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From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Trauma anesthesia demand
Date: 27 Dec 1997 20:40:21 GMT

In <34A556CE.465@columbus.rr.com> Keith Lamb <klamb@columbus.rr.com>
writes:

>  I've had 3 MRI scans attempted on me, all of which were aborted
>because they couldn't get me sedated and couldn't get IVs started.


  Well, your problem there is anxiety.  What you need is for your doc
to write you a precription for some 1 mg Xanax tablets.  Take a couple
on an empty stomach an hour or two before the procedure.  If you're
feeling too anxious during, you can take a couple more.  Just make sure
you have somebody to drive you home.

   This works great for dentists, also-- 4 mg of Xanax or Ativan an
hour or two before, will make many a procedure far more tolerable (the
pain is the same, but you care much less about it).  Often nitrous
oxide and oral NSAIDS are quite enough pain control to do most
procedures, if anxiety is totally controlled.  In addition, many
dentists, oral surgeons and periodontists use oral meperidine or
oxycodone for significant procedures.  IV stuff is really not necessary
for most.  It's just more convenenient because it's more controlable,
and doesn't last as long after the procedure is over.  Again, that's
just a matter of having somebody available to take you home and keep an
eye on you.

                                Steve Harris, M.D.





From: ((Steven B. Harris))
Subject: Re: Zoloft/Xanax
Date: 14 Jun 1995

In <1995Jun13.135735.1185@apgea.army.mil> ksbroadw@apgea.army.mil
(Kimberly S. Broadwater (Piercy)) writes:

>
>Ok, I could really use the expert help of someone who can answer a few
>questions on the combined use of Zoloft and Xanax.  I have a relative
>who had been taking Xanax occasionally, prescribed of course.  As
>of late this person has become depressed, severly. Due to the fact that
>the doctor could not see him for 2 weeks, his primary care doctor
>gave him the go ahead for taking a Xanax to calm him down.  He would
>experience anxiety attacks, and then would become sad and cry.
>So now he is taking up to 4 Xanax per day AND is now taking a
>Zoloft in the morning.  My opinion is that this is dangerous, it
>just doesn;t sound right to me, it seems like the Xanax is keeping
>him down and the Zoloft is trying to life his spirits.  I'm sure
>it is more complicated than that.  Anyway, he went to the local
>hospital over the weekend because he could not stand the depression
>feeligns anymore.  They really were not able to help him out and the
>doctors there were very surprised in the medication he was taking,
>meaning the Xanax 4 times per day. They say he is now addicted and
>will have to be weened off.  I guess what I am looking for is
>something about the drug Xanax and the drug Zoloft as individuals
>and what can happen if they are taken together.  Does anyone
>have the FAQ's handy or any other information?  I would really
>appreciate anything I could get to read, unfortunately I need
>it real soon!  Thanks bunches!
>
>                                            Kim
>
>

Hi, Kim.  I've seen a fair number of people hooked on Xanax, a
phenomenon basically denied by UpJohn and the psych journals both, all
of which insist that most anxious people can be weaned slowly off Xanax
with no problemo.  Uh, huh, and cocaine and heroin, too.

I've been able to get a few people off Xanax in somewhat the same way
heroin addicts are gotten off heroin-- you replace the heroin with a
very much longer acting drug (methadone) which prevents the worst of the
withdrawal problems, and then you VERY slow inch down on the dose of
methadone.  In the case of Xanax, the corresponding drug with the long
half-life which you can inch down on slowly, is Valium.  Xanax itself
has entirely too short an up-and-down course (itself causing panic in
panicky people) to be able to work with very well on a withdrawal
program.  UpJohn will tell you differently, but UpJohn is making
millions and millions a year selling this damned stuff-- what do you
*expect* them to tell you?  That you need something made by Roche?

One more thing-- someone might suggest the use of a drug called Buspar
as a non-benzodiazepine treatment for anxiety in people coming off
Xanax.  Don't even bother.  Buspar is helpful sometimes in people who've
never taken Xanax, but after they've seen Xanax, Buspar might as well be
Tylenol.

That's my two cents worth.  BTW, I'm an internist, so I'll now pull my
head in and wait for the psychiatrists to attack.

                                            Steve Harris, M.D.




From: sbharris@ix.netcom.com (Steven B. Harris )
Subject: Re: xanax
Date: 20 Aug 1995
Newsgroups: sci.med

In <4167p2$i1u@info.evansville.net> William Bebout
<wbbebout@evansville.net> writes:

>>My parents are going through a very stressful situation. Their doctor
>>prescribed Xanax.  I told them I thought could be viciously addictive
>>and told them I would check the this newsgroup.  Now I guess I have them
>>wondering what TO take.  I thought I read someplace that Elavil or
>>something is cheaper and much safer. Also they don't necessarily have
>>"panic attacks", they are in their late 70's and have some situational
>>problems that are causing them tremendous stress. I am quite concerned
>>about them (father has high blood pressure).  I do not live close to
>>them, unfortunately.  Thanks.
>
>Xanax (alprazolam) is a benzodiazepine and like others in this class of
>meds has an addiction potential.  Although this is true if used correctly
>(something to decrease stress and not as a crutch) then the risk is low.
>Personally I don't feel that elavil would be appropriate in their
>situation unless it is being used as a sleep agent.  As for the panic
>attack situation, xanax works well for low level stress. It is not just
>for panic attacks.
>
>--
>Bill
>-----------------------------------------------------
>William Bebout, MD
>Deaconess Hospital Family Practice Residency
>Evansville, IN
>http://www.evansville.net/~wbbebout/
>-----------------------------------------------------



May I add that the addictiveness of Xanax is in direct proportion to
how long it is used?  For two weeks on somebody who is terrified of an
upcoming surgery is one thing.   Using it chronically on people who
have life problems that are not expected to get better quickly is
something else.  Sometimes with people with panic disorder you have no
choice.  For many mildly anxious people, however, getting them hooked
on Xanax will CREATE panic attacks and full blown panic disorder-- when
the morning paper doesn't come.  And when they didn't get their Xanax.
Trust me on this.

                                          Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Ritalin
Date: Mon, 07 Jul 1997
Newsgroups: misc.health.alternative,alt.drugs,sci.med.pharmacy,sci.med

>I have friend addicted to crystal meth. He wants to quit but will not,
>will not, will not, go to treatment. He is scared to crash, can he take
>Xanex or VAlium along with our support?  Or will there be a drug
>interaction?

   Probably not.  The important drug interactions with Xanax involve
synergistic effects with other "downer" drugs, which of course
methamphatamine isn't.  You can usually use it freely to kill anxiety
when getting off addictions to most things (but wait until the anxiety
hits).  Occassionally "downer" type addicts (people who like alcohol or
barbiturates) end up dependent on Xanax, but there are worse things to
be dependent on (like alcohol!).  This happens less rarely with
addiction to uppers and narcotics.  With excitants like meth and
cocaine, the feeling on withdrawal is less anxiety than one of complete
and horrendous depression and lethargy, caused by lack of
neurotransmitters.  Sometimes Xanax/Ativan/Librium/Valium and the like
can keep a person from going crazy during this phase.  If so, use em.

   But get him off the meth.  It's a horrible drug, and will eventually
drive him stark raving mad.  Xanax, at least, will not.

                                            Steve Harris, M.D.


From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Valium for recovering alcoholics
Date: Fri, 11 Jul 1997
Newsgroups: misc.health.alternative,alt.recovery.aa,sci.med.pharmacy,sci.med

In <5q0tsu$b0e@mufasa.harvard.edu> rind@enterprise.bidmc.harvard.edu
(David Rind) writes:

>I do strongly disagree with Dr. Harris about Xanax in particular.  I
>think it is far more addictive than the other benzodiazepines and should
>rarely be used.  It is the only benzo I have ever seen a patient have
>a withdrawal seizure from. (Gotta love those danglin' participles.)
>It sounds like Dr. Harris likes Xanax, and I would be interested in
>whether he feels that it is as safe as the other benzos.
>--
>David Rind
>rind@enterprise.bih.harvard.edu



    I only "like" Xanax in that it doesn't seem to cause as much
sleepiness per unit of anxiety relief, though of course we all know
that benzos differ among each other relatively little (except in
half-life) and patients differ a lot.

    I also have the sujective feeling from my practice that Xanax is
horribly addictive for a lot of people (let me tell you stories).  And
not at all for others, of course (like all "addictive" drugs).
However, if you look up the literature, you'll find it full of Xanax
studies where everybody was tapered from long courses of the stuff
without problems.  Go figure.  The literature is TOTALLY different than
my experience.  Are the only studies in the literature from Upjohn?  I
dunno, but doubt it.

   So, I don't have the answers.  But the only people I put on Xanax
are those who are suffering a hell of a lot, and what they are going
through is worse than the potential of a lifetime addiction to Xanax,
which I tell them all is a possibility (though by no means a
certainty).  How else should I do it?  If I didn't give a damn, I'd
just say to every person with panic disorder "Let them take Buspar."
And for the alchoholics: "Let them do 12 step.  And shoot themselves if
they can't tough that out, the pussies."


                                       Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: bionet.neuroscience,misc.health.alternative,sci.med,
	sci.med.nutrition,sci.med.pharmacy,sci.med.psychobiology,
	sci.psychology.psychotherapy,sci.skeptic,soc.support.depression.treatment
Subject: Re: UPJOHN'S DRUG XANAX ON TRIAL
Date: 22 Mar 1998 20:08:40 GMT

In <35148AB3.FD2A4175@servtech.com> Ed Mathes <emathes@servtech.com>
writes:

>Tom Matthews wrote:
>
>> Upjohn, the manufacturer of Halcion, is on the hot seat again. This
>> time Halcion's sister drug, Xanax, is on trial in a Los Angeles court
>> room. A consumer (Terri Mitchell) has taken the company to court for
>> failure to warn about the dangers of this benzodiazepine.
>
>Sounds like someone trying to blame their addiction on someone other than
>themselves.....
>
>--
>Ed Mathes



   What drug company in its right mind would make a drug to treat
*anxiety*?  Talk about asking for a lawsuit.  The kind of people who'll
be taking your drug are exactly the kind of people who'll decide it's
given them a dozen different incurable diseases, and brain damage.
Even a drug to treat frank paranoia would not be as legally risky,
because really paranoid people generally look and sound crazy.  Anxious
people, by contrast, just create uproar whereever they are, and it's
very hard to see sometimes where the uproar comes from.

   I will agree with the lawsuit in one respect, however: in my
experience in practice, Xanax is indeed far more "addictive" or
"dependence-producing" than its manufacturers admit.  And far more
addictive, strange to tell, than it is in clinical trials, if you
bother to look up such things on medline.  Which trials are mostly
supported by UpJohn <embarrassed grin>.  Hey, I'm not entirely blind to
data that argue against my general beliefs.  There is a grain of truth
in the idea that what "information" doctors know is badly distorted by
who funds the studies.  But that's the nature of information.  It's
like what Churchill said about democracy-- it's a TERRIBLE system-- one
that is bound to produce injustice just by the very nature of it
(Arrow's theorum, etc, etc).  The only problem is that the alternatives
all seem to be worse.

                                          Steve Harris, M.D.



From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.anxiety-panic,sci.med.pharmacy,sci.med.psychobiology,
	sci.psychology.psychotherapy,sci.skeptic,soc.support.depression.treatment
Subject: Re: UPJOHN'S DRUG XANAX ON TRIAL
Date: 28 Mar 1998 10:05:18 GMT

In <351AE26E.3B51@nospam.ix.netcom.com> Lucky Lady
<xanten81@nospam.ix.netcom.com> writes:
>
>Steven B. Harris wrote:
>>
>> In <MPG.f83daccae0ab5b98971e@news.frii.com> hhcs831@mci.net (Juan
>> Enrique Rodriguez) writes:
>> >
>> >> carry severe risk of addiction.  Other treatments for panic are
>> >                       ^^^^^^^^^
>> >
>> >Dependance causing, mind you. I've seen VERY few people
>> >truly addicted to Xanax; and usially they were under the
>> >influence of multiple other drugs at the same time.
>> >
>> >I am really sick of lay people calling things addictive,
>> >when they are generally dependance causing. There IS a
>> >difference.
>>
>>    Some people have tried to make a big deal out of "dependence" vs.
>> "addiction", but I personally don't think it's a useful distinction.
>> The drug seeking behavior of the patient is the same, and so are the
>> strains on the doctor and the patient's family and support system. If
>> you'll sell your grandma down the river to get one more dose, then
>> you've got a problem.  What you call the problem is largely irrelevent.
>>
>>                                         Steve Harris, M.D.
>
>Just who in the hell do you think you are? For your information my
>grandmother would probably swim down that river, just to get me another
>dose because she_knows how helpful Xanax has been for me and my
>problems. Are you sure you are a_real doctor?
>
>	Lucky Lady



   Did I say it wasn't helpful for some people's problems?  I merely
point out that dependence of one sort or another is a big risk with the
drug, and one that a first time user should consider.  For some people,
it's worth it.  For others (who cannot take responsibility) they are
sooner or later going to be blubbering that the doc "got them hooked"
on Xanax.  A drug that the dastardly company makes, more addictive than
cigarettes, that it doesn't WARN you about.

   As I remarked to another reader privately, who wrote to me asking:

  >>You mentioned that in prescribing Xanax you would use among
other things a judgment of the patient's reaction to you if
you declined to prescribe the drug.  I was curious to know if
it is really all that easy to tell a person who is desperate
for the drug because they've come to want it for more than just
a way to cope with severe panic.<<


Comment:
    No, it isn't, and if I said anything about using the
patient's reaction to me refusing a Rx as some kind of index of
what kind of drug dependence they have, it must have been some
time ago (have you got the cite?)-- and in that case, I repent.
Because I've long since changed my mind, and no longer feel that
way.  How badly somebody wants a drug is a function of how
imbalanced their brain chemistry happens to be at the moment, and
there's no real way to tell from that how it got that way.  It
might be almost completely genetic (though people generally need
SOME experience with a drug to exhibit drug seeking behavior), or
it might be a result of a long or short period of drug use.  And
that period of drug use might have been for reasons that seem
medically appropriate, or not.  So one cannot make judgements
from the way the patient presents, although you hear of that
being done all the time.  But people seeking narcotics for
chronic physical pain (cancer) look pretty much like people
seeking narcotics for chronic psychological pain.  Who am I to
judge whether or not, and in what chemical sense, a person really
"needs" a drug?  I can't see into their brains, and the behavior
is the same at the end.

   The only really important distinction I personally make
between patients who are using dependence-producing drugs, is not
really a moral one, but a practical one.  There are patients who
are very "rapid adapters" to drugs, and they build up tolerance
to them very fast, doubtless by changing receptor densities.
Such people require rapidly escalating doses of narcotics to
remain in the same place.  Some fraction of these people also
seem to have a very low tolerance to discomfort, and will (if
given a supply of drug) dose themselves to the point of zero
discomfort, without being able to stop or control themselves.
Often, at this point, they are unable to work or interact
socially, due to being obtunded.

    For obvious reasons, such people are extremely difficult to
deal with medically (or in any other way), and I prefer to let
the experts do it.  Again, this is not a moral judgement, and I
have no doubt that some of these people have just as "legitimate"
or genetic, a need for narcotics or anxiolytics or amphetamines,
as anyone (they just happen to be very unlucky in the way their
brains are put together).  My decision to cut them off does not
have anything to do with whether or not I think they have some
kind of "legitimate" need for the drug (in terms of the genetics of
their neurochemistry)-- for I have no way of telling that.   And,
neither (here's a secret) do I think any other doctors do, either.
They just think they do.  But in this kind of regulatory climate, I
can't just give anyone all the drugs they want, even when the drug
itself seems to be physiologically pretty benign, such as is
the case with alprazolam or morphine.  Nor is it doing anyone
a favor to give them enough drugs to allow them to completely
escape reality and stay in bed, which a certain fraction of
people *will* do, if allowed ad libitum access (exactly as with
alcohol).

   The easy patients to care for are those who need or want a
certain supply of drug, are able to function on this dose, and
their required dose varies little over time.  I'm generally
willing to let such people have what they "need", [so long as the
requirements of the state are satisfied].  Again, it really doesn't
matter to me how people get to this state of need, since as far as I
can see, it's the same state, no matter how they get there (again, I
see no evidence that virtuous persons with a deficiency DISEASE can be
told by their behavior from people who "abused" the drug "for kicks"
and are now dependent for that reason).  I do try to warn people about
getting into this sort of thing, before I START them on such drugs.
Because once there, it's hard to go back.  Not impossible, but hard.

   Or course, the final problem is that some people don't clearly
fit into either category--- or rather, they fit into one category
if managed paternalistically, and another if allowed to do what
they want.   Perhaps this deserves a third category.  One of my
patients in particular is a very anxious person, who describes his
normal reality as a howling maelstrom, and his reality after Xanax as
like being under Cheyenne Mountain and watching the war or the
hurricane on monitors, with the sound off.  He would (if allowed to)
take Xanax to the point of nirvana, and never go to work.  At the dose
I allow him (30 mg a month) he is able to work, but still has some
anxiety.  If I gave him 60 mg a month, he'd take that, and in a few
months he'd have just as much anxiety, but now be at twice the dose.
So there we are.  As a libertarian, it bothers me a little that I'm
acting as the guy's gatekeeper (which he knows very well), but on the
other hand, just because I would legally allow him to have all the drug
he wanted in a libertarian world, does NOT mean I have to assist
him in this, in the present world.

    Note that some people who have problems with binge use of
drugs and high tolerance, are (with help) able to go back to
controlled use-- like the guy above.  It's the same with alcohol,
though the controversy there is whether anyone can do it without
being rationed externally.  Apparently it's quite rare and
difficult.

                                       Steve Harris, M.D.



From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.anxiety-panic,sci.med.pharmacy,sci.med.psychobiology,
	sci.psychology.psychotherapy,sci.skeptic,soc.support.depression.treatment
Subject: Re: UPJOHN'S DRUG XANAX ON TRIAL
Date: 29 Mar 1998 07:42:26 GMT

In <6fk8s5$dbi@senator-bedfellow.MIT.EDU> shapere@mit.edu (H. Elizabeth
Shapere) writes:

>I'm not sure I agree with Steve's position on anxiety disorders (Steve,
>there's a difference between having an anxiety disorder and being
>"neurotic" or hypochondriac [that's considered a somatoform disorder!]),


    Yes, yes.  Remember, however, that DSM-IV is not The Holy Bible nor
the General Theory of Relativity.  It doesn't even contain much
objective pathology.  It's just a bunch of names and labels that people
have agreed on, *temporarily* (yes!) for mental syndromes (NOT
diseases, yet-- we haven't come that far), which by and large are not
yet understood physiologically in even rudamentary ways.  Naming
syndromes of symptoms is the first step on the path to knowledge in
medicine, to be sure, but it's a long way from pathophysiological
understanding.  Which is what comes when you understand what's going on
mechanically.  Right now, arguing over the exact categorization of
mental syndromes in the DSM-IV is about analagous to doctors arguing
over various catagories of "jandice" and "fever" in the 17th century.
It's a start, but let's not pretend to be doing more than we're doing.

   Let me remind you that there is a huge overlap between many of the
problems described in DSM-IV, and that's ever the problem in
psychiatry: how do you know if you're not really looking at two
manifestations of the same disease, vs. two diseases with similar
presentations?  Answer: without a good look into the brain (which we
don't have clinically), you don't.  One day, with PET and its fancier
daughters to come, perhaps we will.  Meanwhile, let us be humble.  If
my colleages in psychiatry are not willing to be humble, I'm quite
willing to be humble on their behalf.  <g>.  But most know better.

    There is a large overlap in borderline personality disorders,
somatization disorders, and anxiety disorders.  It is (for example)
just about impossible to rachet up someone's (anyone's) anxiety very
much without them beginning to somatize, in various ways.  It happens
to me, it happens to you.  This is merely the less politically correct
way of stating the new-age truism that the the state of the mind and
degree of mental calmness affects presentation, theshhold, and degree
of suffering from nearly every symptom of nearly every disease.  Today
the Gurus want to remind us of the remarkable fact that treatment for
anxiety in various forms-- from prayer to ritual to therapeutic
transferance to homeopathy to massage and healing touch and acupuncture
and aromatherapy, to you name it-- cures or ameliorates long lists of
odd problems and chonic complaints.  But the implied and exactly
analogous idea that these things may be just as fairly said to be
caused mostly by modern anxiety (neurosis!), and that they also often
respond to straight anxiolytic pharmacotherapy (yea, even Xanax), is
considered barbarian.  See how much there is in selling the same idea,
but saying it with different words.

                                          Steve Harris, M.D.




From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.chronic-pain,sci.med
Subject: Re: Sedative suggestions
Date: 29 Nov 1998 09:21:11 GMT

In <3660CB94.66BF@columbus.rr.com> Keith Lamb <klamb@columbus.rr.com>
writes:

>I am in desperate need of a powerful anxiolytic/sedative/sleep agent.
>Perhaps someone here can chime in an suggest something.  I do not have
>insomnia, rather, I need something for the day or two before
>medical/dental procedures because I am so anxious and phobic.  I need
>something to get me through the day or two prior without causing me to
>cancel the procedure, and something the night before to help me sleep.
>
>Everything I've tried has failed utterly.  The following produced
>absolutely no anti-anxiety or sedative effects whatever:
>
> tons of different behavioral therapies (hypnosis, relaxation, etc, etc)
> 1.25mg  Halcion
> 2,500mg Chloral Hydrate
> 40mg    Valium
> 1.5mg   Xanax
> 3mg     Versed
> ?       Pentobarb
>
> Nitrous Oxide works, but my docs say that pre-mixed at-house nitrous
>isn't available.  They don't have any more ideas.
>
> What should I try next?



    More Xanax.  At some point, you WILL experience relief of anxiety.
It might take 2 mg every 6 hours.  It might take 4.  But at some point,
it WILL work.  If not, you are a Martian.

                                     Steve Harris, M.D.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Sedative suggestions
Date: 30 Nov 1998 23:42:38 GMT

In <73u66e$4ce$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:


>No, Harris.  I recommend you get someone to get you a stool so you can
>get off your high horse before you fall off.  That is to say, read the
>rest of the post so you can better evaluate the situation.  Did you see
>the whopping dose of valium the guy takes - without success?


   Yep.  Irrelevent.  People resistant to one benzodiazepine may have
excellent effects with another, just as in the case of narcotics.

  And just as with narcotics and neuroleptics, you titrate
benzodiazepines to effect.  That means you give small doses at
intervals, assessing between each, and just keep going until you
achieve effect.  You use whatever it takes.  I've seen MI patients
absorb 100 mg of morphine in an hour.  I've seen schizophrenics require
20 mg of Haldol in the same time.  And I've seen people who need 5 mg
of Xanax to keep from being raving puddles of raw nerves.

> The recommendation made for
>desensitization therapy makes a helluva' lot more sense than pumping
>his body
>full of drugs.

   Desensitization always makes more sense than drugs.  Alas, it
doesn't always work.  Occassionally, it backfires.  Keep reading the
messages being posted, and learn something.

    Treatment of short term anxiety associated with a specific upcoming
procedure, such as surgery, are where benzodiazepines shine as therapy.
If you use enough, they will work, and work well.


>>You snipped that, ofc, close-minded dope pusher that you are.

    As an ignorant anonymous jerk, you can feel free to claim you have
the answer to any medical problem whatsoever, and not that many people
will know how out to lunch you are.  Weren't you the person claiming
ovaries are nicely palpable by an expert, in any woman who has them?
Only somebody who knows some gynecology would know you're full of it.
It's much the same in this case.

                                        Steve Harris, M.D.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.chronic-pain,sci.med
Subject: Re: Sedative suggestions
Date: 30 Nov 1998 23:49:25 GMT

In <73tqam$hca@senator-bedfellow.MIT.EDU> shapere@mit.edu (Elizabeth)
writes:

>>Anyway--if 40 mg of valium didn't help--that is amazing.
>
>Don't laugh dude, I had the same thing happen when I took the same dose
>of diazepam.  (Don't ask why; it wasn't "for kicks," for whatever that's
>worth.) No tolerance.
>
>(Anyone know why this would happen?)
>
>-elizabeth

   There isn't just one kind of benzodiazepine receptor, and the
different benzo drugs aren't just intraconvertable, with no differences
between them except potency and half-life.  Though this is a common
conception.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 21 Feb 1999 14:19:51 GMT

In <7ai2il$og$2@knot.queensu.ca> Emma Chase VanCott
<7elc@qlink.queensu.ca> writes:
>
>Shapere <shapere> wrote:
>
>: In article <7agthd$1i6@sjx-ixn6.ix.netcom.com>, sbharris@ix.netcom.com(Steven
>: B. Harris) writes:
>
>:>Agree with all the above.  Can also add that patients with a big
>:>component of anxiety along with depression who fail multiple SSRIs are
>:>good candidates for an MAO inhibitor, which also isn't considered in
>:>this situation nearly often enough (since these drugs have all those
>:>dangerous dietary rules and problems).  Too often, Nardil is left to
>:>the psych guys, and severe anxiety/depression is too common for that.
>:>
>:>    I've had one patient who failed everything but 8-10 mg a day of
>:>Xanax. And that did the trick and she's been on it for years, no change
>
>	Jeez. that would be ~20 times the dosage i take. (0.25mg bid)
>	WOW.
>
>
>Emma
>;)



    Yep.  Enough to turn most people into Rip Van Winkle, and then
after they woke up, Mr. Rogers.   Can you say "zoned?"

    But not that occassional special person.  Dylan Thomas once said
that the moment he had his first drink he knew he'd been born two
drinks low.  Likewise, there are some people who seem to be born 2 mg
of Xanax low (maybe Dylan Thomas).  Rare, but it happens.  Hypertrophy
of the amygdala or something.  And what Xanax does to you beats what
alcohol does, every way from Sunday.

                                     Steve Harris, M.D.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 22 Feb 1999 08:54:49 GMT

In <36D0E73A.A8B04EBC@interlog.com> Happy Dog <happydog@interlog.com>
writes:
>
>"Steven B. Harris" wrote:
>
>> And what Xanax does to you beats what
>> alcohol does, every way from Sunday.
>>
>>                                      Steve Harris, M.D.
>
>What's that?
>hd
>


  What does alcohol do to you?  Destroys your liver, your frontal
lobes, your social life.  Even your gonads.  Alcoholics commit more
crimes, beat their wives and children, throw up on sofas, kill other
people on the highways.  Do I have to explain the downside of
alcoholism?

   Xanax can certainly make you sleepy and can interfere with your
drive and concentration at too large a dose.  On the whole, however, it
doesn't rot your body or make you a uninhibited sociopath.  In theory
it can be a danger to drivers, but in practice there's no national
crisis of Xanax-impaired motorists (and they do test crash victims for
this class of drugs).  On the whole, it's a much preferable addiction,
if you must have one or the other.

               Steve Harris, M.D. (not an addict of anything chemical)



From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 22 Feb 1999 11:41:55 GMT

In <19990222055649.21203.00000651@ngol04.aol.com>
shapere@aol.comicrelief (Shapere) writes:


>In article <7ar60p$9je@dfw-ixnews7.ix.netcom.com>,
>sbharris@ix.netcom.com(Steven B. Harris) writes:
>
>>Steve Harris, M.D. (not an addict of anything chemical)
>
>Hey Steve, McLean now has a "computer addictions" program....
>
>-elizabeth


   Thanks, but I'm trying to cut back on my own.  Really.  I know I can
do it if I put my mind to it.  Thanks for your concern, though.  I'm
okay.  It's not a problem.  I can stop whenever I want to.



From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 23 Feb 1999 03:57:22 GMT

In <7asab9$d$1@knot.queensu.ca> Emma Chase VanCott
<7elc@qlink.queensu.ca> writes:


>	My only query is why you would give the patient Xanax, instead of, say,
>Klonopin? I'm not questioning your decision, i'm merely curious and trying to
>learn. (eg. why woudn't you give a drug that req'd less Fx dosing?)
>
>thanks,
>
>-ECV


   It's a very good question.  I do use clonazepam and even good old
fashioned cheap chlordiazepoxide when longer durations of action are
called for.  But these things aren't all equivalent except for half
life.  I wish they were.  Like narcotics, I suspect there must be many
different kinds of benzodiazepine receptors, and people differ in their
reponse to each.  Some people (this person) get dysphoric and sleepy on
clonazepam, and there is no dose fixing that does the trick-- no middle
ground between anxiety relief and sleepiness or depression.  Xanax
seems to have a purity of effect for a certain group of people that
nothing else quite touches.  Other people can't tell it from Ativan or
even Ambien.  And I found that out before I really had reason to
suspect it, or believe it was even possible.  So (at least at that
time) it wasn't just my attitude's effect on my patients' expectations.

   Clonapin, Librium, or Ativan (which last is shorter acting and a lot
more expensive) are still the benzos I start with.  And I even have a
couple of people who just need a little off the top, who get by on 2.5
mg a day of Valium (generic diazepam).  No more, no less.  And I have
others who are such Xanax connoiseurs that they can tell Ciba-Geigy
generic alprazolam from the Greenlaw generic (which happens to be made
by Upjohn).  Different benzos for different bozos, is how one of my
patients puts it.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 23 Feb 1999 11:48:35 GMT

In <7atqrk$scq$1@nnrp1.dejanews.com> amp_spamfree@yahoo.com writes:
>
>In article <7at8v2$f8j@sjx-ixn9.ix.netcom.com>,
>  sbharris@ix.netcom.com(Steven B. Harris) wrote:
>> In <7asab9$d$1@knot.queensu.ca> Emma Chase VanCott
>> <7elc@qlink.queensu.ca> writes:
>>
>SNIP
>>  And I have
>> others who are such Xanax connoiseurs that they can tell Ciba-Geigy
>> generic alprazolam from the Greenlaw generic (which happens to be made
>> by Upjohn).  Different benzos for different bozos, is how one of my
>> patients puts it.
>
>That would be Greenstone, not Greenlaw

    Yeah, you're right.


> - and that would be Pharmacia &
>Upjohn, who, btw, still make 70% of the world's alprazolam (bulk).

    Yeah, Upjohn merged with Pharmacia AP in Nov 95.  But people still
call it Upjohn.  You're being a pedant, now.



> Not sure
>that CibaGeneva (generic division of Novartis)	provides a generic version,

   They do.

> I
>know Lederle Generics does, as do Par, Mylan, Novopharm, and a bunch
>of relabelers.


    Yeah, but where do they get it?



>All in the interest of accuracy, Steve.
>
>amp


    Perhaps you could us some?


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: xanax
Date: 25 Feb 1999 11:44:21 GMT

In <19990223164442.25937.00000174@ngol02.aol.com>
shapere@aol.comicrelief (Shapere) writes:

>Here's one: how come the high-potency benzos work in panic disorder and
>the low-potency ones (Valium, Librium) don't (that seems to be the
>difference, anyway). Is it a question of distribution?


    I don't know.  Some people with panic disorder don't get much from
Valium and Librium unless they take huge doses and get sleepy.
However, these drugs USED to be prescribed for this, when they were all
the benzos we had.  "Use the new drugs quickly, young man..."



>Xanax is interesting stuff. It's a triazolo-BZD, and part of its
>structure looks a bit like trazodone. I wouldn't be surprised if it has
>some properties that the other benzos don't have.
>
>A couple people on alt.support.anxiety-panic have had problems with
>depressed mood (like you say, dysphoric and sleepy) on Klonopin - never
>heard of this happening with Xanax.


     Yes, Xanax is supposed to be antidepressant in very high doses.
Very few people seem to have attempted using it this way, tho.  They
have nightmares about phonecalls from people addicted to 20 mg
alprazolam a day.


>
>There are certainly a couple types of BZ receptors - hence, Ambien.

   Fer sure.  Seems to work even in people who've taken a lot of
benzos, and synergistically.

> (Another
>drug that I think may have some additional effects in addition to the
>benzo-like ones.)


    You bet.  Otherwise they could not possibly get away with charging
what they do for it.  People would just take equivalent amounts of some
other benzo.


>Is Mylan going to get its butt kicked for antitrust violations? (Somebody
>or other recently called them "the Microsoft of pharmaceuticals." Ouch.)
>Ativan is very cool for PRN use in panic disorder (say, for breakthrough
>attacks for people on antidepressants) because it's not half as
>offensive-tasting as Xanax, so you can take it SL (people at least claim
>that it works faster this way, though this just might be the power of
>positive thinking).


    I suspect so also.



>What do you use Librium for, BTW, and at what doses?


   Can be used to take the edge off panic attack people at 25 mg two or
three times a day.


>I tried it once and noticed no difference whatsoever, even in "background
>anxiety." No sedation either. (Then again, 40mg of Valium wasn't sedating
>for me, so....)
>
>-elizabeth the unsedatatable


   So say a few of my panic people. And I've had people complain of
depression on Clonazepam, too-- must be doing the opposite there of
whatever happy stuff Xanax does.  Librium's an alternative, and it
works okay as a background suppressor in some.  I know one guy exactly
like you, who is completely unsedatable with Valium (says he can take 3
10's and never know it), but gets by on 50 mg Librium a day and 1 mg
Xanax.  If he could, he'd take Xanax by the boatload, but he's
completely unable to regulate himself when he has lots of it, so I
won't give him any more than 1 mg a day, no refills, and I call it in
every 8 weeks.  With the Librium, he avoids the AM rebound after
evening Xanax. Without the Xanax, however, he's completely unable to
relax or sleep.


From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,sci.med.pharmacy
Subject: Re: xanax
Date: 26 Feb 1999 20:55:46 GMT

In <19990225100038.28017.00000059@ngol02.aol.com>
shapere@aol.comicrelief (Shapere) writes:

[Harris]:
>>Yes, Xanax is supposed to be antidepressant in very high doses.
>>Very few people seem to have attempted using it this way, tho.  They
>>have nightmares about phonecalls from people addicted to 20 mg
>>alprazolam a day.

>Is that really honest-to-god addiction (i.e., dependence as in DSM-IV)
>or just physiological dependence?


Comment:
   I don't quite know how to answer that. I don't have access to my DSM
IV, but my creaky old DSM III makes no distinction between the two, and
simply classes dependence on the basis of tolerance and/or a withdrawal
syndrome.  Which Xanax certainly has. Trying to class withdrawal
syndromes as physical or mental is somewhat philosopical and not very
medically useful in the case of psychoactive drugs, of course.
Withdrawal from some is more physically DANGEROUS, to be sure.  People
withdrawing from benzodiazepines "cold turkey" occasionally have
seizures or other dangerous reactions (as do people going suddenly off
SSRI drugs, for that matter), but on the whole it is not terribly
dangerous, as also with the cases of cocaine and heroin sudden
withdrawal.  That does not mean that SSRI drugs are should be thought
of as addictive, because it's occasionally a physical problem to stop
them suddently, and cocaine not.

  The word "addictive" gets argued about by people who shout a lot
about true and correct meanings, and though there was such a thing.
Exact definitions are common enough in physics, but they are rarer in
medicine, and far more evanescent. And what's more, a word like
"addictive" is far too old, and carries too much baggage in the
language, to let DSM or any new official screed define it in some
definitive way for us, anyway (that would be like making unions
recognize the physics meaning of the word "work." I think not).

   And probably the same is true for "dependence" and "abuse."
One person's "use" of his or her body is another's "abuse," and that
applies to huge spheres of activity (page me when the folks who run the
American Psychiatric Association invent a DSM category for the mental
disorder of parents who want to cut the tips of their children's
penises off).  And as for "dependent", we're all "dependent" on many
things and activities in many different and odd ways.  Should some
count more than others, medically?  Particularly when people will give
up the damnedest things for the damnedest reasons, according to
personal tastes?

   It's all far too complex to be reduced to a set of algorithms in
some green book, to be coded for medicare and all those insurance and
government computers which now keep track of your official mental
status (the Nixonian Ellsberg office break-in would probably be pretty
superfluous by now....).  And more than any place else, psychiatry is
where medicine intrudes on other areas of life (religion, ethics,
morality, value systems, sexual and gender identity) where the sciences
ought rightly fear to tread (except perhaps descriptively).

   We saw that in the case of masturbation ("self-abuse") being defined
as a disease early in this century (from which doctors believed people
occasionally even died-- it got put on death certificates.  No, I am
not kidding); and homosexuality being defined as a disease or mental
disorder in the earlier DSM classicifations not THAT many years ago.
We saw this and failed to learn from it.  I'm not saying that medicine
and even science is not without inherant values-- both activities have
to contain and depend on certain intrinsic values in order to work.
But let us not get overly enthusiastic about universal application to
life.  The medicalization of human behavior is bad enough, but when it
comes to the medicalization of systems of philosophical thought in
particular, it's particularly insufferable.


>
>>You bet.  Otherwise they could not possibly get away with charging
>>what they do for it.  People would just take equivalent amounts of
>>some ther benzo.
>
>Naw, they could certainly get away with charging a bundle for it, just
>by advertising and hype. :-)


Comment:
   Yes, if they did enough of it.  And if use of it was public, like
wearing Calvin Kleins.  But prescription drugs suffer from both
problems.  They do go through fashion cycles, though mainly in doctors'
minds, since advertizing to the public directly is still under some
inhibitions of good taste and FTC and FDA regs, and in the case of
Ambien, there are few more private things you do than taking a sleeping
pill.  If you've got "it" and there are no socially acceptable ways to
flaunt "it," it's not THAT much fun, in the sense you suggest.  So, in
general, if it's a drug and has competition, it had better work.  If
you want to argue that Ambien hasn't been out long enough to see if
it's simply a fashion or a genuine advance (ala aspirin, morphine,
Dilantin... and yes, Valium)---- you may be right.  We cannot tell for
sure right now if it's a "classic", but my sense remains that is a
modest advance, in that it does something nothing else does, for some
people.

>I've noticed that some people get messed up and disinhibited on Xanax
>in particular. Wonder what's with that. Was that what you meant about
>the patient you mentioned, or is it that he tends to abuse it if you
>give him too much at a time?

   Nope.  He just sits home and smiles gently at the walls, happy as a
clam.  But he's not rich enough for that, and even he recognizes that
without some kind of irritation he's not going to make the contribution
to the world that will give his life long-term meaning, in his own
judgement (which as an extremely creative person off Xanax, he's
capable of doing).  So it's the social definition of abuse (one of the
DSM criteria, of course) that comes into play here.  And also that of
the patient.  He's a smart guy, as noted, and could certainly get more
alprazolam by hook or crook.  He doesn't.  However he also could not
resist if he had a bowl of blue pills on his dresser, and maybe not
even if he could buy it at any time at the local 7-11, like cigarettes.
So he abides by our aggreement because he too thinks this is in his
best interests, over the long term.   Those who argue for legal control
of drug use have a point in that some control of drug use does indeed
occur in this fashion.  I happen to think it's not worth the social
cost, but that's another thread.

>A big (2mg or so) dose of Xanax seems to keep me asleep for just the
>right amount of time, but it stops working for this fairly fast (after
>a couple nights). It doesn't knock me out, just makes me mildly tired
>(indeed, my PRN for Xanax - for breakthrough panic - is for 1-2mg at a
>time, 2 being optimal). Never tried taking more than that at once. I
>am pretty sure I could work my way up to the high doses you mentioned
>using for depression, but I'd absolutely *hate* the protracted taper
>if it ended up not working.
>-elizabeth


   So do most people who do it.  Though if you read the many articles
in the scientific literature, most supported by Upjohn research funds,
you will discover that that Xanax is easy to taper off of.  Strange to
say.  Perhaps in some alternate universe I've never lived in, it is.
You know-- that one where the South wins the civil war and so on?  A
certain number of clinical studies seem to leak over from there.

   A story: I was on call for my group last night and very nearly
admitted a woman to the hospital for what the ER doc thought was a
raging cellulitis and thrombophebitis, causing her leg to swell up,
even on antibiotics.  Luckily I had the office chart, and found that
the woman (not my patient) was on 440 mg of Valium a month, being
tapered by 10 mg a month.  That leg's had that much edema (not much)
for years, and she's been dying of thrombophebitis (so she thinks), in
consequence, for years.  And she's too anxious to take full doses of
any drug anyone gives her, except, of course, for Valium.  Including
the antibiotics for her toe infection.  And anxiety is contageous--
even ER docs are affected when they don't have the history.  In this
case, armed with some information, rather than admit her for anxiety,
noncompliance, and an infected toe, we managed to get her outpatient IV
treatment.  Where she is now driving a raft of discharge coordinators
and home health agencies and pharmacists, and so on, out of their
minds.  Did you know medicare pays for all or most of home IV
treatment, except the actual drug?  But that if you go to the hospital
for outpatient IV treatment in the clinic, medicare pays for it all--
but not the taxi?  So what's the half life of that drug, affecting
number of taxi rides? We're now into balancing Keflex at three times
day against Zinicef at twice a day (a little more money-- drug
companies not being stupid) against one less taxi ride.  And which
agency charges a % of medicare reimbursements for a visit, and what's
the percent?  And will they come down on it, or waive it, for the
business?

   That kind of thing, plus a boatload of paperwork, is the essence of
the practice of medicine in the declining years (in more ways than one)
of this century.  "If you won't give your patients Valium," as Oscar
London, World's Best Doctor, says, "you'd better take it yourself."
I've used that quote before on this forum, but it's worth noting again.
I may one day have to use it as a sig.  If the government gets any
larger, I may start to take the blue pills myself.

                                     Steve Harris, M.D.


 





























































































































































































































































































































































































































































































































































































































































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