>
>>
>> Therefore, on all the criteria used to define addiction,
>> benzodiazepines are not addictive drugs.
>> However, they can and very often do cause dependency. Dependence is
>> produced by the presence of a drug causing changes in body systems
>> that then need to time to return to their pre drug state if the drug
>> is withdrawn. A drug doesn't have to be active in the brain for
>> dependency to develop - many cannot pass the blood-brain-barrier, but
>> they must for true addiction to develop.
>>
>> Benzodiazepines do over time produce a small bio-feedback reduction in
>> both benzodiazepine receptors and possibly expression of the
>> neurotransmitter GABA.
>>
>> If the benzodiazepine is discontinued abruptly, this reduction in
>> receptors and neurotransmitter can cause a rebound reaction with
>> symptoms similar to anxiety and panic. In most cases with a slow
>> taper, withdrawal symptoms can be minimized to a comfortable level.
>>
>> Moreover, not all withdrawal symptoms may be due to these
>> physiological changes. Some, perhaps most, can be produced by
>> psychology, that is the mind. It is well known that benzo withdrawal
>> effects can often be induced simply by making patients believe their
>> benzodiazepine dose has been reduced, even though no reduction
>> actually occurs. This has been shown in a number of studies. [6]
>>
>> There is also evidence [7] that withdrawal is more intense in some
>> patient groups, notably those who have neurotic personalities,
>> females, former/current alcoholics, the less educated, and those with
>> dependant personalities. It also appears that the worse the original
>> anxiety disorder, the more severe the withdrawal.
>>
>> Probably the best indication that many of the withdrawal problems
>> experienced by those who were taking benzodiazepines for anxiety
>> disorders are mostly psychological rather than chemical is the fact
>> that the other main benzo using patient cohort, epileptics, seem to
>> have much fewer problems. Indeed, there are very few reports in the
>> medical literature of epileptics having difficult withdrawals and I've
>> been unable to find even one case of "Protracted Withdrawal Syndrome."
>> Yet typical anti seizure benzo doses are much higher than those
>> usually needed to control anxiety, 10mg Klonopin being about average,
>> but 20mg/day or higher is not unusual.
>>
>> It should also be noted that many medications and supplements can
>> produce dependency, even some over the counter ones like vitamin C.
>> This may produce rebound scurvy if stopped suddenly after long term
>> use at high doses (1,000mg+/day). Symptoms may include bleeding gums
>> and nails. Extreme reactions may cause both tooth and hair loss.
>>
>> Other commonly used drugs that can induce dependence include:
>> antibiotics, most heart medications (beta-blockers, ACE inhibitors
>> etc), some cholesterol lowering drugs, antidepressants, most
>> painkillers - including OTC, some cancer drugs, valerian, and St
>> John's Wort.
>>
>>
>>> Addiction vs. Dependency:
>>> Benzodiazepines & Anxiety Disorders
>>>
>>>
>>> RESEARCH
>>> "In patients without histories of substance abuse, who are prescribed
>>> benzodiazepines under medical supervision . . . benzodiazepines almost
>>> never induce behavior that satisfies any reasonable definition of
>>> addiction" (Piper, Jr., A. "Addiction to Benzodiazepines -- How
>>> Common?" Archives of Family Medicine 4.11 (1995): 964-970).
>>>
>>> "Long-term users of alprazolam/lorazepam . . . used a constant or
>>> decreasing dose of medication . . . Persistant use of
>>> alprazolam/lorazepam for therapeutic purposes did not represent abuse
>>> or addiction as the terms are usually understood" (Romach, M., et.
>>> al. "Clinical Aspects of Chronic Use of Alprazolam and Lorazepam."
>>> American Journal of Psychiatry 152.8 (1995): 1161-1170).
>>>
>>> "The vast majority of the use of benzodiazepines is appropriate.
>>> Problems of nonmedical use arise nearly exclusively among people who
>>> abuse other drugs" (Woods, J.H. and G. Winger. "Current Benzodiazepine
>>> Issues." Psychopharmacology 118.2 (1995): 107-115).
>>>
>>> "With panic/agoraphobia patients there is no evidence of abuse. Chronic
>>> use is justified in these patients; risk must be weighed against
>>> benefit, dependence against relief . . . Potential abusers are those
>>> with personality disorders, dysphoria (mood disturbance) and current or
>>> previous substance abuse . . . there is no epidemic of misuse. Abuse
>>> seems to be limited to substance abusers . . . chronic use is justified
>>> in chronic anxiety patients. Chronic use does not usually lead to
>>> abuse" (American Psychiatric Association. Benzodiazepine Task Force on
>>> Use, Dependence, Toxicity and Abuse. May 1990).
>>>
>>>
>>> The Definitions
>>>
>>> The term addiction is often equated with abuse. Addiction is generally
>>> marked by tolerance and/or psychological dependence. With tolerance, a
>>> person needs to increase the dosage of a medication over time in order
>>> to receive the same therapeutic benefits. Studies show that the
>>> majority of people with anxiety disorders do not increase their
>>> benzodiazepine dosages over time; in fact, most lower their dosages.
>>>
>>> When we think of addiction we are often thinking of psychological
>>> dependence. With psychological dependence, a person continues to take a
>>> medication no matter what the consequences. The person will also seek
>>> out the medication no matter what the consequences. Again, as with
>>> tolerance, most studies show that people with anxiety disorders do not
>>> become psychologically dependent on benzodiazepines.
>>>
>>> The exceptions to the studies mentioned above are people who have a
>>> history of addiction to other drugs. People with such a history are
>>> possibly at risk for becoming addicted to benzodiazepines, too.
>>>
>>> A condition which does occur with long-term, regular use of
>>> benzodiazepines is physical dependence. After using benzodiazepines
>>> regularly for a few months (and the time varies for each individual), a
>>> person's body will usually adapt to the drug. If the medication is
>>> stopped abruptly, the person will experience withdrawal symptoms. These
>>> symptoms may be lessened (or even eliminated) by slowly tapering off
>>> the medication, if one chooses to stop taking it. Benzodiazepines
>>> should be discontinued only with the supervision of a qualified
>>> physician.
>>>
>>> People who are on medication for an illness for a long time are not
>>> addicted to the medication; they are medically dependent on it. They
>>> need to keep taking the medication in order to keep the symptoms of the
>>> illness away. The majority of anxiety disorders patients who take
>>> benzodiazepines over the long term fall into the category of medical
>>> dependence.
>>>
>>> The rest of the article is at
>>>
>>> http://panicdisorder.about.com/health/panicdisorder/library/weekly/aa031
>>> 997.htm
>>>
>>
>>
>> J Clin Psychiatry. 2005;66 Suppl 2:28-33.
>>
>> "Benzodiazepine use, abuse, and dependence"
>>
>> O'brien CP. Department of Psychiatry, University of Pennsylvania,
>> Philadelphia, PA 19104, USA. obrien(a)mail.trc.upenn.edu
>>
>>
>> Although *benzodiazepines are invaluable in the treatment of anxiety
>> disorders*, they have some potential for abuse and may cause dependence or
>> addiction.
>>
>> It is important to distinguish between addiction to and normal physical
>> dependence on benzodiazepines.
>>
>> Intentional abusers of benzodiazepines usually have other substance abuse
>> problems. Benzodiazepines are usually a secondary drug of abuse-used
>> mainly
>> to augment the high received from another drug or to offset the adverse
>> effects of other drugs.
>>
>> *Few cases of addiction arise from legitimate use of benzodiazepines*
>>
>> Pharmacologic dependence, a predictable and natural adaptation of a body
>> system long accustomed to the presence of a drug, may occur in patients
>> taking therapeutic doses of benzodiazepines. However, this dependence,
>> which
>> generally manifests itself in withdrawal symptoms upon the abrupt
>> discontinuation of the medication, may be controlled and ended through
>> dose
>> tapering, medication switching, and/or medication augmentation.
>>
>> Due to the *chronic nature of anxiety, long-term low-dose benzodiazepine
>> treatment may be necessary* for some patients; this continuation of
>> treatment should not be considered abuse or addiction.
>>
>>
>> PMID: 15762817 [PubMed - indexed for MEDLINE]
>>
>>
>>
>>
>> "The controversy surrounding benzodiazepine administration and potential
>> abuse or addiction in routine patient use is generally not supported by
>> the
>> available scientific evidence.
>>
>> In a large community study of long-term alprazolam users, Romach and
>> colleagues (1992) found that dosage did not escalate over prolonged use
>> and
>> that most patients used the benzodiazepines as prescribed. In fact, if
>> deviations occured, it was generally that a patient took less than the
>> prescribed dosage."
>>
>> from: "The American Psychiatric Press Textbook of Psychopharmacology" by
>> Schatzberg and Nemeroff, 2nd Edition (1998)
>>
>> ---------------------------------------------------------------------
>>
>> J Clin Psychopharmacol 1992 Oct;12(5):316-21
>>
>> Characteristics of long-term alprazolam users in the community.
>>
>> Romach MK, Somer GR, Sobell LC, Sobell MB, Kaplan HL, Sellers EM.
>>
>> Department of Psychiatry, University of Toronto, Ontario, Canada.
>>
>> The widespread use of benzodiazepines remains a source of concern to the
>> medical profession and the general public, especially as newer compounds
>> come on the market. Our goal was to characterize long-term alprazolam
>> users
>> in the community and to determine whether such use represented abuse or
>> behavioural dependence. We conducted three community surveys to learn
>> about
>> the natural history of long-term alprazolam use. Current long-term
>> alprazolam users (those using the drug for 3 months or longer) were
>> recruited on three separate occasions 1 year apart by identical newspaper
>> advertisements in the metropolitan Toronto area. All respondents were
>> mailed
>> a questionnaire with a stamped, addressed return envelope.
>>
>> Our data from 312 respondents show that:
>>
>> (1) the majority of patients have a substantial history of prior
>> medication
>> use for symptom control (65%),
>>
>> (2) dose escalation is not a characteristic of long-term use,
>>
>> (3) patients change their initial pattern of regular use to one of symptom
>> control only when required,
>>
>> (4) most physicians do not discuss discontinuation of the drug with their
>> patients,
>>
>> (5) patients frequently try to stop their drug use (with a median of 2
>> attempts) and often report symptoms upon discontinuation, and
>>
>> (6) patients perceive a need for medication use and indicate that
>> alprazolam
>> is effective (75%).
>>
>> We conclude that some patients persistently use alprazolam but that this
>> use
>> does not represent abuse or behavioral dependence.
>>
>> PMID: 1479048 [PubMed - indexed for MEDLINE]
>>
>> ----------------------------------------------------------------------------
>> ----
>>
>> Addiction.....Dependence........Withdrawal
>>
>> "Addiction and dependence are frequently confused. 'Addiction' is hard to
>> define, with little consensus on what it means, and in fact is not even
>> defined as a condition in the DSM-IV.
>>
>> 'Addiction' usually refers to a behavioral pattern of drug abuse
>> characterized by overwhelming involvement with use of a drug (compulsive
>> use) and with the securing of its supply and by a high tendency to relapse
>> after discontinuation.
>>
>> The term 'addiction' is frequently employed by those who are not experts
>> in
>> psychopharmacology when 'dependence' is what they mean.
>>
>> 'Dependence' is a physiological state of neuroadaptation produced by
>> repeated administration of a drug, necessitating continued administration
>> to
>> prevent the appearance of a 'withdrawal syndrome'.
>>
>> 'Dependence' is a term that is not frequently used outside of
>> psychopharmacology but in fact is a key feature of many antihypertensive
>> medications, hormones, and other treatments throughout medicine. Thus
>> several antihypertensives can produce 'rebound' hyptertension, worse than
>> the original blood pressure elevation, when suddenly discontinued. These
>> patients are not 'addicted' to the blood pressure medications although
>> they
>> are 'dependent' on them.
>>
>> 'Withdrawal' is the term for the adverse psychological and physiological
>> reactions to abrupt cessation of a dependence-producing drug."
>>
>>
>> from: Essential Psychopharmacology, 2nd Edition (2000), Stephen M. Stahl,
>> published by Cambridge University Press
>>
>> (Dr. Stahl is a PhD and MD, and is a Professor of Psychiatry at the
>> University of California, San Diego. He has conducted numerous research
>> projects awarded by the National Institute of Mental Health, the Veterans
>> Administration, and the pharmaceutical industry. Dr. Stahl is an
>> internationally recognized clinician, researcher, and teacher in
>> psychiatry
>> with subspecialty expertise in psychopharmacology.)
>>
>> --------------------------------------------------------------------------
>>
>> "Although it is wise to avoid prolonged hypnotic use, prolonged use of a
>> benzodiazepine hypnotic may be less harmful than is often said and may, in
>> fact, provide some benefit. The available evidence from sleep laboratories
>> suggests that hypnotics improve sleep measurably for only a few weeks,
>> though placebo-controlled studies have shown no diminution in the efficacy
>> of hypnotics for up to 24 weeks, and single-blind studies show efficacy up
>> to a year. So far, no studies have clearly established a treatment
>> duration
>> after which benzodiazepine hypnotics fail to work. Many confirmed users of
>> hypnotics swear that the hypnotics are always helpful and even vitally
>> necessarry for years."
>>
>> from "Manual of Clinical Psychopharmacology", Edition 2003, Schatzberg,
>> Cole, and DeBattista
>>
>> ----------------------------------------------------------------------------
>> --------------
>>
>> Quoted from "Panic Disorder: The Medical Point of View", by William
>> Kernodle, M.D.
>>
>> "Our society appears to have a phobia concerning benzodiazepines. I
>> believe this fear started many years ago when Valium was prescribed for
>> minor anxiety and patients were not made aware of the potential for
>> developing physical dependence. It is physical addiction that most
>> patients worry about with a benzodiazepine. I believe *addiction*
>> refers to a severe form of drug abuse in which the individual craves a
>> substance despite negative consequences and needs more and more for the
>> same effect. I do not think that patients with panic disorder crave the
>> benzodiazepines for their effect or frequently develop physical
>> tolerance (with the possible exception of substance abusers). It is
>> possible for patients to develop *physical dependence* on the
>> benzodiazepines when used at moderate to high doses over months or
>> years. However, this simply means that the benzodiazepine has to be
>> tapered slowly rather than stopped abruptly to avoid having a withdrawal
>> symptom" (p 115).
>>
>>
>>
>> Title: Maintenance drug therapy of panic disorder.
>> Title Abreviation: J Psychiatr Res Date of Pub: 1993
>> Author: Curtis GC; Massana J; Udina C; Ayuso JL; Cassano GB; Perugi G;
>> Issue/Part/Supplement: Volume Issue: 27 Suppl 1 Pagination: 127-42
>> Journal Title Code: JTJ Publication Type: CLINICAL TRIAL
>> Date of Entry: 940505N Entry Month: 9407 Country: ENGLAND Index Priority:
>> 2
>> Language: Eng Unique Identifier: 94194428 ISSN: 0022-3956
>>
>> Abstract: The efficacy of tricyclics and benzodiazepines in the short term
>> (approximately 2-4 months) treatment of panic disorder is well
>> demonstrated, but
>> efficacy over the longer term is not considered established. The present
>> study
>> provided systematic data from a double blind comparison of maintenance
>> therapy
>> (up to 8 months) of panic disorder with or without agoraphobia with
>> alprazolam,
>> imipramine, or placebo in 181 patients who had responded to the same
>> regimen in
>> a randomized 8-week treatment trial. All three groups had improved during
>> the
>> first 2 months (active treatments more than placebo and about equal to
>> each
>> other), and all maintained or extended their improvement over the next 6
>> months
>> without any significant change in dose. More than twice as many alprazolam
>> and
>> imipramine than placebo patients (15%) remained in treatment for the full
>> 8
>> months and did slightly better on symptom measures than the remaining
>> placebo
>> patients. Both medications were well tolerated during the maintenance
>> period.
>> The data suggest sustained efficacy and safety of imipramine and
>> alprazolam over
>> an extended period. More specifically, they suggest that tolerance does
>> not
>> develop to the therapeutic effects of either drug.
>> Abstract By: Author
>> Address: University of Michigan, Ann Arbor.
>>
>>
>>
>>
>> Some links:
>>
>>
>>
>> http://www.biopsychiatry.com/clonazepam.html
>>
>>
>> http://www.ncbi.nlm.nih.gov/pubmed/7298586?dopt=Abstract
>>
>> http://www.ncbi.nlm.nih.gov/pubmed/17881433?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
>>
>>
>> http://www.ncbi.nlm.nih.gov/pubmed/16103667?ordinalpos=17&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
>>
>>
>> http://www.ncbi.nlm.nih.gov/pubmed/15907150?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus
>>
>>
>>
>> Tolerance to the anxiolytic effects has been shown in
>> various animal studies [94,95], although not by all authors
>> [9,96], and when detected it appears to occur at a slower rate
>> than that of sedative tolerance [88]. Further, it has been
>> difficult to demonstrate tolerance to the anxiolytic [8] or antipanic
>> effects of benzodiazepines [97,98] in man. In fact, when
>> treated for generalised anxiety disorder patients develop
>> tolerance to the sedative effects without there being a reported
>> decrease in anxiolytic efficacy [8].
>> http://www.ingentaconnect.com/content/ben/cpd/2002/00000008/00000001/art00002
>>
>>
>>
>> Benzodiazepine derivatives--side effects and dangers.Lader MH, Petursson
>> H.
>> The benzodiazepines are generally safe and effective drugs with usually
>> only
>> minor side effects, dose-related sedation being the most common. A range
>> of
>> paradoxical effects can occur of which release of aggressive and hostile
>> feelings has excited most attention. These responses are idiosyncratic
>> however, as most patients report decrease of such feelings while taking
>> benzodiazepines. Dependence on benzodiazepines with escalation of dosage
>> and/or social abuse is uncommon set against their widespread use. Recently
>> though, evidence has accumulated that patients on normal doses for
>> prolonged
>> periods can commonly experience withdrawal symptoms, often unpleasant and
>> even
>> severe. These drugs should be reserved for patients suffering from defined
>> clinical anxiety syndromes and not used indiscriminately in patients with
>> normal stress responses.
>>
>> PMID: 6130800 [PubMed - indexed for MEDLINE]
>> http://www.ncbi.nlm.nih.gov/pubmed/6130800?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus
>>
>>
>>
>> They may also be regarded as necessary for more severe psychiatric
>> disorders,
>> usually as an adjunct to other therapy. In such instances the dependence
>> risk
>> is acknowledged but the benefits of treatment are considered to outweigh
>> them.
>> There may also be patients who are dependent on benzodiazepines but the
>> alternative of withdrawing the drug may lead to dependence on a more
>> dangerous
>> drug such as alcohol. In such cases it is reasonable to regard continued
>> prescription of the benzodiazepine as the least dangerous course of
>> action. It
>> is important to maintain a perspective of dependence on minor
>> tranquillizers,
>> particularly as attitudes are in danger of being distorted by excessive
>> media
>> attention. To date there is no evidence that dependence on benzodiazepines
>> leads to any dangerous long term sequelae although there is concern over
>> their
>> effects on higher cognitive function. Nevertheless, the dangers of
>> barbiturates, alcohol and nicotine are so much greater that it would be
>> unfortunate if public concern led to excessive restrictions on the use of
>> benzodiazepines.(ABSTRACT TRUNCATED AT 400 WORDS)
>>
>> PMID: 2894676 [PubMed - indexed for MEDLINE]
>> http://www.ncbi.nlm.nih.gov/pubmed/2894676?ordinalpos=14&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
>>
>> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
>>
>>
>>
>> J Psychiatr Res. 1990;24 Suppl 2:81-90.Links
>> A practical approach to benzodiazepine discontinuation.DuPont RL.
>> Department of Psychiatry, Georgetown University School of Medicine,
>> Washington, D.C.
>>
>> Non-medical use of benzodiazepines is rare among patients with anxiety
>> disorders. Numerous studies have found that non-medical use, or abuse, of
>> benzodiazepines occurs usually among patients with histories of alcohol
>> and
>> drug abuse--those who use those drugs to get "high". This article
>> distinguishes between medical and non-medical use of benzodiazepines in
>> clinical practice, and offers practical approaches to discontinuation of
>> benzodiazepine treatment for both medical and non-medical users of those
>> medicines. The major barrier to clear thinking about the abuse of
>> benzodiazepines is the confusion of "addiction" and "withdrawal".
>> Addiction
>> means high, unstable dosing outside medical and social boundaries for
>> "recreational" purposes, loss of control over use, and continued use
>> despite
>> clear evidence of harm. Alcoholism and heroin addiction are typical
>> examples
>> of addiction (Kalant, 1989). In contrast, withdrawal is a pharmacological
>> consequence of discontinuation of a substance on which a person has become
>> dependent. Many drug-addicted people have only minor withdrawal symptoms
>> when
>> they stop drug use. Many medical patients, with no evidence of addiction,
>> have
>> withdrawal symptoms when they stop treatment, especially when they stop
>> abruptly (e.g. surgical patients using narcotic analgesics and epileptics
>> using benzodiazepines or barbiturates in their treatment). Addiction to
>> benzodiazepines, in the sense of loss of control over use and continued
>> despite harm, is virtually limited to people with pre-existing drug or
>> alcohol
>> abuse, while withdrawal symptoms after prolonged daily use are common
>> among
>> medical users of benzodiazepines. The serious nature of both drug abuse
>> and
>> anxiety disorders is not emphasized sufficiently during medical school or
>> in
>> the professional literature. The distress and disability from which both
>> groups of patients and their families suffer is profound. Fortunately,
>> both
>> drug abuse and anxiety patients receive tremendous benefit from successful
>> treatments, both pharmacological and nonpharmacological (DuPont, 1986a;
>> DuPont, 1984). This article discusses the use of benzodiazepines in two
>> distinct populations--drug abusers and patients with anxiety
>> disorders--and
>> helps clinicians distinguish between the use of benzodiazepines in the two
>> groups. The central distinction made in this article is reflected in the
>> common use of the words "drugs" and "medicines". The former term often
>> denotes
>> non-medical substance use, while the latter term refers to traditional
>> pharmacotherapy.
>>
>> PMID: 1980703 [PubMed - indexed for MEDLINE]
>>
>>
>> August 01, 2007 Vol. 24 No. 7
>> Risk Versus Benefit of Benzodiazepines
>> Jay M. Pomerantz, MD
>>
>>
>> As Salzman31 pointed out, "dependence" is not necessarily "addiction."
>> Developing dependence is a predictable phenomenon, influenced by dosage,
>> duration of treatment, and other patient factors. Most often, dependence
>> is a
>> normal consequence of long-term pharmacological receptor-site activity.
>> Addiction implies not only dependence, but also nonmedical use,
>> pleasure-seeking use, and often polysubstance abuse. Most benzodiazepine
>> use
>> is not addictive, but appropriate use can sometimes result in dependence.
>> http://www.psychiatrictimes.com/topic/Anxiety/showArticle.jhtml?articleID=201201859&pgno=3&topic=Anxiety
>>
>>
>>
>> Issues in the Long-Term Treatment of Anxiety Disorders
>>
>> Edward Schweizer, Karl Rickels, and Eberhard H. Uhlenhuth
>>
>>
>>
>>
>>
>>
>>
>> INTRODUCTION
>>
>>
>> The goal of this chapter is to review issues relating to the long-term
>> treatment of anxiety disorders. The review does not pretend to be
>> exhaustive, but it has been written with the intention of critically
>> addressing clinically important aspects of long-term anxiolytic
>> therapy. The scope of the review is limited to panic disorder with or
>> without agoraphobia, generalized anxiety disorder (GAD), and social
>> phobia. Most of the emphasis is placed on drug therapy. Space
>> limitations, and the limitations of the authors themselves, have
>> dictated that results from psychotherapy studies could only be
>> highlighted. It was felt, though, that the rapidly expanding
>> literature of controlled psychotherapy research simply could not be
>> ignored, because their preliminary results stake a claim to the
>> achievement of sustained efficacy post treatment.
>>
>> The review will first undertake to establish whether there is any need
>> for long-term or maintenance anxiolytic therapy. Long-term therapy can
>> only be justified if there is evidence that the course of illness of
>> panic/agoraphobia, GAD, and social phobia are frequently chronic. The
>> longitudinal nature of these disorders will be evaluated in terms of
>> retrospective reports, prospective studies of community samples (ideal
>> but not generally available), and follow-up studies of treated
>> samples. Acute (short-term) treatment studies will also be reviewed:
>> High rates of relapse or recurrence in the months and years following
>> acute treatment suggest that such treatment is inadequate, and that
>> continuation or maintenance treatment may be beneficial. Establishing
>> how beneficial leads us to a brief review of recent research on the
>> degree of disability and impairment in quality of life caused by the
>> anxiety disorders. The justification section will conclude with a
>> brief review of the extent to which the natural history of the three
>> anxiety disorders is complicated by Axis I and Axis II comorbidity.
>> Long-term treatment planning cannot be undertaken without considering
>> these high rates of comorbidity.
>>
>> Next will come a brief review of published evidence for the efficacy
>> of long-term treatment of each of the three anxiety disorders.
>> Evidence for long-term efficacy will be reviewed for the various
>> classes of antidepressants, as well as for the benzodiazepines and
>> buspirone. Long-term treatment will be conceptualized, in keeping with
>> the terminology employed in the affective disorders literature, as
>> either "continuation" treatment or "maintenance" treatment.
>> Continuation treatment consists of the extension of drug therapy for 6
>> months beyond the acute phase in an attempt to prevent relapse,
>> defined as a return of the current episode of anxiety. Maintenance
>> treatment consists of the long-term use of drugs whose goal is to
>> prevent a recurrence of a subsequent episode of anxiety in a patient
>> who has demonstrated high chronicity, a high rate of recurrence,
>> and/or significant levels of severity or disability associated with
>> previous episodes.
>>
>> The putative benefits of long-term (continuation or maintenance)
>> therapy, insofar as they have been established, will be contrasted
>> with the potential risks attendant upon such therapy. The abuse
>> liability, dependence, and withdrawal risks associated with the
>> benzodiazepines will be especially emphasized. Miscellaneous issues
>> relating to long-term therapy, such as predictors of chronicity,
>> safety and benefits of combination therapy (drug�drug or
>> drug�psychotherapy), compliance, and intermittent medication
>> strategies, will be reviewed next. The chapter will conclude with a
>> review of methodologic issues in studying long-term treatment, suggest
>> some promising research designs, and identify areas for future
>> research.
>>
>> THE EVIDENCE FOR CHRONICITY
>>
>>
>> Only belatedly has it been recognized that the anxiety disorders tend
>> to be chronic and/or recurrent conditions. This recognition has not
>> yet reshaped our basic treatment approach, which still focuses almost
>> exclusively on the acute control of symptoms and only secondarily
>> acknowledges that treatment may need to be either continued or
>> reinitiated. Treatment planning for bipolar disorder, for
>> schizophrenia, and, recently, for unipolar depression is premised on
>> the chronicity of each illness, whether a maintenance or an
>> intermittent drug treatment strategy is ultimately utilized.
>>
>> But what is the evidence for chronicity for panic disorder (with or
>> without agoraphobia), GAD, and social phobia? The evidence comes
>> mostly from cross-sectional and retrospective assessments of duration
>> of illness and, much less frequently, from prospective studies. These
>> latter prospective studies are not long-term, but generally consist of
>> patient samples followed naturalistically post treatment, in which
>> case they provide evidence not only for the chronicity of the
>> disorder, but also for the insufficiency of acute therapy alone.
>>
>> Panic Disorder
>>
>> In the ECA community survey (51), the median age of onset was 23, and
>> the mean duration of panic disorder was 7.1 years for the subset of
>> patients whose panic was in remission. The duration of panic in the
>> majority (81%) who continued to report panic was apparently not
>> computed, because the illness was still ongoing. Treatment studies
>> find a similar mean duration of illness (ongoing at the time of
>> evaluation) in the range of 5�12 years (4, 56, 59). The
>> retrospectively assessed age of panic onset in these treatment studies
>> was in the mid-twenties, comparable to the results obtained in the ECA
>> community survey, suggesting that the reported duration of illness was
>> long not simply due to a sampling bias with respect to the type of
>> patient applying for treatment in a drug study. Overall, the course of
>> illness of panic disorder appears to be chronic in the majority of
>> patients, but with many reporting periods of remission lasting 6
>> months or longer.
>>
>> Generalized Anxiety Disorder
>>
>> For GAD, the ECA community survey reported a median age of onset in
>> the early twenties (51). For the good outcome cases that had remitted,
>> mean duration was 4.5 years, with 40% reporting durations of illness
>> of longer than 5 years. For currently active cases of GAD, the mean
>> duration of illness to date was reported as 8.5 years. Duration of
>> illness for still-active cases of GAD entering both drug and
>> psychotherapy treatment studies (45, 47) ranges from 5 to 15 years,
>> confirming that GAD has high chronicity. Several researchers (5, 29)
>> have noted that the clinical course of GAD is both more chronic and
>> more unremitting than panic disorder. Noyes et al. (35!popup(ch127),
>> in one of the few prospective studies (of anxiety neurosis), reported
>> that 48% of patients continued to have moderate-to-marked symptoms at
>> the 4- to 9-year follow-up.
>>
>> Social Phobia
>>
>> Much less information is available about the course of illness of
>> social phobia, but available data from both community (23, 54) and
>> patient samples (19, 24) suggest an age of onset in the mid to late
>> teens, with a chronicity that is equal to or greater than that of
>> panic disorder, with mean duration of illness exceeding 5 years.
>>
>> AGE OF ONSET: EVIDENCE FROM ADOLESCENT POPULATIONS
>>
>>
>> As has been mentioned, panic/agoraphobia appears to have a mean age of
>> onset, estimated retrospectively, to be in the early to mid twenties,
>> GAD in the early twenties, and social phobia in the mid teens. Because
>> retrospective recollection is prone to bias, in the direction of
>> either over- or underestimation, it would be a useful corrective to
>> study anxiety directly in its early incarnations. This is especially
>> true in light of the lack of reliable course of illness data from
>> prospective community samples followed over time. Fortunately, recent
>> research provides data on the onset of panic,
From: Philip Peters on 14 Jun 2008 09:20
anon schreef:
> BENZODIAZEPINES
>
> Quotations & Abstracts



Sigh.....OK, one more time.
Long term benzo use *does* indeed often cause some (reversible)
short-term memory loss, mostly more annoying than debilitating.
Impairment of cognitive function is highly debatable and mostluy occurs
in the elderly and as a result of unskilled prescribing.
I always admitted benzos cause *dependence* (not to be confused with
*addiction* with its hallmarks *tolerance* and *craving* which hardly
ever occur when medication is properly prescribed for the right
reasons). So do myriads of other prescription drugs including
antidepressants, insulin, digoxin, pain killers etc.etc.
When prescribing a benzo (or one of these many other meds) for
maintenance use the doctor should warn the patient that dependence will
occur and that they can run into problems trying to stop the meds which
should only be done by way of a slow taper. See the Ashton manual and
the Lexington-on-line site.
The second part of this (mis)information contains nothing that is
relevant for the discussion about the prescription of benzos for
anciet/panic. It's about street abuse, dependence in babies (no one
should take benzos while pregnant and the baby's dependence will be the
least of the probems this can cause such as severe birth defects) and
the fact that cognitive (if any) and memory problems are reversible
after stopping the drug which only proves my point.

We are posting here in a newsgroup for people with anxiety disorders.
I'm not in it to win an argument but to balance the information which I
regard as totally lopsided and biased.
I am now seriously leaving this thread and let everyone make up their
own minds on the basis of the presented evidence from both sides.

Philip

>
> Twenty-one patients with significant long-term therapeutic benzodiazepine
> (BZ) use, who remained abstinent at 6 months follow-up after successfully
> completing a standardized inpatient BZ withdrawal regime, and 21 normal
> controls matched for age and IQ but not for anxiety, were repeatedly tested
> on a simple battery of routine psychometric tests of cognitive function,
> pre- and post- withdrawal and at 6 months follow-up. The results
> demonstrated significant impairment in patients in verbal learning and
> memory, psychomotor, visuo-motor and visuo-conceptual abilities, compared
> with controls, at all three time points. Despite practice effects, no
> evidence of immediate recovery of cognitive function following BZ withdrawal
> was found. Modest recovery of certain deficits emerged at 6 months follow-up
> in the BZ group, but this remained significantly below the equivalent
> control performance. The implications of persisting cognitive deficits after
> withdrawal from long-term BZ use are discussed. [SUMMARY p. 203]
>
> "The main cognitive functions assessed in this study include working memory,
> verbal learning and memory, visuo-motor and visuo-conceptual skills. The
> lack of evidence for clinically significant cognitive recovery raises
> concern about the severity and reversibility of any underlying BZ-induced
> organic impairment." [p. 211]
>
> "The adverse effects of acute diazepam administration on memory and arousal
> in man are well known (Lister & File, 1984; Lister, 1985), and have been
> linked to the high density of BZ receptors in the hippocampus and reticular
> formation (Wolkowitz et al. 1987), although the neurochemical basis of
> chronic post-withdrawal deficits has yet to be demonstrated." [p. 212]
>
> "Persisting neuropsychological deficits affecting psychomotor function and
> new verbal learning have occupational implications. Driving and safety at
> work with machinery may both be impaired (Skegg et al. 1979, Roy-Byrne &
> Cowley, 1990).Patients' impairment, following withdrawal from long-term BDZ
> use, is likely to be less than that due to acute drug ingestion or the early
> withdrawal phase. Yet, one must be cautious in predicting either rapid or
> comprehensive cognitive recovery for those patients contemplating or
> undergoing a withdrawal regime, or in estimating the cognitive effects of
> mood dysfunction, which require further investigation." [p. 211] Lack of
> Cognitive Recovery Following Withdrawal from Long-Term Benzodiazepine Use.
> Tata PR, Rollings J, Collins M, Pickering A, Jacobson RR, Psychological
> Medicine 1994; 24: 203-213.
>
> "...the use of benzodiazepines in patients with chronic pain would
> theoretically be ill-advised because they reduce the turnover of serotonin,
> thus interfering with natural sleep and lowering the tolerance to chronic
> pain. However, the most significant problem that benzodiazepines create
> seems to be cognitive impairment with associated EEG changes (--). Acute,
> single dose administration of diazepam does seem to produce impairment in
> learning, memory, and psychomotor functioning." [p. 828]
>
> "...the evaluating psychiatrist noted that a great deal of cognitive
> impairment seemed to occur more often in patients using benzodiazepines than
> in patients using only narcotics." [p. 828]
>
> "...one could conclusively state that benzodiazepines were far more likely
> to produce cognitive impairment, with concomitant EEG changes, than were
> narcotics."[p. 830] " While neither narcotics nor benzodiazepines should be
> used on a long-term basis, cognitive impairment was far more apparent with
> the latter class of drugs. The question of the reversibility of the
> benzodiazepine effect is the subject of current research, but at this time
> one may only underscore a recent suggestion by the Food and Drug
> Administration that benzodiazepines be limited to short-term use." [p. 830]
> Comparison of Cognitive Impairment Due to Benzodiazepines and to Narcotics.
> American Journal of Psychiatry 1980; 137: 828-830.
>
> "The committee further noted that there was little convincing evidence that
> benzodiazepines were efficacious in the treatment of anxiety after four
> months' continuous treatment. It considered that an appropriate warning
> regarding long-term efficacy be included in the recommendations,
> particularly in view of the high proportion of patients receiving repeated
> prescriptions for extended periods of time ... It further suggested that
> patients receiving benzodiazepine therapy be carefully selected and
> monitored and that prescriptions be limited to short-term use" Committee on
> Review of Medicines, Systematic Review of the Benzodiazepines, Brit Med J,
> 29 March 1980, 910-912.
>
> "Benzodiazepine dependence would be of minor clinical significance if it
> occurred only in those few individuals taking high doses of drugs; but it
> would be very important indeed if it supervened even to a minor degree in
> patients on usual clinical doses. Our clinical impression is that many
> patients experience symptoms on reduction or withdrawal of their
> benzodiazepine medication, and that whilst these symptoms somewhat resemble
> those of anxiety they differ qualitatively and are often more severe than
> those for which the medication was originally given" C. Hallstr�m, M. Lader,
> Benzodiazepine withdrawal phenomena, Int. Pharmacopsychiat, 1981, 16,
> 235-244.
>
> "Dependence on the benzodiazepines does occur. Patients taking these drugs,
> even at therapeutic doses, for two or more months, may develop a physical
> withdrawal syndrome. The cardinal feature of the syndrome is anxiety, which
> may be mistakenly interpreted as a recrudescence of the original anxiety for
> which the drug was prescribed" N. Hockings, B.R. Ballinger, Hypnotics and
> anxiolytics, in New Drugs, [London: British Medical Association, 1983,
> 149-155.
>
> "The medical profession took nearly 20 years from the introduction of
> benzodiazepines to recognise officially that these minor tranquillisers and
> hypnotics were potentially addictive. The 'happiness pills', which had been
> propping up a fair proportion of the adult population since the early 1960s,
> were found to have an unexpectedly bitter aftertaste: doctors and patients
> alike were unprepared for the problems of dependence and withdrawal that are
> now known to be common even with normal therapeutic doses" Editorial (Anon),
> The benzodiazepine bind, The Lancet, 22 September 1984, 706.
>
> "The extent of pharmacological dependence with regular as opposed to
> intermittent dosage of benzodiazepines was not fully appreciated until
> recently. This was probably because prominent features of drug dependence,
> such as tolerance and escalation of dosage, are uncommon among patients
> starting on normal doses. The chief manifestation is a withdrawal syndrome
> on stopping the drug" Anon (A. Herxheimer, ed.), Some problems with
> benzodiazepines, Drug & Ther Bull, March 25 1985, 23 (6), 21-23.
>
> "In the UK, 11.2% of all adults take an anti-anxiety drug at some time
> during any one year. But over a quarter of these people (3.1% of all adults)
> are chronic users, taking such medication every day. Even at a conservative
> estimate, 20% of these will develop symptoms when they attempt to withdraw.
> That means a quarter of a million people in the UK. The sooner the medical
> profession faces up to its responsibilities towards these iatrogenic
> addicts, the sooner it will regain the confidence of the anxious members of
> our community" M.H. Lader, A.C. Higgitt, Management of benzodiazepine
> dependence - Update 1986, Brit J Addiction, 1986, 81, 7-10.
>
> "There is now little doubt that regular use of benzodiazepines can lead to
> drug dependence in patients who are not drug abusers. Such patients come to
> rely on the drugs for psychological comfort and suffer withdrawal symptoms
> if the drug is stopped or the dosage reduced. It is estimated that one-third
> of patients taking benzodiazepines for six months become dependent...
> Present estimates suggest that perhaps 500,000 people in the UK... are now
> dependent on benzodiazepines" H. Ashton, Dangers and medico-legal aspects of
> benzodiazepines, J. Med Defence Union, Summer 1987, 6-8.
>
> "It seems likely that many popular beliefs about benzodiazepine 'addiction'
> are related to the clear cut and increasingly documented phenomenon of
> withdrawal reactions following the use of these drugs and to the resulting
> difficulty anxious patients sometimes have stopping drug treatment because
> of such reactions. This phenomenon (ie inability to discontinue the drug
> because of withdrawal symptoms) is termed 'dependence' and by itself is
> enough to qualify patients for the new DSM-III-R. Diagnostic and Statistical
> Manual of Mental Disorders, 3rd ed., revised) diagnosis of 'psychoactive
> substance dependence" (P.R. Roy-Byrne, D. Homer, Benzodiazepine withdrawal:
> overview and implications for the treatment of anxiety, Am J Med, June 1988,
> 84, 1041 - 1052.
>
> "It has been estimated that one in three patients prescribed benzodiazepines
> in normal therapeutic doses for six weeks would experience withdrawal
> symptoms if treatment were withdrawn abruptly. Even with gradual withdrawal,
> patients would request further prescriptions. Thus, there is a considerable
> risk of dependence even in comparatively short-term use" M.A. Cormack, R.G.
> Owens, M.E. Dewey, The effect of minimal interventions by general
> practitioners on long-term benzodiazepines use, J Roy Coll Gen
> Practitioners, October 1989, 39, 408-411.
>
> "The presence of a predictable abstinence syndrome following abrupt
> discontinuance of benzodiazepines is evidence of the development of
> physiological dependence... "Historically, long-term, high-dose,
> physiological dependence has been called addiction, a term that implies
> recreational use. In recent years, however, it has become apparent that
> physiological adaptation develops and discontinuance symptoms can appear
> after regular daily therapeutic dose administration ... in some cases after
> a few days or weeks of administration. Since therapeutic prescribing is
> clearly not recreational abuse, the term dependence is preferred to
> addiction, and the abstinence syndrome is called a discontinuance syndrome"
> American Psychiatric Association Task Force on Benzodiazepine Dependency.
> Benzodiazepine Dependence, Toxicity, and Abuse. Washington DC: APA, 1990.
>
> "I don't think anyone really knows what long-term effects the
> benzodiazepines are likely to have on the brain tissue ... [they] may damage
> your brain cells and produce real physical damage to your thinking processes
> and there is also the risk that the benzodiazepines will cause psychological
> damage." Dr Vernon Coleman, Life Without Tranquillisers, 1985, p55.
>
> Drug companies making these products constantly warn doctors not to allow
> patients to take them for more than a week or two. They advise doctors not
> to make these drugs available on 'repeat prescription'. Evidence showing
> that these drugs are addictive and potentially dangerous has been
> accumulating rapidly since the early 1970s. Numerous research papers have
> been published showing that products in this group can cause problems such
> as memory loss as well as anxiety, depression and sleeplessness.
>
> Ironically, these are the three symptoms for which they are most commonly
> prescribed. The Committee on Safety of Medicines has received reports
> showing that these drugs are well known to cause well over 100 different
> side effects. Earlier this month the DHSS and the Home Office publicly
> admitted that the size of Britain's tranquilliser addiction problem is
> worrying them by bringing these drugs under the Misuse of Drugs Act 1971 -
> the same legislation that controls drugs such as heroin. And yet thousands
> of doctors don't seem to take any notice. It may be true that many still
> don't know what else to do for patients who are suffering from anxiety or
> stress-related diseases. The only conclusion I can draw is that several
> thousand British doctors do not read articles in the medical journals nor do
> they study literature which is published by the drug companies.
>
> These painfully ignorant doctors have between them created the biggest drug
> addiction problem this country has ever known. It's their addiction to
> prescribing these terrible drugs that has given us a nation of junkies. The
> nightmare pills: How millions are caught in the tranquilliser trap, Today,
> 07 May, 1986, Dr Vernon Coleman.
>
> "Anxiolytic treatment should be limited to short periods... because of the
> danger of insidious development of dependence and subsequent difficulty in
> withdrawing the drug... Withdrawal of the drug following either high dosage
> or long-term administration should be gradual as abrupt withdrawal may
> produce confusion, toxic psychosis, convulsions or a condition resembling
> delirium tremens. In milder cases symptoms may be similar to the original
> complaint and encourage further prescribing." 1981 British National
> Formulary.
>
> Anxiolytic treatment should be limited to the lowest possible dose for the
> shortest possible time... Prescribing of these drugs is widespread but
> dependence (both physical and psychological) and tolerance occurs. This may
> lead to difficulty in withdrawing the drug after the patient has been taking
> it regularly for more than a few weeks. Hypnotics and anxiolytics should
> therefore be reserved for short courses to alleviate acute conditions.
> British National Formulary, March 1998 edition.
>
> Benzodiazepines are indicated for the short-term relief (two to four weeks
> only) of anxiety that is severe, disabling or subjecting the individual to
> unacceptable distress, occurring alone or in association with insomnia or
> short-term psychosomatic, organic or psychotic illness. The use of
> benzodiazepines to treat short-term 'mild' anxiety is inappropriate and
> unsuitable. Benzodiazepines should be used to treat insomnia only when it is
> severe, disabling, or subjecting the individual to extreme distress. The
> Committee on Safety of Medicines, January 1988.
>
> "Prolonged or excessive use of benzodiazepines may occasionally result in
> the development of psychological dependence with withdrawal symptoms on
> sudden discontinuation. This is more likely in patients with a history of
> alcoholism, drug abuse or patients with marked personality disorders.
> Treatment in all patients should be withdrawn gradually. Careful monitoring
> of all patients is essential." 1983 John Wyeth Data Sheet.
>
> "It is more difficult to withdraw people from BDZs than it is heroin, it
> just seems that the dependency is so ingrained and the withdrawal symptoms
> you get are so intolerable that people have a great deal of problem coming
> off. The other aspect is that with heroin, usually the withdrawal is over
> within a week or so, with BDZs, a proportion of patients go on to long term
> withdrawal & they have very unpleasant symptoms for month after month, & I
> get letters from people saying you can go on for two years or more. Some of
> the tranquilliser groups can document people who still have symptoms ten
> years after stopping." Professor Malcolm H Lader, Royal Maudesley Hospital,
> "You & Yours" - BBC Radio 4, 1999.
>
> The benzodiazepines are still extensively used in psychiatry, neurology and
> medicine in general. Anxiety disorder and severe insomnia are important
> syndromal indications, but these drugs are widely prescribed at the
> symptomatic level, resulting in potential overuse. The official data sheets
> recommend short durations of usage and conservative dosage. Although
> short-term efficacy is established, long-term efficacy remains
> controversial, as relevant data are scanty and relapse, rebound and
> dependence on withdrawal not clearly distinguished. The risks of the
> benzodiazepines are well-documented and comprise psychological and physical
> effects. Among the former are subjective sedation, paradoxical release of
> anxiety and/or hostility, psychomotor impairment, memory disruption, and
> risks of accidents. Physical effects include vertigo, dysarthria, ataxia
> with falls, especially in the elderly. Dependence can supervene on long-term
> use, occasionally with dose escalation. The benzodiazepines are now
> recognised as major drugs of abuse and addiction. Other drug and non-drug
> therapies are available and have a superior risk benefit ratio in long-term
> use. It is concluded that benzodiazepines should be reserved for short-term
> use - up to 4 weeks - and in conservative dosage. Professor Malcolm H Lader,
> Institute of Psychiatry, University of London, UK. Limitations on the use of
> benzodiazepines in anxiety and insomnia: are they justified? In: Eur
> Neuropsychopharmacol 1999 Dec;9 Suppl 6:S399-405.
>
> The concepts of dependence, addiction and abuse comprise overlapping
> clinical phenomena. The earlier anxiolytic drugs, in particular the
> barbiturates, were prone to abuse, i.e., non-medical use, and to high-dose
> misuse. Their modern counterparts, the benzodiazepines, are abused in a
> patchy way and are sometimes taken in regularly high doses. However, the
> main problem is physical dependence as manifested by a withdrawal syndrome
> on discontinuation of the drug. The withdrawal syndrome has been carefully
> described and comprises physical and psychological features. In particular,
> perceptual symptoms such as photophobia, hyperacusis and feelings of
> unsteadiness may predominate. The syndrome may come on during dosage
> reduction but generally starts 2-10 days after cessation of the
> benzodiazepine, depending on its elimination half-life. About a third of
> long-term users suffer a recognisable syndrome even after a tapered
> withdrawal, its duration usually being only a few weeks. A few patients go
> on to a prolonged withdrawal syndrome, often characterised by muscular
> spasm. The treatment of the withdrawal syndrome is supportive and
> non-specific. A few patients started on benzodiazepine therapy escalate the
> dose. They tend to show the characteristic 'passive-dependent' personality
> features and may previously have misused other CNS depressants such as the
> barbiturates and alcohol. Abuse of benzodiazepines occurs in a rather varied
> way from country to country. Worldwide, flunitrazepam has caused concern
> but, in the UK, the main problem has been the intravenous use of temazepam.
> The molecular pharmacology of the benzodiazepine receptor has been
> extensively studied and is undoubtedly complex. Professor Malcolm H Lader,
> Department of Clinical Psychopharmacology, Institute of Psychiatry, London,
> UK. Anxiolytic drugs: dependence, addiction and abuse. Eur
> Neuropsychopharmacol 1994 Jun;4(2):85-91.
>
> Withdrawal of benzodiazepines is currently advised for long-term
> benzodiazepine users because of doubts about continued efficacy, risks of
> adverse effects, including dependence and neuropsychological impairment and
> socio-economic costs. About half a million people in the UK may need advice
> on withdrawal. Successful withdrawal strategies should combine gradual
> dosage reduction and psychological support. The benzodiazepine dosage should
> be tapered at an individually titrated rate which should usually be under
> the patient's control. The whole process may take weeks or months.
> Withdrawal from diazepam is convenient because of available dosage
> strengths, but can be carried out directly from other benzodiazepine.
> Adjuvant medication may occasionally be required (antidepressants,
> propranolol) but no drugs have been proved to be of general utility in
> alleviating withdrawal-related symptoms. Psychological support should be
> available both during dosage reduction and for some months after cessation
> of drug use. Such support should include the provision of information about
> benzodiazepines, general encouragement, and measures to reduce anxiety and
> promote the learning of non-pharmacological ways of coping with stress. For
> many patients the degree of support required is minimal; a minority may need
> counselling or formal psychological therapy. Unwilling patients should not
> be forced to withdraw. With these methods, success rates of withdrawal are
> high and are unaffected by duration of usage, dosage or type of
> benzodiazepine, rate of withdrawal, symptom severity, psychiatric history or
> personality disorder. Longer-term outcome is less clear; a considerable
> proportion of patients may temporarily take benzodiazepines again and some
> need other psychotropic medication. However, the outcome may be improved by
> careful pharmacological and psychological handling of withdrawal and
> post-withdrawal phases. Ashton CH, Department of Pharmacological Sciences,
> University of Newcastle upon Tyne, UK. The treatment of benzodiazepine
> dependence, Addiction 1994 Nov;89(11):1535-41.
>
> This paper presents the results of a survey carried out to investigate the
> benzodiazepine (BZD) prescribing patterns of the general practitioners (GP)
> in the catchment area of a Drug Dependence Unit located in a general
> hospital in Mataro (Barcelona, Spain). The aims of the survey were: (i) to
> obtain descriptive information on the knowledge of the GPs about BZD and its
> potential for dependence; (ii) to study the frequency of their prescribing;
> and (iii) to examine different factors linked to their prescribing. The
> study was carried out using a combination of a personal interview and a
> self-administered questionnaire. A total of 68 doctors (88.3%) completed the
> questionnaire. The results show that the GPs have, in general, correct
> knowledge about the therapeutic indications for BZD prescribing, but are far
> less aware of their potential to induce dependence and how to manage
> withdrawal. The rate of prescribing seems to be high. Furthermore, the
> results of the external check of validity point out that doctors tend to
> underestimate the number of prescriptions. The majority of GPs express the
> need for alternative resources to BZD prescribing. No significant
> associations have been found between doctor's characteristics, such as
> postgraduate training and type of practice, and their knowledge about BZD
> and frequency of their prescribing. In our view, a more accurate knowledge
> about BZD and alternatives to its use, both factors closely linked to
> training, together with the availability of non-pharmacological resources,
> are likely to improve the quality of doctors prescribing habits, thus
> preventing risks such as dependence of BZD. Benzodiazepines in primary
> health care: a survey of general practitioners prescribing patterns, Boixet
> M, Batlle E, Bolibar I, Unitat Assistencial de Drogodependencias, Servei de
> Psiquiatria, Barcelona, Spain.
>
> Benzodiazepines are medications that are addicting - both in combination
> with other drugs and alone. The scope of the problem is thought to be wide,
> but it has not been well documented for unclear reasons. Pharmacologic
> dependence has been documented in virtually all long-term users. Adverse
> effects occur secondary to their use and these effects are often subtle, but
> significant. Various benzodiazepines present differences in reinforcement,
> withdrawal, and adverse effects. Diagnostic issues, withdrawal, and
> treatment issues are discussed. Benzodiazepines and addiction. Psychiatr
> Clin North Am 1993 Mar;16(1):75-86. Juergens SM Virginia Mason Outpatient
> Chemical Dependency Program, Virginia Mason Clinic.
>
>
> --------------------------------------------------------------------------------
>
> Some Highlights from The Beat the Benzos Conference, Croydon, November 2000:
>
> Dr Nicholas Seivewright
> Dr Seivewright is a psychiatrist working in the area of drug misusers. At
> the end of his talk he mentioned that he felt that his profession had no
> problem with reclassifying benzodiazepines (BDZs). He said that this would
> solve the immediate problem of street abuse of the drugs, although there may
> be problems with other aspects of reclassification.
>
> Dr James Robertson
> Paediatrician at Arrowe Park Hospital, The Wirral. Dr Robertson said he
> categorised BDZs as more dangerous than opiates or methadone to the newborn
> and that "babies affected can go on suffering for months and months" and
> "that the parenting 'benzo babies' receive will be poor, not through any
> fault of the parent, but the fault of the drug plus the parent".
>
> Professor Stefan Borg
> Head of Addiction Medicine, Karolinska Institute, Sweden. Professor Borg has
> been researching the biochemical changes induced by long term BDZ use. He
> said extensive research in this area showed that cognitive /
> psycho-neurological impairment was measurable during long term BDZ use,
> increased during acute withdrawal and very slowly reverses over months or
> years after cessation of the drugs. A most significant finding was that
> flumazenil, a BDZ antagonist ("antidote") when given to people, who had been
> off the drugs for some time but continued with unpleasant symptoms, improved
> or were completely relieved of these symptoms. Flumazenil is a Roche product
> licensed for use in reversing the action of BDZs after anaesthesia and
> overdose.
>
>
From: anon on 14 Jun 2008 13:19
I corrected this point later--see below. No one would have anticipated that
you would have dumped text the size of the Encyclopedia Britannica into a
newsgroup.

"Philip Peters" <philip(a)p-peters.demon.nl> wrote in message
news:4853c0f7$0$14345$e4fe514c(a)news.xs4all.nl...
> anon schreef:
>> This is not a scientific study of a controlled population sample--it is
>> more anecdotal evidence from one physician who overprescribes benzos--
>
>
> Gotcha! You only read the first text which is an interview (I *knew* this
> was going to happen, it's not the first time). You effectively fell into
> your own trap.
>
>
>
>
> of which
>> there are, alas, far too many. In fact, Big Pharma has so corrupted the
>> psychiatric profession in this country that SSRIs get handed out like
>> candy even though carefully vetted studies show that that most of them
>> are no more effective than--or only marginally more effective
>> than--placebos.
>
>
>
> The jury is still out on this, there are conflicting studies out there. I
> totally agree that SRRI's are vastly overprescribed, as I said earlier,
> and often at the expense of those lovely benzo's (which actually were
> overprescribed in the seventies as well which gave them their bad
> reputation instead of the doctors who prescribed them at random without
> even a proper dagnosis). Nowadays Big Pharma has been hyping up SSRI's
> just like benzos were hyped up thirty years ago so what else is new? When
> properly prescribed after a serious diagnosis has been established there
> is a place for both benzos and SSRI's etc. in the treatment of Panic
> Disorder. As important, if not more, is to find a good CBT or
> REBT-therapist; the results of CBT etc. are at least as good if not better
> than those of medication and often it makes sense to combine them, at
> least for a period of time.
>
>>
>> The documentation of the powerfully addictive properties of benzos is
>> vast, along with an equally vast literature demonstrating the potentially
>> life-damaging side effects that can come with long-term use, including
>> short-term memory loss, cognitive deficits, depression, and horrific
>> rebound anxiety and rebound insomnia during attempted withdrawal.
>
>
> See the literature I posted and you refused to read.
>>
>> For a survey of the vast scientific literature on the horrors of benzo
>> addiction withdrawal, see the references at the end of the following:
>>
>> http://en.wikipedia.org/wiki/Benzodiazepine_withdrawal
>
>
>> All of those listings constitute SCIENTIFIC LITERATURE, not the
>> comforting anecdotal bedtime stories proferred by this self-serving,
>> ethically irresponsible megalomaniac, who universalizes from his
>> microscopic corner of the universe.
>
>
> Do you really think Wikipedia is *scientific*? It's totally unreliable
> information brought together by whoever feels like it. In this case
> Wikipedia's stance on benzos reflects the UK *Anti Benzo Squad*'s. It's
> worth less than nothing.
> I universalized nothing from my own personal experience, on the contrary I
> presented a lot of *scientific* literature and opinions by leading
> psychiatrists which you decided not to read. Maybe you could try again.
>
> Oh, I was out of this thread.
> Had to come back one more time to make it clear that I sent dozens of peer
> reviewed studies accompaniet by a lot of anecdotal information and the
> only thing you did is read the first entry.
> Or you chose to ignore the rest because it doesn't help your agenda.
>
> Philip (don't know why I joined this thread after years of bickering with
> the anti benzo boys, but hey, I'm out of it -again ;-)
>
>
>>
>> "Philip Peters" <philip(a)p-peters.demon.nl> wrote in message
>> news:4852fcbe$0$14344$e4fe514c(a)news.xs4all.nl...
>>> anon schreef:
>>>> "Some" this, "some" that--all without any documentation
>>>> but with a lot of
>>>> ad hominem sneering and name calling (the Anti-Benzo Squad), as though
>>>> that compensates for documentation and rational argument. This poster's
>>>> message consists entirely of personal testimony and anecdotal
>>>> evidence--it's pure garbage. I've already posted the relevant
>>>> scientific documentation from a variety of sources, none of which this
>>>> snide smear artist has bothered to try to refute.
>>>
>>> See below.
>>>
>>>
>>> The point is--proceed
>>>> with caution, and try to use them only on a spot or short-term basis
>>>> unless a trusted doctor absolutely feels you must rely on them for a
>>>> longer period.
>>>
>>> Now here we agree. Never self-medicate, always have meds prescribed by a
>>> trusted doctor.
>>> And with this little bouquet of quotations below I gracefully bow out of
>>> this thread on to greener pastures and let everyone judge the matter for
>>> themselves. Enjoy!
>>>
>>> Philip
>>>
>>> ---------------------------------------------------------
>>>
>>>
>>> A Conversation With a Colleague
>>>
>>> from Medscape General Medicine
>>> http://www.medscape.com/viewarticle/457797?src=search
>>>
>>> Thomas A. M. Kramer, MD
>>>
>>>
>>> The following is dialogue with a colleague who is a child psychiatrist
>>> and who has recently expanded her practice to treat more adults.
>>>
>>> Dr K: When do you actually use benzodiazepines to treat anxiety? I
>>> mean, how many other drugs will the patient actually have to fail
>>> before you would prescribe them?
>>>
>>> Dr. F: Well, sometimes none. A lot of the time, I would use them right
>>> away. First-line.
>>>
>>> Dr K: Really?
>>>
>>> Dr. F: Sure. It wasn't that long ago that benzos were used routinely
>>> as first-line treatment for generalized anxiety. It's only fairly
>>> recently that they've been supplanted by SSRIs and SNRIs.
>>>
>>> Dr K: And aren't those drugs better? Don't benzos tend to make
>>> patients sleepy, stupid, and addicted? I mean, not using benzos as
>>> first-line treatment is a step forward, right?
>>>
>>> Dr F: Certainly, SSRIs and SNRIs are important treatment options. But
>>> benzos have their virtues, too. They work right away; antidepressants
>>> in general take a few weeks to work. When dosed appropriately, they
>>> don't make people sleepy or stupid. As far as addiction goes, that's
>>> pretty controversial, but my feeling is that the risk of addiction for
>>> benzos is grossly overstated. Certainly, in a vulnerable population,
>>> like people with substance abuse history or strong family histories of
>>> substance abuse, tolerance and dependence can be a problem. But that
>>> is a very small percentage of patients who present for treatment for
>>> anxiety. I've seen a lot of patients who have taken 10 mg a day of
>>> Valium for years with good result. They don't escalate the dose, and
>>> if they try to come off it or miss a few doses, all that happens is
>>> that they get anxious again. Benzos don't really have very many side
>>> effects besides the ones you mentioned, and since antidepressants have
>>> side effects of their own, there are some patients who can tolerate
>>> benzos who cannot tolerate antidepressants.
>>>
>>> Dr K: So why don't we use them any more?
>>>
>>> Dr F: I do. But the sense I get, in what little adult work I do, is
>>> that they have really fallen out of favor.
>>>
>>> Dr K: You're right, but I don't think that's for good reason. I think
>>> that's basically a function of marketing.
>>>
>>> Dr F: You mean, drug companies are trying to get us to write for their
>>> SSRIs and SNRIs for anxiety as opposed to benzos?
>>>
>>> Dr K: Exactly. The other side of that coin is that nobody is marketing
>>> benzos at the moment. That may change soon with the launch and
>>> subsequent marketing of rapidly dissolving Klonopin and Xanax XR, but
>>> for the time being, all of the marketing efforts of the pharmas for
>>> anxiety treatments are focused on antidepressants.
>>>
>>> Dr F: So you are saying that we all are really controlled by the
>>> pharmaceutical industry? That their marketing efforts really do
>>> control our behavior?
>>>
>>> Dr K: Well, no. I do think that at least some of us are capable of
>>> independent thought. The problem, I think, has more to do with sources
>>> of information. So much research and educational programming is funded
>>> by pharmas that they have an enormous amount of influence over what is
>>> defined as the state of the art. While they may not have direct
>>> control over the results of published research, or the content of
>>> educational programs at meetings, or the information that is sent to
>>> us in the mail, they have enough influence to determine a lot of what
>>> it is you are going to see when you go to "read the literature." You
>>> end up thinking that the treatments for which they choose to fund
>>> research and programs are indeed the state of the art. After all, you
>>> read all of these advantages of these new treatments. No one's putting
>>> material in front of you telling you about the advantages of the older
>>> treatments.
>>>
>>> Dr F: And no one is funding head-to-head studies between the new and
>>> the old treatments, either.
>>>
>>> Dr K: Exactly. Why should they? The only people who fund clinical
>>> trials these days are pharmas -- although that has changed a little
>>> bit with some new NIMH studies that are actually comparing different
>>> treatments without any pharma funding -- and pharmas are certainly not
>>> going to fund such a study because it may not look so good for them.
>>> Look, I have nothing against marketing. I think that the pharma
>>> industry, like any other industry, is entitled to promote its
>>> products. I am also sympathetic to the fact that is not easy for them
>>> to do this. It is hard to get the attention of busy physicians. My
>>> concern is that some things are marketing that aren't labeled as such.
>>> I am tired of hearing the words "unrestricted educational grant."
>>> There ain't no such animal. Simply deciding what it is you're going to
>>> fund with such an unrestricted educational grant gives you a fair
>>> amount of discretion as to what clinicians will hear about and know.
>>> And as far as research is concerned, it seems to me that the results
>>> of studies sponsored by pharmas seem to almost always be good news for<