This article is a transcribed edited summary of a video Bob and Brad recorded in March of 2021. For the original video go to https://www.youtube.com/watch?v=F6CxDNE9hKA&t=1s
Bob: Today I'm joined again by Chris the pharmacist. One of the smartest guys I know. That's my tagline with him. And he's going to talk about understanding the pharmacology of benzodiazepines and how to reduce anxiety, and it also can help us sleep, correct?
Chris: It sure can.
Bob: All right, so let's get started. What role does this drug play? We had another video where we talked about the SSRIs. You maybe want to tell what that is really quick, and what the benzodiazepines are.
Chris: When we're dealing with anxiety specifically, anxiety is an awful, awful feeling. And there are several different forms of anxiety, but most commonly is general anxiety disorder. But the reality of it is when people feel like garbage, you're talking about one in five Americans, so that is a lot of people, upwards of 50 million Americans experience anxiety. And it's horrible.
Bob: And worse this year.
Chris: Yup, it seems to be a lot worse this year, 2020 has been a highly unique year for that. And then at least my pharmacy, I'm seeing more of these drugs going out left and right.
Bob: Than ever, would you say?
Chris: Yeah, I would say so. I mean, it's not scientific, but my staff and I have kind of talked and are like “wow, we're really kicking these out.” But the reality of it is, when we have anxiety, the mainstay of therapy is first talking with your doctor. Well, first seeing your doctor, because we need to know if there's a physical underlying cause. You know, certain medications can cause it, thyroid condition can cause it, cardiac conditions. There's a lot of things. So once we’ve established it's nothing physical that's causing it and it is anxiety, and you're having these horrible thoughts, what they say most days of the week for six months, which again, in my opinion is way too long. You know, they would start you on either cognitive behavioral therapy or the SSRIs, which are the serotonin, selective serotonin re-uptake inhibitors.
Bob: Do they start the cognitive behavior therapy right away, or do they wait until the medication has started to kick in?
Chris: No, I think, the patient drives the bus. I mean the therapy is centered around what the patient's willing to do. So if you're willing to go through therapy, I think it is one of the best things out there, because it's non-drug. Cognitive behavioral therapy basically teaches you, and they have very skilled clinicians that are going to help you to teach you to replace the negative, horrible thoughts with positive ones, to help you to kind of balance things out and understand why those feelings occur when you're having those negative thoughts, so that we can kind of come to a better place where you can control it more naturally.
Bob: I've seen the studies where you take one, drugs, or you take the therapy. They both can help, but together they’re more effective.
Chris: They're far more effective. And I think it's a widely underutilized aspect of our healthcare community. I think counselors have a lot to offer. Unfortunately, there's been a stigma with mental illness and people are like, “well, I don't need that kind of help.”
Bob: The stigma seems much less, but it seems like yeah, it's still there.
Chris: Yeah, and we have to crash that door down. I mean, it's something that, that people need to take advantage of because it's there for them and it's helpful. It leaves lasting beneficial results for the rest of your lives.
Bob: What about like meditation? Does that fall in that same category?
Chris: Yep. Mindfulness and meditation actually are all within that. And you know, it's interesting there's books about it. You can go to group talks about it. Sometimes there's apps on your phone that you can actually utilize. And for some people, they're wonderful opportunities to help you to help mitigate and manage anxiety. But, sometimes we just need the medications. And so, and it's just, sometimes that's the easier choice. Maybe you've got three small kids that are running in five different directions, although with COVID, it's a little bit different these days. But you know, it might not be optimal for you to go in and see a counselor. So medications certainly help. And a lot of times they'll start you on the SSRIs or even the SNRIs but that point, those take time to work. Like four to six weeks.
Bob: They take a long time to work.
Chris: So that's where the benzodiazepines kick in. And so those are the ones that work immediately, but they have a strong, negative connotation. They are addictive. We have to be careful with them. Tolerance develops, and there's lots of side effects that are associated with them, so they're just a small stopgap.
Bob: How quickly, typically, could a dependence occur?
Chris: Within a couple of weeks. So it doesn't take long.
Bob: So if you took it every day for a couple of weeks, you mean?
Chris: Yeah, I mean if they need to, and again, it's kind of intermittent. There's a phrase that doctors put on prescriptions called PRN. It stands for as needed. It's actually just a derivative of Latin, but a lot of times these drugs, depending upon which one, whether it's lorazepam, clonazepam, diazepam, alprazolam, those are the ones that are the most, those are the four most commonly used ones. And there are others, many others actually, and they all have different potencies and lengths of action. So a doctor is going to certainly listen to you and make sure that there's something appropriate. And if it's something that's like, “I am just so panicky, I'm about just explode”, I think sometimes clinicians will say, you know, I think it is reasonable for you to consider taking a benzo.
Bob: Make that bridge.
Chris: And let's get you something so that we can help you to relax, get you the sleep, so that your brain can recover, so that we can wait for the other drugs to kick in. Or your therapy to begin to help you. So it's a short term thing.
Bob: Yeah I have a family member, I’m not going to mention her name, but she had cancer and so they actually let her be on the clonazepam the entire time.
Bob: And it's funny, you know, she, she got off it fairly easy. She did pretty well with it. She said, "I really don't like how I feel on it, so it was easy for me to get off", but apparently she didn't get dependent upon it.
Chris: Yeah, and you know, the things drive addiction, are, you know, there's a genetic predisposition to a lot of these things. And again, your clinician is very skilled at looking for these cues. And so they have to assess you every time you come in. So you're meeting with a doctor, you know, in some cases monthly, three months, six months, depending upon the circumstances that they deem appropriate for your particular situation. And so they're going to be looking for those cues and seeing what's appropriate, what's not appropriate. The generalized guidelines are, you only want to take it for a couple, two to four weeks. And actually if you take it for as long as four weeks, then you have to actually taper off it at about a rate 25% per week to step down safely, because you could have withdrawal effects. And that can be very, very serious even to the point where a severe withdrawal with benzo could actually create a cardiac type of emergency.
Bob: Oh my gosh, yeah.
Chris: So it's things that clinicians are very, very careful with when they're treating their patients. Us as pharmacists in the community, we're kind of looking at to see refill patterns, how they're doing. We want to make sure that they're safe with their medication of use, making sure they're tolerating everything okay. Not having problems with dizziness, drowsiness, falling asleep at work. You know, those are the mainstay. That's why they work, is they make you tired, but they can make you dizzy and they can make you drowsy.
Bob: How long are they in your system?
Chris: Well, and again, that kind of depends.
Bob: On which one you use.
Chris: Yeah. So clonazepam, much longer, diazepam even longer. Things like lorazepam and alprazolam much shorter, but the problem with the shorter acting potent benzos is they can cause rebound anxiety. So these things are not designed to be used, they're just a stop gap until hopefully other measures will take place and really help to the patient to safely manage their anxiety symptoms.
Bob: Yeah, the same girl would use it when she'd fly, because she had a fear of flying.
Chris: Yep, very reasonable, fear. That's a phobia, so that's an anxiety.
Bob: And she would use it for that alone now, and always worked quite well.
Chris: Yeah. And so that's a onetime thing, unless she's flying for a living, I mean, obviously pilots don't get to take it. But it's one of those things where yeah. People that travel, some people do not like sitting in a tube that's 44,000 feet in the air. It's not a comfortable feeling for some people.
Bob: Same storage advice with these?
Chris: Yeah, any medication really, it comes down to, unless we tell you specifically.
Bob: Avoid the moisture.
Chris: Yeah. So it's not in the kitchen, not in the bathroom because those are the two most moisture prevalent rooms in the house. So you want it to be out of reach of children and really somewhere that's cool and dry. So usually it's a bedroom high up where little kids and pets can't get at it.
Bob: Sure. Now, I saw, when I was doing some research, there's people that actually had to go to rehab for the addiction.
Chris: Benzos are absolutely dangerous medications when used inappropriately. And that's the key.
Bob: And again, you talked about the genetic portion of it can really weigh heavily.
Chris: Yeah, I mean, the science of addiction, is fascinating and scary all at once. And I mean there's books and books and programs to help people to try and avoid those perils, but it happens and it happens much more commonly. And right now with COVID, we're seeing even higher addiction rates, with other drugs too. And a lot of times benzos are mixed with other products like alcohol or other drugs. That's where the real dangers can set in, you know, an overdose on a benzo can cause respiratory depression and stop your heart from working, and that's it.
Bob: I know she talked about alcohol that you just don't want to do that. You don't even want to have a glass.
Chris: You don't want to go anywhere near mixing and matching with these types of medications. It can be devastating. I mean, you may not wake up depending upon how much you've imbibed. So we have to be exceedingly careful. And it's something that, as pharmacists, we're kind of looking for that too. We all want to be safe and sometimes it's an accident too. I mean, and some of these drugs affect how you think.
Bob: Yeah, you're not even thinking correctly.
Chris: Yeah. And so all of a sudden it's like, well, I don't remember if I took one a couple hours ago, I'm going to take another one because I feel panicky. Well, all of a sudden now we've taken three or four doses and all of a sudden it can have some devastating consequences. You know, and so as we age, I mean, it can definitely affect your memory and your cognition, so it's certainly something that clinicians, again, they look very, very carefully at their patients. Sometimes some more than others, it just kind of depends. I mean, there's, we run into clinical inertia all the time. We see, you know, an 80-year-old lady taking these medications, and is this really the safest thing for you to do? Sometimes that's a very hard conversation to have because these people have taken these medications for a number of years, which again, you heard me say earlier, only a couple of weeks, and you heard me just now say a couple of years. And so, it's the clinician's responsibility to make sure that the patient's using it in a responsible way without the side effects. But sometimes, you know, doctors can be busy and also, it's like a quick visit. And it's like, that one just got by the goalie.
Bob: Oh yeah, you maybe have so many medical issues to address.
Chris: There were seven other things on the docket that you wanted to talk about. And that one just got, it just slid under the rug, so to speak.
Bob: I was talking to a doctor friend who has all these little old ladies and they're on Ambien and, they don't want to be off.
Chris: They don't want to be off, nope.
Bob: It gets them to sleep, they don't want to get off it.
Chris: Exactly. And that's one of the hard things, it's very hard. I actually was reading an article last night about a doctor suggesting how do people stop these things? And it's like, they try.
Bob: It's difficult.
Chris: And it is, long-term, it's just not a good solution. And so we don't want people on them indefinitely.
Bob: Do you have to take these with food or not?
Chris: No, in a lot of cases, it's not. The biggest thing, just stay away from alcohol and some other substances while you're on it. But you know, it can be with, without food. Kind of depends on your stomach and you know, what your GI tolerances are. So if it's something that you got a little bit of a touchy tummy, you have piece of toast, some crackers with that. And always, you know, full glass of water is ideal from that regard. But for the most part, there's not a lot of GI side effects. The biggest things that we watch for are central. So it's going to be the dizziness, the drowsiness, the impaired driving of an automobile. I mean, and that's a big thing with benzos, take it with a panic attack and let's say you're at work. All of a sudden, now you have to get home. Taking these types of drugs, if you got in a car accident and the police are like, “were are you on any medications?” Well, I just had some little alprazolam at work. That's now a DUI at that point, driving under the influence.
Bob: If somebody got hurt, you'd be…
Chris: It's devastating. And I mean, their responses you know, I mean, it can go on forever, depending on how bad the scenario is. So these are things that you don't want to drive on because they do affect your coordination. I mean, you wouldn't go out and play baseball or golf on these things because you wouldn't be able to control, you just don't have the coordination physically because of how they work with the polarization in your cells and why it relaxes you. It's also why it works so effectively is because it allows the communication in those nerves to work a little bit more efficiently so that they tell the cells to kind of calm down.
Bob: These, I imagine there's over the counter meds you don't want to take with this, too.
Chris: Correct, there's actually several, a lot of the herbal products like kava, dangerous.
Bob: Well maybe, some that make you sleepy.
Chris: Antihistamines. So, I mean, if you look at, let's say Benadryl. Benadryl is kind of the granddaddy of all antihistamines, what is the number one side effect? Well, it's sedation, because it binds the histamine receptor and it makes you sleepy. It's also why you don't itch or have allergy symptoms. Well, when we take something that makes you sedated by itself, and then we add another ingredient that, we'll just pick on alprazolam today, that makes you tired. We take them both together, you see a synergistic response. And so what would be maybe somewhat tolerable or okay, now all of a sudden becomes, “wow, I am really knocked out.”
Bob: So it's not one plus one equals two, it might be one plus one equals three?