TCR: Dr. Talmadge, in your practice, do you ever prescribe benzodiazepines to people with substance abuse histories?
Dr. Talmadge: Yes, I do.
TCR: Obviously, that’s a controversial practice. What has been your experience with this issue?
Dr. Talmadge: Well, let me tell you a story that will clarify my thinking. About ten years ago I posted an email on Ivan Goldberg’s psychopharm listserv (www.psycom.net) in which I criticized a psychiatrist who was treating a recovering alcoholic with alprazolam, saying that it was a bad idea, it was extremely risky, that they were setting the alcoholic up for relapse, et cetera. Ivan promptly jumped on this and challenged me to back up my statements. I sort of huffed and puffed through cyberspace about this and ultimately realized I had no evidence. And when I really looked into it I found that quite the opposite was true – that there was research showing that the proper management of anxiety disorders is essential if we are going to maximize the recovering alcoholic’s chance of staying sober. So in the last ten years, I have had the experience with many alcoholics of giving them benzodiazepines for generalized anxiety or panic and having them do very well.
TCR: The common and perplexing clinical situation is how one decides whether a given patient with a substance abuse history is a reasonably good candidate for not abusing a prescribed BZ. What is your thought process in determining this risk as you are sitting with a patient?
Dr. Talmadge: First of all I get a sense of the patient’s honesty and authenticity. Some of that has to do with history. If someone gives us a very ragged history of antisocial behavior and dishonesty, if the patient has been through a number of doctors or has what appear to be formidable Axis II issues, your index of suspicion goes up that the patient ultimately will be unreliable in terms of prescribing. If, on the other hand, you get a genuine sense that the person is hanging on with white knuckles trying to stay sober, suffering a great deal of anxiety, and may in fact be disinclined to take a medication because it is frowned upon by their Twelve-Step program, then we are talking with a different kind of patient. So, it does constitute “clinical feel” to some extent, but it also has to do with a realistic appraisal of whether we are dealing with a person who has a comorbid disorder or a person who is trying to get us to think they have a comorbid disorder.
TCR: And how on earth do you figure that one out?
Dr. Talmadge: People who are seeking drugs will very often recite a list of symptoms that sounds very much like it comes straight out of DSM-IV. They have a handle on what they need to say to get the medication. The person who is simply suffering from anxiety may come in not even mentioning “anxiety.” For example, I have had several patients who have come in asking me if they had attention-deficit disorder or bipolar disorder and as I listened to the history, and began to parse it out in terms of actual symptoms, it becomes very clear that they actually suffered a severe anxiety disorder.
TCR: Any other clinical examples?
Dr. Talmadge: Yes, there are other patients in a different category–I’ll describe them for you and you will recognize them very quickly. These are the patients who come in absolutely convinced they have panic disorder and that they need a prescription for (usually) Xanax (alprazolam). They are quite sincere in this and they really believe it, because they actually have had panic. But what they actually end up having is an iatrogenic dependency on a benzodiazepine and then every time they withdraw from it they have a panic attack. These are people who started going to see their PCPs a few years ago for situational anxiety, got put on Valium, then skipped the Valium for a couple of days and had a full-scale BZ withdrawal panic attack. They then got put on Xanax for “panic disorder,” and find that every time they don’t take their Xanax they go into a panic. And in some ways, that is a very gratifying kind of case to manage because if your patient is motivated you can tell them they probably don’t need a benzodiazepine at all, and you can gradually taper the dose and see if they need any medication at all.
TCR: When you’re treating a patient with “legitimate” anxiety who has a history of alcohol abuse, what medication do you like to start with?
Dr. Talmadge: Of course, I like to try SSRIs, because when you hit a home run with an SSRI, there is hardly anything better in terms of efficacy and side effect profile. But if that’s not effective or not tolerated, and you move toward benzodiazepines, I think there are two or three very logical choices. Many patients do quite well on Klonopin (clonazepam) because it is long acting. They can take it just at bedtime or add one or two small doses during the day and do very well. For panic disorder specifically, I don’t think that there is a better BZ than plain old Xanax.
TCR: And how will you typically dose Xanax?
Dr. Talmadge: I usually start them with a bedtime dose of 1 mg, and then beginning the next morning I have them take a baby dose (0.25 mg or 0.5 mg) twice a day. Then I ask patients to call me the next day or the day after, and I might titrate higher based on response.
TCR: So you don’t start out by dosing it on an as needed basis?
Dr. Talmadge: No, I am always stressing prophylaxis. I think if someone suffers from anxiety to the extent that they come to see a psychiatrist, which usually means they are having anxiety almost every day and they consider it really disabling, then it is better to be on a regimen that is going to knock the anxiety out for a while. Once the patient is free of symptoms, we’ll then talk about whether to reduce the dose or stop completely.
TCR: What are the typical doses that most of your patients end up on?
Dr. Talmadge: For Xanax, most of my patients take 1 mg at bedtime, .5 mg in the morning and .5 mg in the afternoon. With Klonopin, I think a lot of psychiatrists dose it too low to have much of an effect. I have many patients taking 3 to 6 mg per day. I have one patient, a recovering alcoholic, who takes 2 mg four times a day and does very, very well. She is back at work, working with her sponsor, goes to AA meetings and has been sober for a year and a half now.
TCR: You certainly have an unusual dosing strategy. Many psychiatrists, including myself, have a maximum dose of BZs beyond which they won’t go, usually in the range of 3 or 4 mg of Xanax or Klonopin.
Dr. Talmadge: That’s true, but I remember many years ago discussing with Ivan Goldberg a bipolar patient who seemed refractory to what would be considered the PDR-standard doses for medications. Ivan said if you are not having side effects, push the dose and what you are going to see is that a lot of your patients are going to get better. And I have practiced that gospel and preached it for a decade and I am absolutely convinced that it is true.
TCR: How do you tend to dispense benzodiazepines to patients with a substance abuse history?
Dr. Talmadge: I do it very conservatively. I have the good fortune in the settings where I practice that I can see patients back as often as is necessary. I don’t write for a large supply right off the bat, but I don’t want my patients to feel that I don’t trust them, either. So I’ll typically say something like, “Let’s not pay for a pound of this stuff until we know it works. I’ll write you enough for ten days and let me see you back in a week and we will look at what we want to prescribe from there. Call me if you have any problems.” I do the same sort of thing with refills. I think this it is a matter of clinician preference, but it bothers me when I look at a medical record I see that a physician has given a benzo or even an antidepressant with eleven refills and they only see the patient twice a year.