When can you use benzos appropriately?

I’ve seen a fair number of elderly patients on benzos at bedtime. The patients claim that it calms their nerves and helps them sleep better.

To which I say, yeah, I’d like to have that, too.

Too often, benzos are used to treat symptoms, and do not address the underlying cause. For instance, I saw one 85 year old patient on TID Ativan, which is VERY IRRESPONSIBLE because it’s like throwing nitro patches on someone with new angina and not doing a stress test.

Benzos are appropriate for people with:

  • short-term treatment of anxiety disorders
  • insomnia for short bouts (2-4 weeks, dosed intermittently) although patients can get rebound insomnia
  • maintenance benzos can be used in people who are refractory to other treatments or who have already become dependent and would have a difficult time withdrawing

Here are some guidelines when prescribing benzos:

  • If it’s the first time someone is taking benzos, don’t prescribe for more than 1 month at a time
  • Always use the lowest effective dose
  • If someone is on maintenance benzos, use a long-acting one and do not exceed the equivalent of 15 mg of diazepam daily
  • In elderly patients, avoid long-acting benzos (these can cause cognitive and gait abnormalities and sedation). Make sure you are not treating depression with benzos, because this will only make it worse.

If a person on high-dose, daily benzos comes into the hospitals, do not stop their benzos as this can precipitate withdrawal. But see if they’d be willing to start on a taper, or reduce their benzos.

Pearls about anxiety disorders

Anxiety disorders, which include generalized anxiety disorder, social anxiety, phobias, and PTSD, cause great personal distress, missed work, and overuse of medical services. They are also associated with neuro-hormonal changes that might predispose patients to other medical conditions such as COPD, diabetes, hypertension, and osteoarthritis. However, it’s important not to become fatalistic since recovery happens for many people–40% within 2 years.

It can be hard to decide if a patient truly has an anxiety disorder: do they have something else, like an MI, a PE, hyperthyroidism, or drug-induced feelings of anxiety? Do they have somatization and complain of symptoms that can’t be explained by diagnostic workups? Do they have obsessive tendencies? Do they live in a dangerous neighborhood and have a “normal” reaction to their surroundings? Are they being abused?

Are they depressed? Just as there is a PHQ-9 for depression, there is a GAD-7 for anxiety that patients can fill out in the office to help figure out if they have treatable anxiety. Most people would say that a score of 10 qualifies a patient for treatment.

Speaking of depression, the DSM-V states that a patient who has been diagnosed with depression can only be diagnosed with anxiety AFTER their depression has gone into remission. There’s controversy surrounding this, but suffice to say in a patient with depression and anxiety, depression should be treated first.

Generalized anxiety disorder in particular carries an independent risk for suicidality. It’s always important to ask patients with anxiety if they have suicidal ideation!

As far as treatment goes, meta-analyses have found no difference between medications and therapies like cognitive-behavioral therapy. Plenty of patients cope through activities like yoga and meditation.

If prescribing medication, SSRIs and SNRIs should be your first choice. Because they take 2-4 weeks to see an effect, you can use benzos in the meantime to provide relief for acute anxiety. Try to avoid using benzos long-term, obviously–and pause before prescribing for elderly patients, patients with seizure disorders, hepatic impairment, or respiratory issues. Pregabalin (Lyrica) may be helpful for anxiety attacks, and buspirone (Buspar) for generalized anxiety. Re-evaluate the treatment in 6 months.

Why is my HIV patient going into opioid withdrawal?

from: fda.gov
from: fda.gov

Nowadays, most patients are on some form of once-daily antiretroviral therapy that has made HIV a more manageable chronic disease.

One of the most popular combination pills is Atripla, which is composed on efavirenz and emtricitabine/tenofovir. Efavirenz (brand name: Sustiva) is a non-nucleoside reverse transcriptase inhibitor that is metabolized by the same CYP enzymes that metabolize opioids.

Clarke et al report that in a sample population of patients who started efavirenz, a 22% increase in methadone dose was required. This infochart is helpful in looking up the specific interactions between classes of HIV medications and opioids. It should be noted that the same effect was not seen between efavirenz and buprenorphine.

Tips on choosing meds for depression and anxiety

Screen Shot 2015-07-01 at 10.58.58 PMThese are tips only, and not intended to be a comprehensive review of all the antidepressants and anxiolytics!!!

*When starting someone on an antidepressant, always ask them if they have experienced hypomania or mania- if you prescribe them an antidepressant, it could trigger a manic episode.

SSRIs are good for depression and pathological anxiety (people who “make mountains out of molehills”).

  • Common starting side effects: headache, nausea, and “jitters.”
  • A patient who experiences sexual side effects on one SSRI will likely experience them on another. It’s best just to switch classes.
  • Bupropion is more activating.
  • Mirtazapine can cause insomnia, GI distress, anxiety, and weight gain (however, for the same reasons, it’s good for cancer patients).
  • Paxil should be your last resort. It is associated with weight gain, sexual side effects are more common, and a strong withdrawal syndrome when compared with other SSRIs. (Effexor also has a strong association with withdrawal syndrome.) When you want a patient to stop Paxil, taper them slowly. You can add Prozac at the end of the taper to protect against withdrawal.

Benzodiazepines are good for anxiety due to external stress (someone who is “going through a tough time and just needs to get over the hump”)

  • Most non-addicts don’t abuse benzos
  • But you should avoid them in older individuals because they have sedative effects
  • Ativan is what I’d consider my “go-to.” If Ativan isn’t lasting long enough, Klonopin and Valium are other options because of their longer half-lives.
  • Xanax should be a last option, because its extremely short half-life (about three hours) gives it high addictive potential

Tips for getting a history on addiction

It can be really difficult to get an accurate history from someone who abuses substances if they don’t want you to know the details. Here are some tips for getting a history on addiction from a couple of substance abuse counselors I talked to:

  1. Assessment requires:
    1. Knowing context of addiction
    2. Network of support the patient has
    3. Problem-solving with the patient, figuring out level of insight, drawing them to see the conclusions you’ve come to by asking them rhetorical questions. Try to figure out the discrepancy with what the patient believes vs reality is where progress takes place.
  2. Tell a patient that their information stays with you, “it goes nowhere,” and you are just there to help them with their course in the hospital. Point out that substance abuse can affect them if they go into withdrawal, or if they need a higher dose of pain meds.
  3. Be supportive by acknowledging disclosures and encouraging details. Ask how they feel or what happened in their lives. “I’m going to be as transparent with you as you are with me.” Understand that deception may be part of the course; lying may be a mechanism to get what they want, or they may be scared or mistrustful of the healthcare system.
  4. One interesting question that can be asked is, “Where do you see yourself in 1 year? 5 years? Ten years?”

It’s not depression if they’re asleep

This clinical pearl requires a story. When I was a medical student on the psych consult service, we were called to see a 44-year old woman with obesity, recurrent pancreatitis, and past bilateral PEs for” increased depressive mood.” She had been admitted for an abdominal abscess; this was drained and she was now on antibiotics. When I examined her, she and a flat affect and kept on falling asleep. She apologized, saying she was tired from the pain. But her medications included:

  • 5 mg valium 1XD
  • 40 mg fluoxetine 1XD
  • 50 mg topiramate 1XD
  • 100 mg quetiapine qhs
  • 100 mg trazodone qhs
  • 75 mg bupropion 1XD
  • 1200 mg gabapentin 2XD
  • 7.5 mg oxycodone q4h for pain

Instead of realizing that she was on enough meds to tranquilize an elephant, her team attributed her new behavior to “depression.” Lesson #1 is that we often forget the CUMULATIVE effect of medications and need to prescribe responsibly.

Lesson #2 is that this woman had real cognitive impairments secondary to psychomotor slowing. There is a difference between mood and cognition in describing psychiatric disease. Even though she “looked more depressed,” she did not have a MOOD disturbance. She had a COGNITIVE impairment.

The attending on service commented that he’d done an informal survey, and out of 8 consults for “increased depression,” the diagnoses were actually Wernicke’s encephalopathy, Parkinsonian dementia, neurodegenerative disease, and motor neuron disease in someone with schizophrenia.

Lesson #3 is that just “being sick” can cause someone to seem more depressed. A benign urinary tract infection or pneumonia can “slow people down,” especially the elderly. There may be inflammatory factors at play.

After we nixed about half of her meds, we went to see her several hours later. She was much more alert, and even doing the mini-mental with a British accent.

How do you manage a patient on suboxone?

Suboxone is a formulation of buprenorphine + naloxone (aka Narcan) that is used in managing opioid addiction. It should NOT be used for induction therapy or pain management on its own; it is a drug that is meant to be weaned off.

First of all, for the difference between suboxone and methadone, read this.

Let’s say you have a patient who admits heroin use and wants to stop. In order to start them on suboxone, explain that they will go through minor withdrawal at first. They can be kept afloat by anxiolytics like benzos, or sleep aids. Patients have to agree to adhere to suboxone therapy, come in for weekly/biweekly appointments and urine tests, do regular counseling (anything from a psychiatrist to Narcotics Anonymous to new programs like SMART), and obviously not take other substances. Don’t start a patient on suboxone and then leave them to dry out over the weekend: try to have a followup appointment the next day or the day after at latest.

Most patients become comfortable on 16 mg suboxone pills or film strips. The goal is to wean them down to zero, but it can take years to reach that point. At their visits, ask them not only about side effects they might be having (the usual opioid withdrawal sx like fatigue, nausea, rhinorrhea, etc), but also how their lives are and what they’re doing to stay active and stay away from drugs. “What do you spend most of your time doing?” can provide a huge amount of insight into your patient’s lives.

They will need urine tests every visit. Urine needs to be positive for suboxone and its metabolites: one drug rep told me that some wily patients will put a crushed suboxone tablet in the urine, in which case the suboxone will be positive, but the metabolites (norbuprenorphine) will not be. The urine obviously also needs to be negative of other illicit substances or meds.

If a patient on suboxone is admitted to the hospital, they can be given IV morphine for pain relief. They may require much higher levels of pain meds than a typical patient because buprenorphine binds much more tightly to opioid receptors than most other opioids. However, always use your clinical judgment!