Posted by Elizabeth on February 24, 2002, at 23:52:49
In reply to Re: benzos for alcoholics? » Elizabeth, posted by jazzdog on February 23, 2002, at 14:57:14
Well, the medical consensus (based on clinical psychiatry and pharmacology textbooks and reviewing the literature, as well as personal impressions and individual physicians' opinions) seems to be that some persons who have abused alcohol in the past can be treated safely with benzodiazepines. In particular, research findings appear to contradict the supposition that benzodiazepines are likely to induce relapse in alcohol-dependent patients.
A physician charged with deciding whether to treat an alcoholic anxiety-disordered patient with benzodiazepines has a number of pros and cons to consider; there's no black-and-white, deterministic algorithm that will produce a certain answer. A lot depends on the patient's strengths and weaknesses: severity and duration of alcohol abuse, past tendencies to relapse, duration of remission, presence or absence of social supports, lifestyle, participation in relapse prevention therapy, etc. The extent of the individual's need for benzodiazepines should also be considered: are there other treatments that might work, and have they been tried? is the anxiety disorder mild enough that it can be tolerated while waiting for a less rapid-acting treatment (such as antidepressants or CBT) to take effect? etc.
If the decision is made to use benzodiazepines, the patient should be monitored closely and the treatment program should include regular individual therapy sessions with a therapist who has a good rapport with the patient. If possible, the patient's family (esp. spouse or partner) should be involved in treatment. In some cases where there are both serious need of fast treatment and serious risk of relapse, the treatment might even be initiated in an inpatient setting.
One thing that physicians *shouldn't* do is make blanket assumptions about what will happen without considering the patient's individual needs. Seldom is the outcome of any medical treatment predetermined, and this is all the more true in psychiatry. The belief that all alcoholics who are prescribed benzodiazepines will relapse or abuse the benzos is such a blanket assumption. When physicians adopt this attitude, they do a disservice to patients who have a serious need for these medications. Making generalizations is intellectually lazy, and in this case it is harmful, too.
I'm sure that some recovering alcoholics experience cravings if they take benzodiazepines; this sort of phenomenon is well documented. I'm also sure that some do not (indeed, as noted above, the available evidence suggests that benzodiazepine-triggered relapse is the exception, not the rule). In any case, there are ways to minimize the risk of a relapse of the addiction without withholding treatment for the anxiety disorder. You seem to believe that if *any* former alcohol abuser takes a benzodiazepine, then that person's relapse is inevitable (or nearly so). The available facts don't support this belief.
It is a good idea for any recovering alcoholic to take steps to minimize the probability of a relapse. If a person being treated for anxiety is concerned that benzodiazepines will trigger cravings, there are lots of things that s/he can do to protect against a relapse: taking a antiaddiction medication a sensitizing agent (e.g., disulfiram) or an anticraving agent (e.g., naltrexone); selecting a benzodiazepine that may be less likely to feel like alcohol (e.g., Klonopin instead of Xanax; Librium instead of Valium); using blood and/or urine tests to make sure that if the person abuses the benzodiazepine or drinks, the doctor will know about it; designating a person (therapist, relative) who the patient could get in touch with any time for help and support if the patient started to experience cravings; involving family members (for example, having the patient's spouse hold on to the medication and watch for signs of drinking); and, in some cases, initiating benzodiazepine treatment in an inpatient setting so that if there are cravings, there won't be a risk of relapse and the patient can let staff know. There are many nonpharmacological therapies that could be helpful in reducing risk of relapse; for example, Marsha Linehan's dialectical behavior therapy has demonstrated efficacy in reducing a variety of impulsive behaviors. (I'm sure there are lots of other steps that could be taken; these are just a few examples.) There is no way to reduce the risk of relapse to zero, regardless of whether the patient is taking a benzodiazepine, short of locking him or her up permanently. As you are no doubt well aware, relapse is a risk that all alcoholics live with every day.
As with all decisions, one has to weigh the risks against the benefits. This has to be done on a case-by-case basis. Alcoholics are as diverse as any group of people. Some are at greater risk of relapse than others; and on the other hand, some have a greater need for benzodiazepines than others.
Can I ask in what settings you've encountered the many alcoholics you have known? I wonder if there might not be some sample bias working there. I'd also be interested to know what benzodiazepine(s) you believe triggered alcoholic relapses. I think that some benzodiazepines probably have greater abuse potential than others, and that these may also be more likely to trigger alcohol cravings.
Alcoholism has an extraordinarily high relapse rate, and exposure to alcohol-related cues is only one possible antecedent to relapse; life stressors and other factors may lead to relapse in the absence of any such cue. As such, it's difficult to swallow the idea that if a person relapses while on benzodiazepines then the benzodiazepine must have triggered the relapse, even if the person had been taking the benzodiazepine for years without relapsing.
I'm sure you didn't mean it this way, but your suggestion that a person who hasn't "been there" doesn't have right to have an opinion on the subject -- that the only valid information is that obtained by first-hand experience -- came across as pretentious and self-righteous. We've all experienced suffering here, and I believe that all or most of us are able to empathize with others' suffering. The idea that a certain group has known a degree of suffering that is much greater than anything the rest of us could comprehend seems quite disrespectful and invalidating of what others go through (again, I'm sure that you didn't mean it to sound that way). This board doesn't need to be a one-downsmanship contest. Could you please try to exercise more care and consideration about what you say about other people in the future? Thanks.
Aside from that, there are other ways of learning about something besides experiencing it. I've known a number of people -- some of them close friends -- who have suffered a lot as a result of addictions. I think it's tragic that people feel like they have to turn to dangerous drugs like alcohol and heroin in order to feel okay. I am not in any way minimizing the seriousness of addictions. But I recognize that anxiety disorders (which often lead people to turn to drugs) need to be taken seriously as well.
-elizabeth
poster:Elizabeth
thread:94946
URL: http://www.dr-bob.org/babble/20020222/msgs/95393.html