Often, I find myself torn between the art and the science of pharmacology - that ambiguous divide between clinical trials and (my somewhat limited) relevant clinical experience. One word that will conjure this dilemma every time is benzodiazepines.
Love them? Hate them? I like to think I walk the middle-ground, keeping the peace between the need for a fast-acting anxiolytic and a "happy pill". If so, then why do I still worry that I am being played every time I prescribe something ending in -azepam?
At first, I had the idea that I could have the decision be relative to each client. To hold my individualized care flag high and pat myself on the back for being less jaded than others in the field I had met. Maybe that would work... if I had more experience at reading people quickly or was a human lie detector. But once on my own with no Yoda-like preceptor to guide my way, things quickly became clouded. I've learned that meeting someone for the first time for forty minutes doesn't give you any deep insights, just a glimpse at past patterns.
So, a 55 year-old male with a h/o MDD, GAD, PTSD and ETOH dependence walks into... your office and wants to go back to drinking because his panic attacks and PTSD symptoms have gotten to be too much and the medications you have him on (AD plus non-benzo add-ons, likely some Naltrexone on the side) and his therapy just aren't cutting it. What do you do? Maybe he was using ETOH to self-medicate his anxiety? But then again, perhaps he is only now feeling his 'true' feelings and he can start the 'real' therapy work?
There is no easy answer. So, what I've done for now is to come up with a formula. Well, honestly its what I always do when I don't know the solution. I have my own set of rules I follow to figure out if benzos are even an option. After explaining how therapy, especially CBT is great for anxiety, I come at it two ways: (1) Long-term anxiety management - some kind of SSRI usually and (2) Short-term panic/anxiety management. The short term fix is a non-benzo to start, varying depending on their symptoms/meds/health conditions/etc... options include but aren't limited to hydroxyzine, clonidine, or gabapentin. This gets me by, but its no cure-all to the benzo dilemma.
If I decide to start someone on a benzo, it is to cover them while the LT anxiolytic takes effect and I am very clear about this (I even have it in writing). I tell them the plan is to keep them on the lowest therapeutic dose of a benzo as needed for 6-8 weeks and then taper them off and see what the LT med is doing for them. Also, that they should fully expect to feel some anxiety and that we are aiming for manageable levels not a cure. I (and evidence-based practice) are huge fans of therapy for anxiety remission and management.
I'm sure as my green wears off and I get wiser, I will look back on this post and shake my head at my over-simplification of it all. But, faced with a daunting number of decisions in a day, I need some way to narrow down my choices and let me sleep at night without worrying that I've become the next 'candy lady'.
Love them? Hate them? I like to think I walk the middle-ground, keeping the peace between the need for a fast-acting anxiolytic and a "happy pill". If so, then why do I still worry that I am being played every time I prescribe something ending in -azepam?
At first, I had the idea that I could have the decision be relative to each client. To hold my individualized care flag high and pat myself on the back for being less jaded than others in the field I had met. Maybe that would work... if I had more experience at reading people quickly or was a human lie detector. But once on my own with no Yoda-like preceptor to guide my way, things quickly became clouded. I've learned that meeting someone for the first time for forty minutes doesn't give you any deep insights, just a glimpse at past patterns.
So, a 55 year-old male with a h/o MDD, GAD, PTSD and ETOH dependence walks into... your office and wants to go back to drinking because his panic attacks and PTSD symptoms have gotten to be too much and the medications you have him on (AD plus non-benzo add-ons, likely some Naltrexone on the side) and his therapy just aren't cutting it. What do you do? Maybe he was using ETOH to self-medicate his anxiety? But then again, perhaps he is only now feeling his 'true' feelings and he can start the 'real' therapy work?
There is no easy answer. So, what I've done for now is to come up with a formula. Well, honestly its what I always do when I don't know the solution. I have my own set of rules I follow to figure out if benzos are even an option. After explaining how therapy, especially CBT is great for anxiety, I come at it two ways: (1) Long-term anxiety management - some kind of SSRI usually and (2) Short-term panic/anxiety management. The short term fix is a non-benzo to start, varying depending on their symptoms/meds/health conditions/etc... options include but aren't limited to hydroxyzine, clonidine, or gabapentin. This gets me by, but its no cure-all to the benzo dilemma.
If I decide to start someone on a benzo, it is to cover them while the LT anxiolytic takes effect and I am very clear about this (I even have it in writing). I tell them the plan is to keep them on the lowest therapeutic dose of a benzo as needed for 6-8 weeks and then taper them off and see what the LT med is doing for them. Also, that they should fully expect to feel some anxiety and that we are aiming for manageable levels not a cure. I (and evidence-based practice) are huge fans of therapy for anxiety remission and management.
I'm sure as my green wears off and I get wiser, I will look back on this post and shake my head at my over-simplification of it all. But, faced with a daunting number of decisions in a day, I need some way to narrow down my choices and let me sleep at night without worrying that I've become the next 'candy lady'.
