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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by football on April 23, 2007, at 2:06:10
It seems like Klonopin, Xanax, Atvian, and Valium are far and away the most commonly used benzos. Why is this? Do the others tend to be less effective?
I mean, there are around 25 different benzos, so it seem odd, that so few are used on a regular basis.
http://en.wikipedia.org/wiki/List_of_benzodiazepines
Posted by Quintal on April 23, 2007, at 2:20:33
In reply to How come it seems only 3-4 benzos are ever used?, posted by football on April 23, 2007, at 2:06:10
Well, temazepam, oxazepam and nitrazepam are commonly used here in the UK. Klonopin and Xanax aren't used at all in psychiatry on the NHS, in fact doctors are strongly discouraged from using them. Ativan is also frowned upon, with Valium being the mainstay of most benzo prescribing - almost the opposite of the prescribing habits in the US.
Librium is often used in alcohol and benzo detox, and midazolam is often used as a sedative during uncomfortable surgical procedures.
As with ADs doctors tend to have their own individual preferences for specific benzos and trends tend to develop over time where some fall into disuse, not necessarily because they're ineffective or especially dangerous, but because they've gone out of fashion.
Q
Posted by James_glasgow on April 23, 2007, at 7:37:23
In reply to Re: How come it seems only 3-4 benzos are ever used? » football, posted by Quintal on April 23, 2007, at 2:20:33
Hi Quintal
I am also in the UK and not sure I agree with you on the issue of the use of clonazepam. My GP has been prescribing it to me since 1993 at my request, he is pretty good with benzodiazepines (with the expection of loprazolam and flurazepam there is nothing he has not prescribed both on the NHS and privately). After a few years I asked him if he knew exactly what I was taking it for and he rhymed off a long list of off label uses, I was most surprised. Turned out he had a friend in the states who is also a doctor.
My Consultant Psych has also given it to me although he prefers lorazepam (Ativan).
James
Posted by Quintal on April 23, 2007, at 8:25:11
In reply to Re: How come it seems only 3-4 benzos are ever used?, posted by James_glasgow on April 23, 2007, at 7:37:23
Hi James,
I know it's certainly possible to obtain clonazepam on prescription under special circumstances in the UK - I was prescribed Rivotril too by my GP for about four years, but that was only because I managed to persuade a fairly liberal young locum doctor to give me a trial of it, and from then on - well doctors are like sheep aren't they? My usual GPs would never have entertained the idea, and the psychiatrists did everything they could to try and force me on to diazepam, and off benzos altogether.
I was referring to general prescribing habits, and in the UK diazepam reigns supreme while clonazepam has no license for anxiety and very few would prescribe it off-label even if you asked nicely (I'd say most aren't even aware of it as an anxiolytic). I also had a private prescription of Xanax from the same locum GP (it isn't available on the NHS at all), and my usual GP went bezerk when she found out what he'd been prescribing. Apparently they'd had a warning/reminder notice against prescribing the potent short-acting benzos like Ativan just weeks before, and sure enough they got queries over the unusual prescribing habits from the local health authority a short while later (I went through nearly every benzo in the book in a short space of time). I think that might have been one reason why they wanted me off Rivotril so badly. The same thing happened when my psychiatrist started me on Depakote - a warning letter from Big Brother saying ordinary sodium valproate would have to suffice as Depakote was too expensive/inappropriate by their standards.
I'm just guessing you might be living in Scotland from your posting name? I think there are substantial differences in the way the health system operates in England and Scotland, but I would be very surprised if clonazepam or alprazolam accounted for more than a tiny fraction of psychiatric benzo prescriptions on the NHS even in Scotland. It seems they're used almost exclusively in the private sector, or on rare occasions at the request of an individual patient on the NHS, but that's far from common.
Good to hear from others in the UK anyway! Good luck with your current treatment.
Q
Posted by James_glasgow on April 23, 2007, at 9:01:55
In reply to Re: How come it seems only 3-4 benzos are ever used? » James_glasgow, posted by Quintal on April 23, 2007, at 8:25:11
Hi
Thank you for your good wishes with my treatment, I hope yours is going well also.
I agree completely with you, I have the equvialent of the locum you met as my permanent GP, have know him 13 years now (it is funny actually when he is on holiday and I see a locum they look at my records rather strangely). He has given me just about everything I have requested (mind you I have been studying pharmacology for a long long time and have a degree in Medicinal Chemistry which might have made a difference) including Nardil and Parnate (that made my Consultant pull a face, I am sure you can imagine). Just today I was given 56 5mg nitrazepam tablets as last month I asked for and was given lormetazepam 1mg, but considering how much I cost the NHS even I dont like the idea of them paying £35 for a packet of sleeping pills.
I also agree with your comments about the difference between Scotland and England. I was on holiday in York and ran out of some of my medicine. I saw a GP as a temporary patient, who refused to give me the Losec I was taking as it was "far too expensive", and she gave me cimetidine instead. I dont think doctors here have the same budget restraints.
I am currently just recovering from a 3 week mania, and have been taken off of everything expect the benzo's (I could open a pharmacy with the collection I have). Clonazepam has brought me back to the ground. Thinking of going back on lithium and seeing how it goes.
Take care.
James
Posted by Phillipa on April 23, 2007, at 10:08:57
In reply to Re: How come it seems only 3-4 benzos are ever used?, posted by James_glasgow on April 23, 2007, at 9:01:55
Seems like klonopin is the favorite of most US docs.Love Phillipa
Posted by xbunny2007 on April 23, 2007, at 15:49:03
In reply to Re: How come it seems only 3-4 benzos are ever used? » James_glasgow, posted by Quintal on April 23, 2007, at 8:25:11
> I know it's certainly possible to obtain clonazepam on prescription under special circumstances in the UK
> I was referring to general prescribing habits, and in the UK diazepam reigns supreme while clonazepam has no license for anxiety and very few would prescribe it off-label even if you asked nicely
>(I'd say most aren't even aware of it as an anxiolytic)It is worth noting that the use of clonazepam is specifically mentioned in the BNF as a treatment for panic attacks even though its off-label. None of my GP's, psychiatrists and CPN's have been unaware of it or reluctant to use it. Compared to flupenthixol, pericyazine, trazodone and reboxetine which several were unaware of.
While I was in hospital the benzo I was given was either alprazolam or lorazepam - dont recal which, was a long time ago...Regarding the initial question, aside from the hypnotics is there really much difference in the effects of benzos? I thought most of obscure ones were cashins during the time benzos were popular.
Bunny
Posted by harry_in_philly on April 23, 2007, at 18:23:00
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by xbunny2007 on April 23, 2007, at 15:49:03
Tranxene (clorazapate) is still occasionally prescribed..often for ethanol w/d. Doral and Dalmane were popular in the 1980s for insomnia. Restoril is really the only benzo still commonly prescribed for insomnia and that is quickly being replaced by Ambien, Lunesta, Sonata, etc.
Personally, I've tried many benzos and have found that Tranxene and Xanax have been most effective for my GAD
Posted by Quintal on April 24, 2007, at 2:07:38
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by xbunny2007 on April 23, 2007, at 15:49:03
Hi Bunny,
>It is worth noting that the use of clonazepam is specifically mentioned in the BNF as a treatment for panic attacks even though its off-label.
I'm aware of that - it was my main defence when new psychiatrists tried to tell me it had no official endorsement for use in psychiatry in this country.
>None of my GP's, psychiatrists and CPN's have been unaware of it or reluctant to use it.
I'm curious, how was the subject of using clonazepam (as opposed to more commonly prescribed benzos) raised? Did they suggest it spontaneously to you, or did you make a request to them? I suppose some doctors will have used clonazepam to treat rare forms of epilepsy (my GP told me she had treated only one other patient bar me with Rivotril and that was for an unusual form of epilepsy) and will know that all benzos are anxiolytics, but out of 7 GPs, 5 psychiatrists and 3 CPNs only one GP was aware and had used it, and only then for epilepsy. All were reluctant to use it and provide repeat prescriptions, and I think that would be a typical reaction of most medical staff in the UK.
>While I was in hospital the benzo I was given was either alprazolam or lorazepam - dont recal which, was a long time ago...
Lorazepam is often used in hospitals because of it's quick onset of action, which is especially useful in calming agitated or manic patients when given by injection. Most people are withdrawn from it before they're discharged and transferred to a more 'acceptable' drug like an AP or Valium. This doesn't reflect the prescribing habits of the wider outpatient medical community in the UK. Alprazolam seems rarely used in hospitals even in the US for some reason, possibly its short half-life and (relative) lack of sedative effects.
>Regarding the initial question, aside from the hypnotics is there really much difference in the effects of benzos?
Some are more hypnotic, some more anxiolytic, some more effective at suppressing seizures than others, and then there's the difference in half-lives.
>I thought most of obscure ones were cashins during the time benzos were popular.
Probably :-)
I'm sorry we seem to be getting a little polarized in the UK Klonopin debate. The point I'm making is that the likelihood of a person walking into their GPs surgery complaining of anxiety and walking out with a script for clonazepam is close to nil, unlike the US where it seems fairly typical of their prescribing habits. There are always some professionals who have unorthodox views and prescribing habits, and perhaps they influence the staff who support them? I think it would be misleading to say though that clonazepam is commonly used in England, and I'd be interested to hear Kaleidoscope's views on this.
Kind regards
Q
Posted by Quintal on April 24, 2007, at 2:30:55
In reply to Re: How come it seems only 3-4 benzos are ever used?, posted by James_glasgow on April 23, 2007, at 9:01:55
Hi James,
Although I complain about them, my GP and psychiatrists have prescribed most things I've asked for too - usually because I approached them with solid evidence and research to support whatever treatment I was requesting. It can feel like an uphill struggle just to get adequate treatment at times though, as if I'm the one doing all the work.
Nardil is the only MAOI I haven't taken, and yes it can be hard to get psychiatrists to use them these days. The last one told me they were almost useless and far too dangerous when I asked for Parnate - "How about sertraline instead?" - he was very young and newly graduated. He gave me it anyway after a bit of heavy persuasion, but refused to raise the dose above 30mg and Parnate only worked for me in the 80-120mg range. He labelled me as an abuser for raising the dose of my own accord and discharged me, so now I'm having to go it alone.
There was a lot of controversy here a few years ago about Scottish women getting the breast cancer treatment Herceptin, while English women were being refused by their local health authority, so there certainly are differences in budget restrictions.
Good luck with the lithium :-)
Kind regards
Q
Posted by James_glasgow on April 24, 2007, at 4:33:53
In reply to Re: How come it seems only 3-4 benzos are ever used? » James_glasgow, posted by Quintal on April 24, 2007, at 2:30:55
Hi Quintal
You make some very good points. Hopefully when I am feeling better I will be in a position to engage myself in the coversation with somemore salient points myself.
Over the years I have had just about every label stuck on me possible, mainly because I have argued with SHO's in psychiatry about benzodiazepines. One once told me that if she gave me 5mg of diazepam today, next week I would be asking for 10mg, then 15mg and so on. When I tried to correct her she took umbrigde at this and refused to speak to me any further. Some of them are just plain stupid (one Consultant said to me "where does the NHS get them from"), one SHO once said to me "you know if you answer yes to this next question I am not going to let you out of here", it was are you planning on killing yourself, I promptly said "no", took my jacket and left. When I told my Consultant he said he liked my sense of humour.
Are you still on the Parnate at the moment. On my third course of it I had a spontaneous hypertensive reaction, which I could hardly beleive was happening. I got a taxi to the local casualty department, and was first asked "are you trying to kill youself?", then, "do you suffer from migraine", unfortunately for me the answer to that one was yes and as I doubt they had ever seen this before they though it was a migraine. The headache was expectionally painful and I did not want to be seen as drug seeking but after 10 minutes I could stand it no longer, so I asked for pain relief. To my astonishment they attempted to inject me with tramadol (when I protested that it would give me serotonin syndrome and likely kill me in my current condition, they start going on about me reading things on the net and turned it around as me refusing proper treatment) Only later did the doctor say thanks for stopping him from killing me. It just gets worse from there, I was discharged home with no treatment. When I got there when I attempted to lay down the head got even worse, and I decided I was either going to call an ambulance (and end up back in the same hospital where they clearly did not know what they were doing) or chew one of the nifedipine capsules I was give for something else ,but I know it is used to bring down blood pressure and to end these episodes although there is concern among some doctors that it can bring your blood pressue down too low too quickly leading to a stroke. Within another 10 minutes the headache was gone and I wish I had done that in the first place. So my warning to you would maybe to get a medic alert braclet so that no one gives you pethidine or tramadol (as tramadol has now replaced nalbuphine as the medicine ambulance crews carry to treat pain).
Hope I have not scare you too much.
Take care.
James
Posted by xbunny2007 on April 24, 2007, at 19:04:28
In reply to Re: How come it seems only 3-4 benzos are ever use » xbunny2007, posted by Quintal on April 24, 2007, at 2:07:38
Hi!
> I'm curious, how was the subject of using clonazepam (as opposed to more commonly prescribed benzos) raised? Did they suggest it spontaneously to you, or did you make a request to them?
I ask them about diazepam alternatives and they say clonazepam is one of them.
> I'm sorry we seem to be getting a little polarized in the UK Klonopin debate. The point I'm making is that the likelihood of a person walking into their GPs surgery complaining of anxiety and walking out with a script for clonazepam is close to nil,
Agreed, the chance of getting any benzo is pretty close to nil and clonazepam far closer to nil even than that!
Kind regards,
Bunny
Posted by James_glasgow on April 25, 2007, at 3:37:47
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by xbunny2007 on April 24, 2007, at 19:04:28
Hi
In an earlier post someone pointed out it is now mentioned in the BNF as a treatment for panic, albeit unlicensed. Most GP would be happy to go along with what the BNF says in this regard as they use things off license every single day, TCA's for post herpetic neuralgia.
What I have done in the past is rather than go in armed with lots of printout of studies from the net, which I beleive GP's dont look upon very favourably, post them with a letter to your doctor outling your problem and why you would like to try it. They then are practically forced to actually read it and consider it. Sneaky but it can be effective and it gets past the time constraints of an average 5-7 minute appointment.
James
Posted by Quintal on April 27, 2007, at 17:37:16
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by James_glasgow on April 25, 2007, at 3:37:47
Hi James,
I've found that sometimes GPs get very prissy and refuse anything off license, particularly psychiatric drugs for which they have little training. My GP recently refused to prescribe Lyrica for anxiety (even though I've taken Neurontin) because she has no experience of using it for this purpose, she would have referred me to a psychiatrist to discuss it further but he discharged me, so the point is moot.
Having a mention in the BNF wasn't enough to persuade my last two psychiatrists to keep on prescribing clonazepam. They wanted me off benzos altogether and when persuasion failed they just cut off my prescriptions and placed a block on the surgery computer to stop me going to another locum GP to re-start my scripts. As I said before, doctors are like sheep and once one stops the scripts they all follow suit.
I sent letters to my first psychiatrist all the time, but the last one didn't want to hear of any ideas he didn't think of himself and I was asked to stop mailing him. I agree, most of these techniques work if you have a good relationship with your doctor, but if you don't then the chances of getting adequate treatment are slim unfortunately.
Q
Posted by Phillipa on April 27, 2007, at 18:31:22
In reply to Re: How come it seems only 3-4 benzos are ever use » James_glasgow, posted by Quintal on April 27, 2007, at 17:37:16
Q well I'm glad I don't like in the UK as lately the docs are the opposite. Wonder how many switched from atypical antipsychtics with the law suits here? Watch TV and you see another one at least the stations I watch we have satellite. Love Phillipa
Posted by James_glasgow on April 27, 2007, at 18:51:09
In reply to Re: How come it seems only 3-4 benzos are ever use » James_glasgow, posted by Quintal on April 27, 2007, at 17:37:16
Hi Quintal
I am sorry to hear you are getting such poor treatment.
I am in the process of being transfered from addiction psychiatry (they have decided that liking a drink is not what is causing my illness, the illness is causing me to like drinking), and hope I dont encounter the same problems. As it has just dawned on me that as the addiction psychiatrist is dealing with benzo's all the time that might be why he was more happy to use them, as when I was in general psychiatry before I was always arguing with doctors about them and their prejudice getting in the way of effective treatment. This resulted in them refusing to talk to me. I was in hospital in the early 90's and I had one consultant who told me she was very old fashioned in her prescribing habits and did not even like using SSRI's. I sat there wondering how many patients on the ward were suffering because of what "she did not like".
I think I even read on hear not that long ago that Prof Ashton, the famous anti-benzo doc had said she was misquouted and beleives some patients do benefit from long term treatment.I have tried lyrica myself and did not like it (I got it a few days after it was licensed for anxiety, but I had shingles years ago and still suffer some pain so my GP gave it to me for that). I personally did not like it, after 2 days I could not walk in a straight line and was slurring my speech and that was on a low dose. Although again I have heard people raving about it. I used the letter writing last to ask for a trial of topiramate as an anti-craving agent, well that was my stated reason for my request (it actually was more to see if it would help me lose some of the weight the SSRI's and other psychiatric drugs have helped me put on over the years, and if it was any use as a mood stabiliser, it turned out to have too many side effects). I am one of those people who unfortunately seem to get lots of side effects and little benefit from most psychiatric drugs with the expection of a few SSRI's, and benzodiazepines.
I should be seeing this new psychiatrist soon, so will let you know how things go. I think I might saving a copy of this entire thread somewhere, as I am not too sharp at present and you are coming across to me very eliqouintly (sorry I can't spell it) in your writing. I wish there was more I could suggest to help, it is a tricky one.
Take care.
James
Posted by James_glasgow on April 27, 2007, at 19:02:49
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by James_glasgow on April 27, 2007, at 18:51:09
Please excuse my poor English in my threads, I think it is as a result of my concentration not being good. I have noticed that there has not been one email I have sent in the last few months that is not riddled with errors. Sometimes I wonder if one day some form of brain damage is going to be found to be associated with SSRI use in the same way as the long term use of neuroleptics. I have been on anti-depressants, mostly SSRI's since January of 1993, with only a very few small breaks, this being one of them.
James
Posted by Quintal on April 29, 2007, at 17:54:17
In reply to Re: How come it seems only 3-4 benzos are ever use, posted by James_glasgow on April 27, 2007, at 18:51:09
Hi James,
I'd have thought an addiction specialist might be even more wary of using benzos than a 'regular' psychiatrist - one of my psychiatrists wanted to refer me to an addiction specialist to come off benzos? Unless he thinks they're helping to curb your desire for alcohol a little?
I started a thread on here called 'Ashton Rocks!' a few months ago after I read a letter she wrote to the health minister Rosie Winterton defending benzo addicts right to proper treatment. Like most people I hated Ashton with a passion all the time I took benzos, but only after having my prescriptions stopped did I realise I would have had much more humane and appropriate treatment if I'd been under her care, or if the doctors who were treating me had followed her guidelines properly. This was misinterpreted by a few posters and as you might imagine, a heated debate ensued ending with me being blocked. She does say some people will require long-term benzo prescriptions, but doesn't specify who they might be.
I'm doing very well on a combo of tianeptine and nicergoline (do you know anything about it?), which I couldn't get on the NHS anyway, so it doesn't really matter I no longer have a psychiatrist :-)
Hope you get good treatment from your new psychiatrist. I found the first few appointments can be very trying for both parties when they discover you are an 'informed consumer' and most don't take kindly to it. I think that was the main reason my last psychiatrist wanted rid of me.
Q
P.S. You come across fine in your writing - I thought you were very eloquent and knowledgeable too. Just run your posts through the spellchecker on your email package like I do and everyone will imagine you're effortlessly word-perfect!
Posted by James_glasgow on April 30, 2007, at 3:52:05
In reply to Re: How come it seems only 3-4 benzos are ever use » James_glasgow, posted by Quintal on April 29, 2007, at 17:54:17
lol. Thank you.
I also know the first meeting can be difficult.
I had a very odd relationship with the Psychiatrist I am leaving, and had many theories. When someone I know ended up an inpaitent in the ward he works in, he overhead another doctor saying "Dr x has a problem with intelligent patients". I asked my nurse (which with hindsight was not very fair on him), but he handled it briliantly, managed to dodge the question perfectly, but would not say "no".
I don't imagine it could get worse than it was, but this is the NHS, you never do know.
Take care.
James
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