TCR: Dr. Gitlow, let’s get right into the issue of benzodiazepines. A typical scenario for many of us in office practice is that we will see a patient recently out of detox who will say, “Well doctor, I have always had terrible anxiety whether I have been drinking or not, I have tried this and I have tried that, and if I can’t take something that will help my anxiety, I am sure I am going to start drinking again.”
Dr. Gitlow: The way you phrase it is almost exactly the way it is always phrased. It is phrased in a manner by the patient that is meant to make the psychiatrist think or feel that the burden or the onus is on them. And I think psychiatrists need to be aware that the patient with the substance abuse disorder is almost always going to play it exactly that way.
TCR: So how do you recommend we deal with this?
Dr. Gitlow: The trick is to turn it around and place the burden of the illness back where it belongs, which is on the patient. If a diabetic patient came in and said to me, “If you don’t give me medication X, I will purposely take 50 units of insulin when I only need 10,” we would say to ourselves, “What a silly thing for the patient to say. What they are saying is that they are going to purposely make their illness worse or make themselves uncomfortable as a result of something that I do which is only in their best interest.” That makes no sense. And by the same token, it makes no sense for an alcoholic to say he’ll drink if he can’t get benzos. You really have two different choices: one would be to keep them on the benzodiazepine as the result of the veiled threat they have made; the second would be to gradually taper it off as makes sense medically. Tapering them off might make them more uncomfortable, and they might actually pick up alcohol in part as a result of that. But if you leave them on the benzodiazepine on the same dose, it has to be done with the understanding that they are going to grow increasingly tolerant to that dose and in a month or two it will be even more difficult to taper them off. So, as far as I am concerned, it never pays to go down that path. It is only making things inevitably worse for the patient, although indeed in the short term it will assist them in getting through whatever level of anxiety they are experiencing.
TCR: Why are benzos so risky in alcoholic patients?
Dr. Gitlow: Because when you prescribe a benzodiazepine to an alcoholic, it isn’t very different from saying to them, “You may have no more than 2.5 beers a day with the intake spaced out evenly throughout the day.” That would be a measured amount of a sedative used in a controlled way. The problem is that anytime controlled drinking studies have been done, they have been shown to fail. And they inevitably fail for the same reason: because the individual has not learned what modalities and interactions with other people are necessary when they feel stressed or uncomfortable. So what will happen to them ultimately is that their house will burn down or they will lose a job or their kid will move across the country or something will happen that they will see as being traumatic and they will have nobody to turn to during the time of stress. And, in the meantime, they know that this 2.5 beers a day or the 20 mg of Valium has been helping them to feel better and therefore, why won’t 3.5 beers or 30 mg of Valium be even better? And of course, they will be right. It will be better and for a short amount of time it will help. But they will find that when they go back to the originally prescribed dose they get quite anxious because now they are used to the higher dose, and you know where that ends.
TCR: What do you like to use instead of benzos for these patients?
Dr. Gitlow: I tend to minimize the use of any anti-anxiety drugs until I feel that somebody has hit a solid recovery.
TCR: What constitutes “solid recovery”?
Dr. Gitlow: Do they have an AA sponsor? Do they have a good AA home group, that is, a meeting that they are going to repetitively and have gotten to know the people there well. Are they participating actively in their recovery and taking responsibility for their illness? If those pieces are in place, and there is still anxiety, I’ll use medication, but this necessary in only about 15-20% of my patients.
TCR: What are your favorites non-addictive meds?
Dr. Gitlow: I will look at a few different classes. Out of the SSRIs and the newer generation antidepressants, I will use Paxil (10-60 mg QHS) or Remeron (7.5-30 mg QHS), because the level of sedation they provide can be helpful for anxiety and depression in alcoholics. I also frequently use Seroquel 25-50 mg either during the day for anxiety or at night, and I’ve had good success with Elavil at 25-50 mg HS.
TCR: Why do you like Elavil?
Dr. Gitlow: I find that alcoholics in recovery tend to complain of nightmares on Paxil or Remeron, whereas Elavil tends to cause a little amnesia about what happened overnight, so if they are having nightmares they don’t remember them.
TCR: What about Ambien or Sonata? Some psychiatrists swear that these are addictive yet others feel they are pretty benign for alcoholics.
Dr. Gitlow: I haven’t seen very much in the way of abuse of either of these medications; however, the way that they work is similar to benzos. Some patients who take these compare them to having a glass of brandy before bed and I don’t want them coming close to thinking that.
TCR: Any other nostrums that come to mind that you find helpful?
Dr. Gitlow: BuSpar comes to mind. I know people tend to chuckle about BuSpar as being in many ways a placebo. On the other hand, over the years, I have found a small number of patients who seem to respond very nicely, and I tend to use it in concert with an activating drug like Wellbutrin. However, BuSpar alone doesn’t seem very helpful for alcoholics because they look it up online, see that it is marketed as an antianxiety drug, assume that it will work like Valium and then be annoyed when it doesn’t work quickly enough.
TCR: Let’s shift to a different clinical scenario: The patient who has been sober for many years and has been on a stable dose of a benzo, without signs of abuse. How do you approach such patients?
Dr. Gitlow: I will tell them that it is not in their best interest to stay on the benzo, but if they have been taking medication for many years without any evidence of increasing the dose or having problems, and if they are not comfortable with the idea of discontinuing it, I won’t. But many patients like this will eventually begin to feel as if they are having a problem. They might have read something that concerns them or felt the old twinges of wanting to take an extra pill, and at that point I will generally taper them off.
TCR: More easily said than done!
Dr. Gitlow: Very true, and one of the biggest problems that I see in the field is doctors attempting to taper such a patient from a benzo too rapidly. Almost anything is too rapid if the patient is feeling significant discomfort. If somebody has been on 3 or 4 mg of Klonopin a day for 5 years, I will often do a taper that takes nine or ten months. I might taper by 0.5 mg per day each month with the very last mg being reduced by 0.25 mg a month. I continue to divide the dose evenly throughout the day, rather than removing the morning, afternoon, or evening dose. Using this approach, I have not found any patients who cannot complete the taper nor have I met a patient who didn’t feel better off the medication. They all feel worse each time the drug is lowered. They all feel certain that they are going to feel worse when the taper is complete and yet every one of them at the end of taper comes in and says that they feel significantly better off the drug.
TCR: In what way do they feel better?
Dr. Gitlow: They don’t feel as sedated. They don’t feel as clouded in their thought process. They don’t feel that they put their car keys down and can’t find them anymore. They don’t feel as if they have to reread paragraphs in the paper in order to figure out what it says. They will always end up feeling brighter.