Xanax Withdrawl

Xanax Withdrawal

Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.

As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.

They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.

To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.

Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.  

Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary. 

Signs and Symptoms

The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.

Physical Withdrawal Symptoms

As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.

Psychological Withdrawal Symptoms

Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.

Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.

Xanax Withdrawal Timeline

Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected. 

Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.

Factors Affecting Withdrawal

Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present. 

Coping with Xanax Withdrawal

The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax. 

Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.

In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well. 

Alleviating Symptoms of Withdrawal

An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.

Xanax Withdrawal Safety

Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death. 

People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.

The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.

No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Alprazolam Use Disorder

Alprazolam Use Disorder

Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right. 

If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder. 

Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction. 

This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug. 

Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:

-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.

-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.

-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.

-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.

-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.

-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it. 

-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use. 

-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.

-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.

-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.

As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.

Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:

-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.

-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.

-Continued Xanax use despite hazardous circumstances.

-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.

-Continued Xanax use despite experiencing one or more negative personal outcomes.

-Using more Xanax or using it for longer than recommended or intended.

-An inability to stop using Xanax despite an ongoing desire to do so.

-Obsessive craving for Xanax.

-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.

-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.

-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.

These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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CounterfeitDrugs:Fake Xanax

Counterfeit Drugs: Fake Xanax

For this week’s alprazolam blog, I want to know if I can fake you out. We’re going to talk about fake Xanax. Look at the picture above. Can you tell which Xanax are fake? Are you certain? Enough to roll the dice with your life on the pass line? Because, make no mistake- if you get your Xanax from anywhere other than a licensed pharmacy, you are absolutely, positively doing so every single time you take it. By the end of this blog, you’ll definitely know the answer to the first question. As to the second, I’d hope you already know the answer, because even Captain Obvious won’t bother with that one, people. 

When you think of counterfeit drugs, you may not be too concerned if you consider them to be just weakened copycat versions of the real thing, made with a bunch of essentially harmless junk. Probably the worst that could happen is it won’t work, right? Wrong! Obviously, the main problem with counterfeit drugs in general is that they’re clearly illegal and therefore unregulated, so you don’t know what you’re getting. I mean, with counterfeit drugs, there’s no truth in advertising. And helll-ooo, they’re produced in somebody’s gnarly basement, so there sure as hell isn’t any quality control. While they can be cut with innocuous things like baking soda or baby powder, they can also be laced with extremely harmful substances, things like rat poison, bleach, and formaldehyde. Unfortunately, many drug users don’t know, or don’t care, how dangerous it is to ingest substances like these. But there are cases where counterfeit drugs are especially dangerous, and fake or counterfeit Xanax is at the top of that list. In late 2015, the entire country learned this lesson the hard way when in three months, there were nine documented cases where people in San Francisco suddenly overdosed from “Xanax.” To be clear, it wasn’t Xanax at all. That number included a baby, who had picked a tab of it up off the floor and put it in their mouth. It also included one person who didn’t even get to live to regret it. I think we got off pretty easily in that singular event, but obviously more have followed. 

By the Numbers… Without Numbers (?)

Again, since production and sale of fake Xanax is illegal, underground, and unregulated, there aren’t national or global databases to collect information or statistics as there are with other drugs. But I found some reports from various global sources that were interesting. And by that I mean frightening. Some highlight snippets include a report citing that 25% of 2018 drug overdose deaths in Northern Ireland were caused by counterfeit Xanax. Another report from U.S. Customs and Border Protection stated that in the first four months of 2020, during unspecified smuggling attempts, their CBP officers seized 27 shipments of fake Xanax, totalling over 35 pounds. I also listened to part of a podcast on the subject that featured an officer from Portland, Oregon talking about a spate of teenage overdoses on fake Xanax, and the subsequent investigation. They apparently did a round up of all the street dealers they could find, and busted down doors and did everything they could to clean up the area. The goal was to get every Xanax pill off the street, and he stated that of all the “Xanax” pills they recovered, not a single one was legit. He didn’t say exactly how many that was, but it seemed like a lot. Every pill in the area was fake. That’s huge. And very scary. 

Fake Xanax: Beyond the Obvious

“Good” counterfeit Xanax pills look exactly like the real thing. And clearly, by “good” I don’t mean that in the traditional sense. That means they have the same color, size, shape, and pharmaceutical markings, aka imprints, on the pills as the bonafide prescription versions do. While the difference isn’t obvious to the naked eye, there is one huge difference between real and fake Xanax that makes it especially scary: the latter usually contains fentanyl, an extremely potent opioid that is responsible for countless accidental overdoses in numerous counterfeit and legal preparations. In fact, it’s estimated that many thousands of U.S. citizens ingest a deadly dose of  each year without ever even realizing it. How horribly tragic and senseless is that?  

Fentanyl is a schedule II synthetic opioid that is 50 to 100 times stronger than heroin and morphine, respectively. It is typically prescribed by a specialized physician strictly for patients struggling with severe or chronic pain, and it is such a potent and dangerous drug that the DEA has advised officials to take extra protective precautions, like gloves, even just when handling it, to avoid accidental death. This is because it is easily absorbed through the skin, and takes so little to be lethal. While other opiate doses are measured in milligrams, fentanyl is dosed in micrograms, and an amount equal to two grains of salt is lethal to nearly all individuals. Clearly, a drug that is 100 times stronger than morphine is no joke, and it officially now kills more Americans annually than any drug in history.

People who take fentanyl accidentally will be unaware of what they have taken, or how much, so they face an even higher risk of an opioid overdose. In the case of fake Xanax exposure, if or when a person does overdose on it, in the unlikely event that they’re lucky enough to make it to a hospital, it presents a unique problem. As a physician, I can tell you that when a person’s symptoms present differently from what is expected, it delays treatment, and Xanax overdose and fentanyl overdose present very differently. So when it’s reported that a person took “Xanax,” or some pills are found on their person, but their symptoms don’t look like a benzodiazepine overdose, those few minutes a medic or doc takes to assess the situation may be the few that end up costing them their lives. But that can be the case fake percocet or oxycodone as well, because fentanyl is commonly used in producing counterfeit versions of all of those. Even cocaine- maybe especially so because of the cost differential- fentanyl is so much cheaper that it’s very commonly used to cut it. And talk about presenting differently: cocaine and fentanyl overdose are not even remotely similar to one another. Even if users are aware that fentanyl is in the product, and aren’t that concerned about it, there’s still no way to know how much fentanyl is in it, or exactly how potent that fentanyl is. As a result, it is extremely easy to overdose after consuming any counterfeit product. 

Since the pills look exactly like the real thing, it’s nearly impossible to tell the difference. But, if someone consumes counterfeit Xanax made with fentanyl, there will be noticeable symptoms and side effects that wouldn’t ordinarily be present with genuine Xanax. The side effects of fentanyl include excessive itching, slowed breathing, nausea and vomiting, flushed skin, and constricted pupils. These can quickly progress to overdose, and those signs and symptoms are progressively shallow breathing, usually followed by gurgling or choking sounds, or sounds like “snoring,” pale, blue, cold, or clammy skin, limp body or unresponsiveness, and finally suppressed breathing. People often report that they didn’t recognize that someone was overdosing, even though they literally sat there watching it. They usually think they’ve nodded out and are snoring, and then just stop snoring. In reality, they’re really choking, then their breathing is severely suppressed, and when they stop making noise, they’ve simply stopped breathing. Fentanyl also yields some dangerous psychological effects, such as depression, hallucinations, difficulty sleeping, and nightmares. These are all signs to be aware of if you ever take a drug from a questionable source.

Fake Xanax: How it’s Done

Counterfeit Xanax is made using a pill press, which is exactly what it sounds like: it’s a device that is used to press powders together with a binding agent, to make the substance into a solid pill form. Pill pressing devices can be smaller than the size of a person’s palm, or large enough to need a small room for storage. Pill molds are added to the pill press to press the pills into certain sizes and to make markings or indentations. Sometimes they’re called “stamps,” and manufacturers use these to customize the appearance of the pill and mimic the exact imprint used by the legit pharmaceutical company. Currently, it’s not illegal to own a pill press, and in fact, some people use them to make their own vitamins or supplements at home. But it is illegal to own a pill mold that is used in a pill press. As a result, counterfeit pill molds are usually designed in other countries and sold to the U.S. as “spare parts” or “equipment.” This allows street dealers and manufacturers to purchase their supplies without gaining attention from the police, and continue to make fake drugs in their gnarly basements.

Fake Xanax: Why it’s Done

Helll-oooo! People who sell drugs don’t do so because they enjoy it, they do it to earn a profit. It behooves them to find a way to make their drugs cheaper and more potent, because that’s the best way to generate more profit from a smaller amount of product- that’s just common business sense. Believe it or not, many street-level dealers can get their hands on fentanyl very cheaply, either through theft, or through overseas production of cheap, sketchy fentanyl look-a-likes, so they commonly use it to cut their drugs, and this actually makes their products cheaper and more potent. To be clear, these fake products may not even contain the actual primary component. But in cases of fake Xanax, if it does contain actual alprazolam, the combination makes it even more dangerous-  but the fentanyl alone can just as easily provide or mimic the effects the user is looking for. The result is a product that looks and feels pretty much like real Xanax, but is infinitely more dangerous; sold at a fraction of the price, as compared to the real thing, brought to you by your friendly neighborhood street thug. 

Fake Xanax: How to Avoid It

Clearly, the easiest way to avoid purchasing fake Xanax is to never purchase the drug on the streets in the first place. In fact, the only reason anyone should ever take Xanax in the first place is if they have a prescription for it and are instructed to by their doctor. Unfortunately, some people who are prescribed the medication seek out cheaper ways to fill their prescription, such as purchasing it from shady online pharmacies or from overseas stores. But you’d be surprised how enterprising some dealers are, and a “pharmacy” selling counterfeit drugs is certainly not unheard of. So kids, the take home lesson is that if you have a Xanax prescription, you should always get it filled at a licensed pharmacy.

Fentanyl: The Masked Killer

As a final word of caution, I just wanted to include a short synopsis of three stories I read about counterfeit drugs containing fentanyl. None of them have happy endings. 

A 28-year-old smoked “a powdery substance” at his mother’s home, where he was living at the time. His mother found him unresponsive in the living room, and having no idea of what had happened, called 911. He was pronounced dead on arrival. The death investigation determined that the substance had been given to him by a friend, who stated they both thought it was cocaine. Toxicology confirmed that while he had a non-lethal level of cocaine in his system at the time of death, the cause of death was acute fentanyl intoxication- he died of a fentanyl overdose.

A 20-year-old college student suffering from undiagnosed anxiety was panicking about a test the following day, so consumed a single oxycodone pill he had obtained illegally before going to bed. His roommates found him dead the next morning. Toxicology confirmed that he died from a fentanyl overdose.

A 19-year-old purchased two Percocet from a friend. He consumed both pills and subsequently died from an overdose. His friend confirmed the purchase, but then toxicology showed the presence of lethal levels of fentanyl. His friend swore he didn’t know they were fake and was very distraught. That friend was also later found dead of an overdose. It was confirmed that it was also due to fentanyl, but it wasn’t clear if it was suicide or accidental. 

These are cases where four individuals died of fentanyl overdose, with all of them consuming a different drug, and three of them never even realizing they were consuming fentanyl. On that note, have you decided which group of Xanax in the picture were fake? I’ll tell you now: both are fake. Guess it’s a good thing you couldn’t actually choose. Get my point?

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Opiates:History,Use,Abuse,Addiction

Opioids: History, Use, Abuse, Addiction

How Did We Get Here?

Anchored in the history, culture, religion, mythology, biology, genetics, and psychology of the earliest civilizations to the societies of present day, humans have long tried to balance the positive medicinal properties of opioids with the euphoric effects that have so often led to their use and abuse.

Before we get into their history, first a quick fyi lesson in the semantics of the terms opiates vs opioids vs narcotics. While the terms are often used interchangeably, they are technically different things. 

The term opiate refers to any drug that is derived from a naturally occurring substance, ie from opium alkaloid compounds found in the poppy plant. Types of opiate drugs include opium, codeine, and morphine. The term opioid is broader, and refers to any synthetic or partially synthetic drug created from an opiate. Examples of opioid drugs include heroin, methadone, oxycodone, and hydrocodone. Narcotics is an older term that originally referred to any mind altering compound with sleep-inducing properties.

For the general public, only the term opioid is really necessary, as it includes all opi- substances. In my practice and in my blogs, I sometimes make a distiction between the terms, but if you’re looking for a safe bet, or maybe a trivia win, the term opioid is the best and most accurate choice. Regardless of the word used, one is not any safer than the other; any opiate or opioid has the potential to treat pain, to be abused, and to cause dependence.

Following are some of the most common opioids and their generic names, listed in order of increasing strength.

Codeine

Hydrocodone (Vicodin, Hycodan)

Morphine (MS Contin, Kadian)

Oxycodone (Oxycontin, Percocet)

Hydromorphone (Dilaudid)

Fentanyl (Duragesic)

Carfentanyl (Wildnyl)

History of Opiates

A long, long time ago, opiate use began with Papaver somniferum, otherwise known as the opium poppy. Native to the Mediterranean, it grew well in subtropical and tropical regions fairly easily, a fact that contributed to its historical popularity. Unripe poppy seed pods were cut, and the milky fluid that seeped from the cuts was scraped off, air-dried, and treated to produce opium. 

In case you’re wondering… today, legal growing of opium poppies for medicinal use primarily takes place in India, Turkey, and Australia. Two thousand tons of opium are produced annually, and this supplies the entire world with the raw material needed to make the medicinal components. Papaver somniferum plants grow from the very same legal and widely available poppy seeds found in today’s many seed catalogues. But, planting these seeds is less legal, with the DEA classifying them as a Schedule II drug, meaning that technically, they can press charges against anyone growing this poppy variety in their backyard. You can ask this one dude in North Carolina about it, as he was busted for having one acre of these big blooming beauties behind his house. At about 9 feet tall and topped with big red blooms, they’re not exactly inconspicuous. Another grow was discovered after an Oregon state patrol officer stopped to look at a field of beautiful “wildflowers,” wanting to cut a bouquet for his wife… a story that I personally find totally hilarious. Evidently, when he cut the first one, he was surprised by the sap that got all over his hands, so instead of taking some home to his wife, he took one to a fellow cop friend that was big on horticulture, and she enlightened him on what it was. Good thing too, because he had even thought about how cool it would be to dry the “wildflowers” to seed and plant them in his side yard! You just can’t make this stuff up.

Archaeologists have found 8,000 year-old Sumerian clay tablets that were really the earliest “prescriptions” for opium. The Sumerians called the opium poppy “Hul Gil,” meaning the “Joy Plant,” which was regularly smoked in opium dens. Around 460-357 B.C. Hippocrates, known as the “Father of Medicine” acknowledged opium’s usefulness as a narcotic, and prescribed drinking the juice of the poppy mixed with nettle seed. Alexander the Great took opium with him as he expanded his empire- it’s surprising that he was so great, because some accounts seem to suggest that he was a raging addict. Arabs, Greeks, and Romans commonly used opium as a sedative, presumably for treating psychiatric disorders. In the 15th and 16th centuries, Arabic traders brought opium to the Far East. From there, opium made its way to Europe, where it was used as a panacea for every malady under the sun, from physical ailments to a wide variety of psych issues. Biblical and literary references, and opium’s use by known and respected writers, leaders, and thinkers throughout history, including Homer, Franklin, Napoleon, Coleridge, Poe, Shelly, Quincy, and many more, made opium use perfectly acceptable, even fashionable. 

19th Century Opiates to Opioids

There was a lot of unrest and violence around the globe throughout the 1800’s. Wounded soldiers from the American Civil War, British Crimean War, and the Prussian French War were basically allowed to abuse opium. And sure enough, beginning in the 1830’s, one-third of all lethal poisoning cases were due to opium and its opiate derivatives, and this really marked the first time that a “medicinal” substance was recognized as a social evil. Yet, most places around the world still really turned a blind eye to opium and opiate use. But, so many soldiers developed a dependency on opiates that the post-war addiction state was commonly known as “soldier’s disease.”

In 1806, German alkaloid chemist Friedrich Wilhelm Adam Sertürner isolated a substance from opium that he named “morphine,” after the god of dreams, Morpheus. The prevailing wisdom for creating morphine was to maintain the useful medicinal properties of opium while also reducing its addictive properties. Uh huh, sure. In the United States, morphine soon became the mainstay of doctors for treating pain, anxiety, and respiratory problems, as well as consumption and “female ailments,” 

(that’s old-timey for tuberculosis and menstrual moodiness/ cramps) In 1853, the hypodermic needle was invented, upon which point morphine began to be used in minor surgical procedures to treat neuralgia (old timey for nerve pain). The combination of morphine and hypodermic needles gave rise to the medicalization of opiates.

Well, morphine turned out to be more addictive than opium, wouldn’t ya know it. So, as with the opium before it, the morphine problem was “solved” by a novel “non-addictive” substitute. Of course… I mean, what could possibly go wrong? Your first clue is that this novel compound was the first opioid, and was called heroin. See where this is going? First manufactured in 1898 by the Bayer Pharmaceutical Company of Germany, heroin was marketed as a cough suppressant, a treatment for tuberculosis, and a remedy for morphine addiction. Well, as you can probably guess, that worked great, until heroin proved to be far more addictive than morphine ever thought of being. So what to do? Hmmm… what…to…do… I know! Let’s make a “non-addictive” substitute for the heroin! That’s the best plan, definitely. 

20th Century: Opiates to Opioids

By the dawning of the 20th century, the United States focused on ending the non-medicinal use of opium. In 1909, Congress finally passed the “Opium Exclusion Act” which barred the importation of opium for purposes of smoking. This legislation is considered by many to be the original and official start of the war on drugs in the United States. Take that, Nancy Reagan! In a similar manner, the “Harrison Narcotics Tax Act of 1914” placed a nominal tax on opiates and required physician and pharmacist registration for its distribution. Effectively, this was a de-facto prohibition of the drug, the first of its kind.

In 1916, a few years after Bayer stopped the mass production of heroin due to the dependence it created, German scientists at the University of Frankfurt developed oxycodone with the hope that it would retain the analgesic effects of morphine and heroin, but with less physical dependence. Of course they did, because this worked out so swimmingly before. What could possibly go wrong? 

Well, we know how this story turns out.

First developed in 1937 by German scientists searching for a surgical painkiller, what we know today as methadone was exported to the U.S. and given the trade name “Dolophine” in 1947. Later renamed methadone, the drug was soon being widely used as a treatment for heroin addiction. But shocker… unfortunately, it too proved to be even more addictive than its predecessor heroin. Captain Obvious says he’s sensing a trend here.  

In the 1990’s, pharmaceutical companies developed some new and especially powerful prescription opioid pain relievers. They then created some equally powerful marketing campaigns that assured the medical community that patients would not become addicted to these drugs. Gleefully, docs started writing for them, and as a result, this class of medications quickly became the most prescribed class in the United States- even exceeding antibiotics and heart medications- an astounding statistic. Well, we now know that the pharma co’s were full of crap: opioids were (and still are) the most addictive class of pharmaceuticals on the planet… and so in the late 90’s, the opioid crisis was born. 

Opioids: True and Freaky Facts

The real fact is that 20% to 30% of all patients who were/ are prescribed opioids for chronic pain will misuse them. Further, studies on heroin addicts report that 80% of them actually began their addiction by first misusing prescription opioids. That’s a big number people, but I think it’s actually higher. Food for thought for all the pill poppers out there saying ‘I’ll never use a street drug like heroin.’ And speaking of that, by the turn of the 21st century, the mortality rate of heroin addicts was estimated to be as high as twenty times greater than the rest of the population. Twenty times, people.

Opioid Addiction and Overdose

Opioids produce a sense of wellbeing or euphoria that can be addictive to some people. Opioids are often regularly and legitimately prescribed by excellent, well-meaning physicians when treating patients for severe pain. The problem is that even when taken properly, many people develop tolerance to these opioids, meaning they need more and more to get the same effect and relieve their pain. That’s just one factor that makes them so insidious. In addition, we cannot predict who will go down this tolerance and potential addiction path, because it can happen to anyone who takes opioids. However, there are some factors that make people more susceptible to addiction, such as the presence/ prevalence of mood disorder(s) and especially a genetic/ familial history of addiction, which contributes to nearly 50% of abuse cases.

When people become addicted to opioids, they begin to obsessively think about ways they can obtain more, and in some cases they engage in illegal activities, such as doctor shopping, stealing prescriptions from friends and family, and/ or procuring them on the street. 

Another insidious facet of tolerance is that the tolerance to the euphoric effect of opioids develops faster than the tolerance to the dangerous physical effects of taking them. This often leads people to accidentally overdose as they chase the high they once felt. In this attempt to get high, they take too much and overdose, dying of cardiac or respiratory arrest. Drug overdose is the leading cause of accidental death in the United States, and there are more drug overdose deaths in America every year than deaths due to guns and car accidents combined. According to the CDC, 2019 drug overdose deaths in the United States went up 4.6% from the previous year, with a total of 70,980 overdose deaths, 50,042 of which were due to opioids. 

There’s a kahuna in Opioidland that’s so big and so bad that it bears a special mention… fentanyl. Referencing the above statistics, of the more than 50,000 opioid overdoses, fentanyl is specifically indicated in more than 20,000 of those fatalities. Again, I think it’s way higher than that. Regardless, I think we can all agree that it’s deadly. Fentanyl is so crazy dangerous because it is 50 to 100 times more potent than morphine, so it takes the teeny tiniest amount to overdose. A lethal dose of fentanyl for adults is about two milligrams- that’s the equivalent of six or seven grains of salt people! 

Obvi, there are tons of chilling statistics about fentanyl, but here’s another one for you: in one-third of fentanyl overdoses, the individual died within seconds of taking it. Get this- they died so quickly that their body didn’t have enough time to even begin to metabolize the drug, so no metabolites of fentanyl were found on toxicology screens at the time of autopsy. The moment you ingest or inject any drug/ pharmaceutical, the body immediately begins to break it down into components called metabolites. After a certain period of time (which varies according to many different factors) the drug is completely metabolized by the body, so a toxicology screen will pick up those metabolites rather than the complete molecule(s) of the drug. Every drug has a known rate of metabolism, so tox tests can tell how long ago a drug was used or ingested. This data is saying that in one-third (33%) of fentanyl overdose deaths, tox screens pick up zero metabolites, because the body had no time to even begin to start the process of making them. The screens detected the presence of the full complete molecule(s), but no breakdown products. It’s a very significant and scary hallmark of fentanyl use/ abuse/ overdose: the fact that you may not live long enough to regret using it.  

How did fentanyl become such a big part of the opioid epidemic? Around 2010, docs were getting smart to the use and abuse of opioids and the ensuing crisis, and many stopped prescribing them. This left a lot of addicted people, including many who legitimately required relief from pain, unable to get prescriptions and SOL. At the same time, buying prescription drugs on the street was crazy expensive due to increased demand and decreased supply. But also, heroin had became so abundant that it suddenly became cheaper than most other drugs, so addicts started to switch to heroin. In one survey, 94% of people in treatment for opioid addiction said they used heroin only because prescription opioids became much more expensive and harder to obtain. 

Next, to make things exponentially worse, drug cartels discovered how to make fentanyl very cheaply, so huge quantities of fentanyl started flooding the market. Because fentanyl is easier to make, more powerful, and more addictive than heroin, drug dealers recognized the opportunity, and began to lace their heroin with fentanyl. People taking fentanyl-laced heroin are more likely to overdose, because they often don’t know they’re taking a much more powerful drug. Fentanyl can be manufactured in powder or liquid forms, and it can be found in many illicit drugs, including cocaine, crack, and methamphetamine. And let’s face it folks, the people making this garbage aren’t exactly rocket scientists, so all of these drugs can (and usually do) contain toxic contaminants and/ or have different levels of fentanyl in each batch, or even varying levels within the same batch. These facts just add to the lethal potential of this stuff. 

Now fentanyl has found its way onto the street in yet another form: pills. When fentanyl pills are created for the street, they’re pressed and dyed to look like oxycodone. Talk about insidious! If you go looking to buy oxy’s on the street and the dealer is selling them dirt cheap because they don’t know any better, or care is probably more accurate, you’ll probably think ‘Wow- these oxy’s are cheap! Let me get those!’ If your body is accustomed to using real oxy’s and you unknowingly take fentanyl, you will absolutely overdose. Like see ya later, bye overdose.

But believe it or not, it gets worse… A new variation of fentanyl is finding its way into the drug trade. Carfentanil is 100 times stronger than fenatanyl, which makes it 10,000 times more potent than morphine. While it was originally developed as an elephant tranquilizer (hel-looo??!!) the powdered form of carfentanil is now commonly used as a cutting agent in illicit drugs like heroin, cocaine, and methamphetamine.

Opioid Withdrawal

Opioid withdrawal can be extremely uncomfortable. But an important thing to remember is that opioid withdrawal is not generally life threatening if you are withdrawing only from opioids and not a combination of drugs. This is because each drug class is pharmacologically different, so withdrawal is different for each one. FYI, the most dangerous withdrawls are from benzodiazepines (Valium, Xanax, etc) and alcohol, even though alcohol isn’t technically a drug, it reacts, is metabolized, and physically withdraws from the body like any drug. Individually, either can be lethal in withdrawl and require medical supervision. 

Opioid Withdrawal Symptoms

Withdrawal typically includes the following symptoms to varying degrees:

Low energy

Irritability

Anxiety

Agitation

Insomnia

Runny nose

Teary eyes

Hot and cold sweats 

Goose bumps

Yawning

Muscle aches and pains

Abdominal cramping

Nausea

Vomiting

Diarrhea

Stages of Opioid Withdrawal

-The first phase (called acute withdrawal) begins about 12 hours after the last opioid use. It peaks at around 3 – 5 days, and lasts for approximately 1 – 4 weeks. This acute stage has mostly physical symptoms.

-The second phase (post-acute withdrawal) can last for a long time, with some references documenting up to two years. The symptoms during this phase are mostly emotional, and while they are considered less severe, they last longer.

Symptoms include mood swings, anxiety, variable energy, low enthusiasm, variable concentration, and disturbed sleep.

But, don’t let concern over withdrawl symptoms keep you from getting off of opioids. There are medications that can significantly decrease all of these. Two of the most common are methadone and buprenorphine. Being that drug detox is one of my specialties, in next week’s blog, I’ll outline both of these and tell you my reccommendations.

Until then…

Now that we’ve covered the history and background on opioids, if you think you might have an opioid addiction, I have a separate quiz that will bring some clarity to you on that question. I will upload a more detailed assessment as a separate blog, but for now, here’s a short generalized screen to take first. 

Do You Have an Opioid Addiction?

Answer yes or no to each of the following questions. If you answer yes to at least three of these questions, then you are likely addicted to opioids and should definitely take the detailed addiction self-assessment test which follows. I also suggest that you print the assessment and answers and take them with you for a professional evaluation.

Addiction: Basic Screen1) Has your use of opioids increased over time?2) Do you experience withdrawal symptoms when you stop using?3) Do you use more than you would like, or more than is prescribed?4) Have you experienced negative consequences to your using?5) Have you put off doing things because of your drug use?6) Do you find yourself thinking obsessively about getting or using your drug?7) Have you made unsuccessful attempts at cutting down your drug use?

Again, if you answered yes to at least three of these questions, then you are likely addicted to opioids and should take the detailed addiction self-assessment test which follows as a separate blog. Be sure to print both with you for a professional evaluation. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Secrets For Surviving Panic Attacks

Well, it’s another Saturday. My avid blog readers might know what that means…I’m at the carwash again for my Inside-Out Wash and Hand Wax. And yes, I know I’m pretty particular about the state of my car, thank you very much, but in my professional opinion there’s no pathology there whatsoever. Anyway, I’m stuck for a minimum two hour sentence at this joint. It’s always the longest two hours of my life, and if I don’t find something to occupy my mind I might just lose it. I usuallly sit inside for the A/C, but the weather was beautiful, so I sat outside on what barely passed as a patio: two of those round concrete table jobbies with the rough curved benches encircling them, surrounded by tall but sparse hedges on three sides. I wasn’t the only one with the bright idea to sit outside- Floridians get very excited in November when the temperature dips below 75 for a second and the cooler breezes make it onshore- we flock to outdoor spaces like Aztecs worshipping the sun. I spied a concrete bench that was empty and sat down with my coffee from my fave place on US-1. There was a dude at my table on the bench across from me, and he didn’t so much as acknowledge my presence when I sat, so engrossed in his phone was he. Fine by me. As I surveyed my company, what struck me was that there were literally zero words being exchanged among the other waiters, even those that were clearly there together. It was like a freaking monestary- if the monestary was right next to a carwash with its particular “music” of Inside-Out Washes and Hand Waxes in the background. I don’t know why I still find the lack of communication, especially in the very most basic sense, to be so alarming, almost disturbing even. I know I’ve gotten into this in so many different blogs and videos, and of course in my book, but it seems like no one talks to anyone anymore. People talk more to Alexa and Siri these days than other people. Anyway, what were my fellow waiters doing while they weren’t talking? They were of course on their phones, just like everyone always is, always on freaking cell phones. I wasn’t the least bit shocked to see what looked like a ten-year-old girl buried in a phone. These days, young kids, I’m talking like age three and up, have phones to play games on, because moms can’t bear to give up their phones to allow the kids to play on them, and if the kids don’t have phones to play on, they’ll drive their moms crazy and make it impossible for the moms to be on their phones. So the obvious solution, nay, the only solution, is to get your four-year-old a phone. I wonder what Dr. Spock or Mr. Rogers or Bert and Ernie would say about the Romper Room set having phones, or even worse, needing phones. 

Anyway, as I sat on the hard and scratchy concrete bench on the “patio” surrounded by the sparse hedges, a woman entered the scene. She walked up and asked if anyone was sitting next to me, to which I said no. The way these benches are curved and situated, it makes it a little awkward to sit at one with a stranger, but she smiled and took a seat next to me. She looked about 40 or so, medium height and weight,  with jet black hair. I guessed she had more than a little Latin blood in her. She was not dressed Saturday casual like the rest of us waiters: she wore a nice black skirt suit with a bright pink blouse, and I assumed she was on her way to work. At where or doing what I had no clue, but realtor was at the top of my guess list. I noticed she wore no wedding ring, though that doesn’t really mean anything these days. She looked like a woman of means, and she was fairly attractive, but something was off. She looked kind of shocked for lack of a better term, like psyche shocked, and she nearly visibly vibrated, like she was plugged into a light socket. She was clearly very unsettled by something, or maybe several somethings, and it or they were simmering just below the surface. I could see she was accustomed to the valiant effort to keep them there, but they were clear as the day to me. Your average person on the street wouldn’t see any of this in her, but I’ve made my living watching and listening to people as they lay bare their pain and fear, and this woman had plenty of both. 

She said her name was Pilar, and that and her slight accent confirmed my previous guess that she was of Latin descent. I knew damn well that something was wrong with Pilar, something that I might be of help with, but also that I might not. My mental machinations continued. She could be in denial, and she could be offended if I offered an opinion. I mean, how many people want to be analyzed by a shrink they just met while waiting at the carwash? I decided that I would not open Pandora’s box. Not going there. I’m just going to sit here in the sun and be polite, but be surface. Mind my own business. Polite, surface. After a moment sitting at the little concrete table, she asked me how long the carwash takes. I dutifully explained that the Inside-Out Wash and Hand Wax took a bare minimum of two hours, especially on a Saturday morning, but that it was well worth the wait. At this, she blew her bangs out on a long resigned sigh. Then motioning to my cup, she asked where she could get good coffee. I gave her directions to my fave spot, which was just up the street on US-1 and told her to ask for “Bailey the Barista, the best barista in the Easta” I had given this name to a barista named Bailey at my fave place because she really is the best barista ever in the vast history of baristas. (ADD side note: what the hell did we call the people who made our coffee prior to the advent of Starbucks?) Pilar laughed and said she’d be back; right after she left, even the guy across from me stood up and said that with my glowing recommendation, he just had to go for a cup as well. How to win friends and influence people…with coffee…who knew, I mused. Maybe the next book? I filed that under ‘Later’ in the grey matter. 

I took Pilar’s absence as an opportunity to remind myself not to get involved, to not play the curious shrink role. No matter how bored to tears, how desperately in need of a distraction I became, I would be strong. I would not go there. Be polite, be surface. You may be wondering why I don’t just announce my profession and delve into stuff with people at every opportunity. First, that would mean I’d have to be ‘on’ and wearing my Dr. hat a lot when I’m at social events and such, when I’d really prefer to be chill. But it goes beyond that. Here’s the thing. Unless someone asks me straight up what I do, I don’t usually tell random people I’m a psychiatrist, because invariably I end up spending a lot of time listening to a story about someone’s Aunt Edna from Des Moines who has 53 cats and hasn’t left her home in 12 years because she’s purposely hoarded it with old newspapers, jars full of pee, and her old fossilized poopy diapers, all as an excuse to never leave, and do I think that maybe she’s depressed and can I give her a prescription for Prozac? There’s a lot of that kind of thing. Another issue that can happen is someone tells me their story, and in my opinion they may actually need help, but when I tell them they should seek that help, they get all pissed off at me. Plus, when I talk to people when I’m out and about, they don’t know that they should have no expectation of privacy because they aren’t patients and we aren’t in my office, and they may tell me some deeply private things, and it just gets messy for me that way. So, for those reasons, and a lot more, I don’t generally just announce that I’m a psychiatrist. But there is a flip side. It’s no secret that I hate to do nothing. I hate waiting for my car to have its Inside-Out Wash and Hand Wax because I have nothing to do while I wait. And remember: I hate doing nothing. So sometimes, like during my interminable wait for my car, when I’m bored out of my skull and climbing the walls, I might be less averse to telling people I’m a psychiatrist, because 100% of the time, it starts what might be an interesting conversation, one that might help pass the time until my car is ready. All I have to do is introduce myself and my profession, “Hi, I’m Dr. Mark Agresti, I’m a psychiatrist. What’s up?” and we’re off to the races. People spill their guts. Other times, I don’t use my last name or announce my profession, but I still engage in the conversation. So it’s kind of like the little cartoon with the angel on one shoulder and the devil on the other and do I dive in or mind my own business? It’s an internal tug-of-war I’m familiar with. Earlier, I had simply introduced myself to Pilar as Mark. In this case, I knew that Pilar was genuinely troubled, but if I told her that I was a psychiatrist, I wasn’t sure how she would take it; she seemed fragile to me. All the more reason for me to be polite but be surface. But on that flip side, I did have time to kill, and Pilar seemed very nice, and maybe I could help her just as another human rather than as a physician. So much for polite and surface. Maybe she wouldn’t even want to open up to me. But maybe she would. I had the feeling it could get deep on this carwash patio. Guess I’d find out. 

With time to kill, I decided to be like everyone else and get on my phone to check my Facebook, or Fakebook as I like to call it. They recently refused to boost one of my posted blogs. Interestingly, it was called “Carwash Psychiatrist” and was all about a different Saturday morning conversation with a steroid-raging mountain-sized man. Fakebook refused to boost it citing inappropriate content. I call total bs on that. I thought it was really informative and interesting, if I do say so myself. It’s on my website if anybody wants to read it and decide for themselves. I re-read it again as I sat there, and still I didn’t think it was inappropriate. I wished I could figure a way to get around Fakebook to boost it. As I considered that, Pilar returned and sat down next to me with her cup of coffee. Her expression was more open than it had been. I think she was more comfortable with me because now we had this coffee connection. Somehow, sitting next to each other drinking coffee together set a mood to talk, a vibe like we were old friends catching up. Glancing at my watch, I saw that I still had an hour until my car would be ready. More than enough time for a conversation, if one arose. I had given up the mental jujitsu match and decided to be polite and open. I could feel Pilar’s dis-ease, referring to her uneasiness, not illness, though she always kept it hidden…or tried to. She looked at her watch and sort of tisked the time, saying that she hoped her car would be done soon because she had to get to work. When I asked her what she did and if she usually worked weekends, she said that she designed and sold high end kitchen cabinetry, and that no, she didn’t normally work weekends, but she was behind because she’d missed a lot of days recently because she’d been sick. This was it. This was the turning point. I could be in or out. Polite and surface or open. I know something’s going on with her, maybe there’s something I can do to help her, so I go there, unable to resist the psychiatrist in me, but at this point still unwilling to tell her there was one. So I went there, I asked her the obvious question that her answer had begged: what was wrong?

She answered, “I thought I was dying.” Okay, I’m looking directly at this woman, and while she looks troubled, she is definitely not dying. I’ve seen dying. I know dying. I decided to take the light-side approach and gave a little non-committal laugh as I said she’d have to narrow that down with some details. She began, “A month ago, I had to go to the emergency room.” I expressed surprise and asked what happened to land her in the ER. She replied, “I woke up one morning and I had this tightness in my chest. I couldn’t breathe, and my heart was racing. I was sweating buckets, and I was so uneasy, like something awful was happening. I thought for sure I was having a heart attack. I had this sensation of pins and needles in my fingers. I didn’t know if I was losing my mind or really actually dying, because I felt like I didn’t know who I was or where I was…I felt like it wasn’t real. Crazy, right?” Before she had even finished her second sentence, I knew that Pilar was describing anxiety, maybe a panic attack, so I said, “Let me take a wild guess, when you went to the ER, they took your vitals, started an IV, drew blood for labs, did a chest x-ray and an EKG and when the results came in, they told you everything was normal, that you just had anxiety.” Surprised, she said yes. When I asked if she’d had other similar episodes, she said, “You know, I have been getting these attacks in the middle of the night when I’m sleeping. When it happens, I wake up and I’m sweating, I can’t breathe, my heart’s hammering, and I feel like I’m honestly losing my mind, because I can’t calm down. I really feel like I’m dying, like I’m having a heart attack, and I’m sure I’m going to die.” When she followed up with her family doctor, he repeated the same tests that the emergency room doctor did and came up with the same conclusion of anxiety, so he gave her 2mg Xanax and told her to break them in half and take a half twice a day. She said it helped a lot, but that she had been living on them for the past 3 weeks, and she was very worried about becoming addicted, because she had read that they are very addictive. She was definitely right on that count. Xanax is very effective at treating anxiety and panic disorders, but it’s a dual edged sword at best and not good as a long term solution. Then she told me that about two weeks ago, she had another attack, and she wanted to try to avoid going to the ER if possible, but she wanted to be close in case she needed them. So she decided to drive to the ER but not go in. She parked and sat in the lot for about 90 minutes, waiting for the attack to subside, but she didn’t go in. She did that same thing twice. Then, she said that she had plans to go out with her friends about a week ago, and she had an attack in her house. She was just about to get in her car to meet them, and she had an another attack. She said that this one was the same deal: shortness of breath, sweating like crazy, feeling like she isn’t real, like she is losing her mind, like she’s having a heart attack and that she’s going to die. It seemed that this had been going on for about a month. Then she said that she was living in a constant state of fear, always scared that she was going to have an attack. And that was why she was working this weekend, because she had called out of work so many times in the past 4 weeks that she was really behind on some projects. I asked her how things stood now, and she said she had stopped all social engagements. She was pretty much confined to her house, only leaving for necessities like going to her office, grocery store, and gas station. It seemed like that was pretty much it, and she needed a Xanax just to do those few things. She was living in constant fear of having the attacks, but now that fear had expanded; now she had fear of getting in her car, fear of driving, fear of being out in public, and even fear of meeting up with her friends. She’s pretty much stuck in her home, only leaving if she absolutely must. So a month into her anxiety and panic attacks, that’s where she stood. It wasn’t good. She’d have to get help to get it under control.

Keep in mind, Pilar doesn’t know what I do, but I kind of needed to push the envelope a little. I asked what her family practice doc’s diagnosis was, and she said he had told her that it was just plain old anxiety. That didn’t jive for me; this wasn’t garden variety anxiety. When I told her that I didn’t think it was just anxiety, she kind of freaked out, eyes wide, asking if she could die from it, if she would be like this for the rest of her life, and if there was a cure for it. And only then did she finally think to ask what it was. I told her with a smile, “I think you’re going to live. I’m pretty sure you have something called panic disorder. I’ve read about it. You should see a psychiatrist, because there are ways to treat it without using addictive drugs like Xanax.” She looked relieved as she asked what panic disorder was. I explained that it’s not a physical illness, it’s a psychiatric illness with attacks exactly like she was describing, and that Xanax works, but that there were other medications for it, and that’s why she should see a psychiatrist. When she asked how I knew about all this, I told her that I had read up on it a lot because I had a sister who was diagnosed with panic disorder. I went on to say that her doctor gave her Zoloft, and that seemed to work really well for her. After two weeks on it, her attacks had basically stopped, and it wasn’t addicting at all like Xanax. When she asked if I knew what caused the attacks, I told her that I’d read that the panic attacks were the result of a false alarm going off in the brain, a suffocation alarm. You think you’re suffocating, you think you’re about to die, but you’re really not. She said she never imagined that something in her brain could cause her to feel like she was really dying, but that she was glad that it was treatable. I told her that when she got on the right medicine, the attacks should go away, just like they had for my sister. She thanked me profusely and assured me that she would see a psychiatrist. Then she lifted her coffee cup, took a big sip, and said she was so relieved. I told her that by the way, caffeine wasn’t the best idea, that my sister had to give it up because it encouraged more attacks. She said she understood, but that between waking up with attacks and taking the Xanax, she was exhausted and needed the boost, but that she would make the effort to stop the caffeine. I reiterated that she should get off the Xanax asap, that it was just a very temporary fix, and she smiled and gave me a funny salute and an “Aye aye, Captain!” 

We continued to talk, and she said that she was glad she had sat down next to me. I kind of felt badly about my little white lies, not telling Pilar that I was a psychiatrist while telling her that I knew about anxiety and panic disorder because I’d read up on it when my sister had been diagnosed with it. The next thing I knew, I heard two last names called, mine being one. The other actually turned out to be Pilar’s. We stood up simultaneously, laughed, and then shook hands as she thanked me again. I told her no problem and to be well. And that’s how it was left. As I got into my freshly Inside-Out Washed and Hand Waxed car, I assuaged the bit of guilt I felt by reminding myself that there is risk in telling people you’re a psychiatrist these days. I didn’t tell Pilar. Maybe I should have, I don’t know. I think I helped her despite holding back the truth, and I felt good about that. I was sure that she would see a psychiatrist and make the effort to stop the Xanax. How weird would it be if she actually came to me, to my office to see me? It could happen. If it did, she might be angry. I’d have to cross that bridge when and if I came to it.

Pilar’s panic disorder is not at all uncommon, unfortunately. By some estimates, approximately two million adults in the United States suffer with panic disorder each year. There are two types of panic disorder: with agoraphobic features and without. Agoraphobia is defined as an extreme or irrational fear of entering open or crowded places, of leaving one’s own home, or of being in places from which escape is difficult. Most people with panic disorder start off without agoraphobia, but if the condition persists without adequate treatment, it can progress to include agoraphobia, where people find it almost impossible to leave their homes. It can be very debilitating, but it doesn’t have to be. Emma Stone, Amanda Seyfried, Sarah Silverman, Oprah Winfrey, John Mayer, Kristen Bell, and Caitlyn Jenner… What do these people have in common? They’re just a few of the many notable people that have panic disorder. That just goes to show that having a psychiatric illness like panic disorder isn’t the end of the world, and it doesn’t have to hold you back. You just need to make the choice to seek appropriate treatment if you suspect that you have it or have been told that you have it. Don’t make the mistake of ignoring it with the hope that it’ll just go away, because it won’t…it’ll only progress.

For more “psych stories,” check out my book, Tales from the Couch, available on Amazon.com.

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Marianne asks “how can I get off klonopin’’

A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do. 

What are they?

Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them. 

How do they work?

Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.  

Why can using them be problematic?

Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term  and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population. 

A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically. 

The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.  

When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick. 

What about withdrawl from benzos?

Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before. 

I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.

I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions. 

To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.

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45 Things People Say When They Use Alcohol and Drugs

1. Wanted to get high.
2. Just wanted to.
3. To get a mini vacation.
4. Just wanted to checkout.
5. Needed a reward.
6. Out of anger.
7. Out of frustration.
8. Works hard and deserves it.
9. Thought I could have just one.
10. Everyone else was doing it. (more…)

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How to Detox from Benzodiazepines

http://206.189.200.158 ~ (561) 842-9550

Dr. Agresti, West Palm Beach Mental Health Specialist – Psychiatrist, talks about Benzodiazepines Detox.  Though benzodiazepines detox can have some serious problems, such as seizures, it is possible.  There are medications that can help during benzodiazepines detox.  If you or a loved one is addicted to benzodiazepines, do not stop abruptly or at home.  Get professional help and benzodiazepines detox safely.

Call Dr. Agresti today to get help with Benzodiazepines Detox.

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