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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by mikeyb on October 24, 2006, at 16:08:31
Please help!! have tried alot of the the antidepressants and benzodiazepines,
as well as a range of anticonvulsants and antipsychotics, nothing has has helped my anxiety,it seems medications just go straight through me!.. am kind of running out of ideas. Am trying CBT but just cant see it ever being able to control the physical symptoms, extreme tension in the head being the main problem.Does anyone have any experience with phenobarbital (or other barbituates) for long term management of anxiety? Even cycling it e.g month on month off? or other ideas? GHB etc Thanks! Please!!
Posted by ed_uk on October 24, 2006, at 16:27:53
In reply to Phenobarbital for Anxiety, posted by mikeyb on October 24, 2006, at 16:08:31
Hi M
Pheno was widely prescribed for anxiety before the benzos were introduced. It's not generally prescribed for anxiety anymore though, has your doctor said that you can try it?
Pheno is a long-acting drug which is associated with similar withdrawal symptoms to the long-acting benzos (such as diazepam). If you have previously had difficultly withdrawing from benzos pheno probably isn't the way to go.
I don't know what sort of anxiety you are suffering from so I can't really recommend anything but.......
Have you tried phenelzine (Nardil)?
Ed
Posted by Phillipa on October 24, 2006, at 18:39:16
In reply to Re: Phenobarbital for Anxiety » mikeyb, posted by ed_uk on October 24, 2006, at 16:27:53
Ed you really believe in nardil for anxiety. Have you ever taken it? Why do you feel so strongly about it for anxiety? Love PJ O
Posted by Rjlockhart on October 24, 2006, at 20:01:45
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by Phillipa on October 24, 2006, at 18:39:16
Phenobarbital lasts very long. Similar to Klonopin. My stepdad took it for petit-mal siezures 1 year ago, which was too big of a sedative. He is on Trileptal now.
I dont know, but phenobarbital from what i've seen just slow, and zoned.
I have though about asking my doctor about phenobarbital once, he said no, even though he is 81 years old, he said too old and out dated, i was put on Xanax for panic attacks. He said phenobarbital doesnt really take care of panic attacks, mainly anxiety, siezures, and insomnia. He got his liscence in 1955!
Phenobarbital would be for like grand-mal siezures, when nothing else works for anxiety, even though i dont know if it works for anxiety better than benzo's.
Matt
Posted by yxibow on October 25, 2006, at 6:01:41
In reply to Phenobarbital for Anxiety, posted by mikeyb on October 24, 2006, at 16:08:31
> Please help!! have tried alot of the the antidepressants and benzodiazepines,
> as well as a range of anticonvulsants and antipsychotics, nothing has has helped my anxiety,it seems medications just go straight through me!.. am kind of running out of ideas. Am trying CBT but just cant see it ever being able to control the physical symptoms, extreme tension in the head being the main problem.
For getting rid of the physical symptoms, but not the actual root cause of anxiety, propranolol (or similar non-cardioselective beta blockers, its the most common) is actually the best for what you mention. Plus maybe the slew of migraine medication for any possibility of physical head pain that you have.
There is the old Miltown (or Soma) which might relax your head, but I wouldn't go down that road as it is not as dangerous as a benzodiazepine but it is much more habituating unless you had a tiny dose and kept to it.
>
> Does anyone have any experience with phenobarbital (or other barbituates) for long term management of anxiety? Even cycling it e.g month on month off? or other ideas? GHB etc Thanks! Please!!
>GHB/Xyrem is a very restricted drug, you have to have a condition for it. At least in the US.
I assume you've tried BuSpar (works for around 30% of people).
How long have you given a trial for all the above medications -- I don't mean to be rude, but I just get a sense of "a range of..." and often people quit a medication after just two weeks when in fact it may take two months for some positive effects.
Phenobarbital is going to do nothing more than a good long term trial of Valium, except much more dangerous. They're both GABA-A agonists and the range between the MED (minimum effective dose) and LD50 (50% of rats, dogs, etc.) for barbiturates is far closer than trying a sky high dose of Valium (like 100+ mg, for example). Lung collapse can occur on overdoses much more than the rare events on benzodiazepines and you would have to give up taking alcohol pretty much. That's why benzodiazepines were created in 1958.
Also when you say "medications go through you", you may be a fast metabolizer. I know I am. I take greater than "typical" doses of certain medications for my complex disorder. You may pass things through the P450 system in your liver much faster than others. This is not a fantasy, genetically we are all a little bit different.
Just a few wordsand hope
-- tidings
Jay
Posted by med_empowered on October 25, 2006, at 11:13:43
In reply to Re: Phenobarbital for Anxiety » mikeyb, posted by yxibow on October 25, 2006, at 6:01:41
As barbiturates go, phenobarbtial is probably among the safest. It is also probably the most unpleasant.
Barbs are still used, but usually its in the form of like a 1-week seconal RX for hardcore insomniacs; barbiturates for anxiety are probably ill-advised.
Benzos are actually a lot like barbs, only non-toxic; you might want to try upping the dose, trying another benzo, or perhaps trying a 2-benzo combo (ex: Klonopin, ativan for flare-ups as-needed). Or...Benzos plus Buspar, Benzos plus low-dose antipsychotic (not my favorite, but an option nonetheless), benzos plus antidepressants... so on and so forth.
Posted by ed_uk on October 25, 2006, at 13:07:15
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by Phillipa on October 24, 2006, at 18:39:16
Hi PJ
>Ed you really believe in nardil for anxiety. Have you ever taken it? Why do you feel so strongly about it for anxiety?
I haven't taken it myself no. Nardil seems to have a good sucess rate for certain types of anxiety, specifically social phobia.
Ed xx
Posted by ed_uk on October 25, 2006, at 13:10:59
In reply to Re: Phenobarbital for Anxiety » mikeyb, posted by yxibow on October 25, 2006, at 6:01:41
Hi Yxi
>LD50
Phenobarbital is considerably less toxic in overdose than the short-acting barbiturate hypnotics.
Ed
Posted by mikeyb on October 25, 2006, at 14:24:18
In reply to Re: Phenobarbital for Anxiety » mikeyb, posted by yxibow on October 25, 2006, at 6:01:41
hi guys,
thanks for ur quick response - in answer to your question Ed, no doc has agreed to prescribe the phenobarb, the only way to get it is probably with a balaclava and a bb gun (joke!), tho haven't actually put it to any of them as yet. Thanks for your ideas though, Jays point about being inpatient with meds certainly has some truth to it, think i might try a few methodical combinations as suggested, pushing the doses up higher. Have never actually tried the buspar, just figured that it plays with the same neurotransmitters as the AD's which have never helped so probably wasn't worth trying, maybe worth a go? Soma's another one that i haven't tried - i've just done some research and read that muscle relaxants such as bacoflen and zanaflex may be effective at releasing physical tension (and therefore anxiety?) without being habituating? Any experience or thought on this?? Just something to take the physical edge off so i can work on the other aspects!Vistaril is another med i came acrosss on this board that looks interesting, tho if the benzos (diazepam, librium) didnt help i'm not holding out too much hope...
Jay, I did try the propranolol (beta blockers) a while back not to much avail though, i think they're more effective for fast heart rate, sweating, butterflies etc than for the
physical tension, well for me anyway. thanks for all ur comments
M X
Posted by ed_uk on October 25, 2006, at 16:40:12
In reply to Re: Phenobarbital for Anxiety, posted by mikeyb on October 25, 2006, at 14:24:18
Hi M
>Soma's another one that i haven't tried - i've just done some research and read that muscle relaxants such as bacoflen and zanaflex may be effective at releasing physical tension (and therefore anxiety?) without being habituating?
Carisoprodol (Soma) is a sedative and muscle relaxant. It is related to the old sedative drug meprobamate. Unfortunately, carisoprodol is associated with the development of physical dependence - as are the barbiturates and benzodiazepines.
Have you tried clonazepam (Klonopin, Rivotril)? Clonazepam is a high-potency benzodiazepine.
Ed
>
Posted by yxibow on October 26, 2006, at 4:41:04
In reply to Re: Phenobarbital for Anxiety » yxibow, posted by ed_uk on October 25, 2006, at 13:10:59
> Hi Yxi
>
> >LD50
>
> Phenobarbital is considerably less toxic in overdose than the short-acting barbiturate hypnotics.
>
> EdI was generalizing barbiturates, Ed... I know phenobarbital is on the low end of the scale but its pointless today except for perhaps esoteric epilepsy cases with a nearly 50 year modern history of safe benzodiazepines that can be dialed as high as is recommended or necessary (and combined as suggested before) with due caution to operation of machinery, etc, etc, as with all CNS depressants.
Posted by yxibow on October 26, 2006, at 5:12:16
In reply to Re: Phenobarbital for Anxiety » mikeyb, posted by ed_uk on October 25, 2006, at 16:40:12
> Hi M
>
> >Soma's another one that i haven't tried - i've just done some research and read that muscle relaxants such as bacoflen and zanaflex may be effective at releasing physical tension (and therefore anxiety?) without being habituating?
>
> Carisoprodol (Soma) is a sedative and muscle relaxant. It is related to the old sedative drug meprobamate. Unfortunately, carisoprodol is associated with the development of physical dependence - as are the barbiturates and benzodiazepines.
Yes -- I just mentioned this as a sidebar -- most doctors will also not prescribe Soma or Miltown unless a given need is there (spasms, back pain, etc.). It is a distant cousin of barbiturates, and is safer in those regards but it -can- form physical dependence without due regard to restriction of dosage (or even with.)
Baclofen is a wierd one -- more for GABA-B, and although I think has been tested like everything in psychiatry it is not generally used. It wouldn't really address the GABA-A that you would need.
I don't recall if I went through the hoops of Zanaflex, I think I didn't. Skelaxin did nothing for me (we're talking back stuff.) And Flexeril is a truly yucky tricyclic. So I'm with Robaxin, which being also a carbamic derivative, is basically "really diet Soma" chemically. Curiously structurally related from what I have read to the expectorant Guaifenesin although not particularly chemically I believe. But this is just a back muscle discussion at any rate.
> Have you tried clonazepam (Klonopin, Rivotril)? Clonazepam is a high-potency benzodiazepine.
>
> Ed
>High or low potency (number of tablets and milligrams), its the dosage that works that counts, Klonopin or Valium really share similarities in long half lives (although Klonopin is usually dosed twice daily because the actually half life may be less than a day), although I swear now more by Valium for anxiety.
An increasing chatter on here has noted that Klonopin (clonazepam) can cause some depression. But that is only for certain people. I've never felt it personally. Klonopin is a very subtle agent, one really doesn't feel it once established; Valium is a bit less subtle (personal opinion.)
There's also the slightly more esoteric Serax (oxazepam) which is another anxiolytic benzodiazepine (lower potency, higher dosing may be necessary but generally doesnt go through the liver.)
And then there are polypharmacy combinations.a dose as high as necessary of Luvox/Paxil and low dose Seroquel/Zyprexa.
BuSpar plus something else.
etc.-- tidings
Jay
Posted by ed_uk on October 26, 2006, at 13:43:32
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by yxibow on October 26, 2006, at 4:41:04
>its pointless today
Phenobarbital has a different mechanism of action to the benzodiazepines. Saying 'it's pointless' is not sensible.
Posted by ed_uk on October 26, 2006, at 13:50:19
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by yxibow on October 26, 2006, at 5:12:16
Hi J
>High or low potency (number of tablets and milligrams), its the dosage that works that counts, Klonopin or Valium really share similarities in long half lives (although Klonopin is usually dosed twice daily because the actually half life may be less than a day), although I swear now more by Valium for anxiety.
There is a tendency to prescribe diazepam at subtherapeutic doses. Clonazepam is more likely to be prescribed at doses that actually help. In this way, the high potency of clonazepam is relevent.
>There's also the slightly more esoteric Serax (oxazepam) which is another anxiolytic benzodiazepine (lower potency, higher dosing may be necessary but generally doesnt go through the liver.)
You certainly like the work 'esoteric' J! I think oxazepam is probably best reserved for elderly or debilitated patients who may have trouble metabolising other benzodiazepines.
Regards
Ed
Posted by ed_uk on October 26, 2006, at 13:58:17
In reply to Re: Phenobarbital for Anxiety » yxibow, posted by ed_uk on October 26, 2006, at 13:43:32
Oh dear, I sounded a bit snappy there! Sorry.
Ed
Posted by yxibow on October 27, 2006, at 2:28:03
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by ed_uk on October 26, 2006, at 13:58:17
> Oh dear, I sounded a bit snappy there! Sorry.
>
> EdIts okay... but we don't need to trade barbs online. We all get the favourite word of the week, or even the month. I forget what one my friend always used in a variety of situations.
Posted by yxibow on October 27, 2006, at 2:29:11
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by yxibow on October 27, 2006, at 2:28:03
> > Oh dear, I sounded a bit snappy there! Sorry.
> >
> > Ed
>
> Its okay... but we don't need to trade barbs online. We all get the favourite word of the week, or even the month. I forget what one my friend always used in a variety of situations.Oh my god, that was funny. Barbs. Barbiturates. Okay, realistically this fellow is looking for help, I'm just laughing at myself, nobody else.
Posted by yxibow on October 27, 2006, at 3:16:21
In reply to Re: Phenobarbital for Anxiety » yxibow, posted by ed_uk on October 26, 2006, at 13:43:32
> >its pointless today
>
> Phenobarbital has a different mechanism of action to the benzodiazepines. Saying 'it's pointless' is not sensible.Well, lets see, it was brought to market in 1912. Its not pointless for certain types of epilepsy although it is not a first line agent. It is not a second line agent typically either. Phenytoin is. For status epilepticus.
And you're right to a point, I quote:
"Barbiturates augment GABA responses by promoting the binding of GABA to the receptor and increasing the length of time that chloride channels are open. The mechanism is distinct from the benzodiazepines, which increase the frequency of channel openings."
-- Clinical Pharmacology.
But they both act on GABA and one class is far more safer today than a drug discovered before the FDA or even the Controlled Substances Act.
However, the LD50 is still significantly more than clonazepam or diazepam. Not going to list the grams for obvious reasons. But the verse about the "weeks worth of Valium and slept" from The Verve Pipe "The Freshmen" is only parable. People have survived xxx dose of many benzodiazepines.
The generic of Donnatal to this day is still sold for certain gastrointestinal disorders -- that barbiturate mixture is more self-limiting in terms of dose escalation because one quickly discovers what atropine toxicity is -- essentially psychosis, and hopefully stops there.-- Jay
Posted by yxibow on October 27, 2006, at 3:20:45
In reply to Re: Phenobarbital for Anxiety » yxibow, posted by ed_uk on October 26, 2006, at 13:50:19
> Hi J
>
> >High or low potency (number of tablets and milligrams), its the dosage that works that counts, Klonopin or Valium really share similarities in long half lives (although Klonopin is usually dosed twice daily because the actually half life may be less than a day), although I swear now more by Valium for anxiety.
>
> There is a tendency to prescribe diazepam at subtherapeutic doses. Clonazepam is more likely to be prescribed at doses that actually help. In this way, the high potency of clonazepam is relevent.
Only because of the "mother's little helper" doctor syndrome. Its actually as safe as it gives a 24 hour window or more. Klonopin is milligram for milligram not particularly different in the grand scheme of things except that in some people it can have a half life of as little as 16 hours, thus twice daily dosing.
> >There's also the slightly more esoteric Serax (oxazepam) which is another anxiolytic benzodiazepine (lower potency, higher dosing may be necessary but generally doesnt go through the liver.)
>
> You certainly like the work 'esoteric' J! I think oxazepam is probably best reserved for elderly or debilitated patients who may have trouble metabolising other benzodiazepines....."trouble metabolizing..." It was just a suggestion for a fellow who may not have tried it, even if it is as ineffective for anxiety as Librium except at high doses.
-- Jay
Posted by ed_uk on October 27, 2006, at 14:28:19
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by yxibow on October 27, 2006, at 3:20:45
>...."trouble metabolizing..."
The half life of certain benzodiazepines can be extremely prolonged in a proportion of elderly people (eg. alprazolam, diazepam, midazolam). This may lead to accumulation......oversedation, confusion etc. Benzos metabolised by conjugation (eg. oxazepam, lorazepam and temazepam) do not accumulate.
Posted by ed_uk on October 27, 2006, at 14:39:46
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by yxibow on October 27, 2006, at 3:16:21
>It is not a second line agent typically either
No, it isn't, but that doesn't mean that it's pointless.
>But they both act on GABA
So do a lot of the other anticonvulsants, but their effects are not the same. For a start, phenobarbital and benzodiazepines bind to different receptors in the brain. Phenobarbital is not simply a 'less safe version of a benzo', it is a drug with a different mechanism of action. You cannot predict the efficacy of pheno based on whether or not a benzo was effective. The opposite is also true.
>However, the LD50 is still significantly more than clonazepam or diazepam
A large number of drugs are potentially dangerous in overdose. This does not make them pointless however. Phenobarbital still has a role in the treatment of epilepsy when other drugs have not worked or have caused intolerable side effects.
>Donnatal
Interesting. We don't have any pheno combinations in the UK. Pheno is only available on its own, as 15mg, 30mg and 60mg tablets, and as an injection.
Ed
Posted by Phillipa on October 27, 2006, at 19:26:39
In reply to Re: Phenobarbital for Anxiety » yxibow, posted by ed_uk on October 27, 2006, at 14:28:19
Ed am I elderly? Must seem it to you. Love PJ O
Posted by yxibow on October 27, 2006, at 23:22:24
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by Phillipa on October 27, 2006, at 19:26:39
> Ed am I elderly? Must seem it to you. Love PJ O
Elderly is a charged word in part -- don't self-absorb it, Jan. Its a natural part of aging though that say 60 or 70+, one has to be more careful of whatever set of medications one is on because of diminished elimination capacity. Doses may be adjusted for that reason. Doesn't mean you're not full of life -- don't forget that. Keep your mind and body going, people are living to 80+ with proper medical care, especially women.
Posted by ed_uk on October 29, 2006, at 10:49:40
In reply to Re: Phenobarbital for Anxiety » ed_uk, posted by Phillipa on October 27, 2006, at 19:26:39
Hi PJ
I think of you as middle-aged! :)
Ed xxxx
Posted by Phillipa on October 29, 2006, at 19:31:17
In reply to Re: Phenobarbital for Anxiety » Phillipa, posted by ed_uk on October 29, 2006, at 10:49:40
Thank-you my sweet Ed. That was kind of you. Made me feel better so I just rode 7.5miles on my bike in the dark. See you're the magic pill!!!!!!Love PJ O
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