Benzodiazepines and the art of self adjusting medications–how to drive your psychiatrist bananas

In responce to my blarticle about the limits of usefulness of Klonopin, e-chimp writes in with the following barrage of thought provoking questions and comments: 

What’s your opinion on the thin line between mis-use and self-medication? Say someone’s prescribed a small supply of 2mg diazepam, finds that this dosage does nothing and adjusts it up to a higher dose than prescribed? Would you class this as mis-use? If a patient admitted that they’d done this, would you prescribe it at that level or refuse to continue to prescribe it due to concerns with potential abuse?

I have another question, which I suspect will be more controversial. I’ve found benzodiazepines fairly ineffective in dealing with anxiety. I have, however, found a drug that does help. This drug happens to be codeine. Obviously this isn’t something that is usually prescribed for psychiatric conditions and, indeed, I haven’t been prescribed it. Now, in one sense I’m abusing an opiate, because I use high doses in a way that hasn’t been authorised by a doctor. In another sense I’m self-medicating, because it certainly does help lower anxiety and it’s often a better choice than self-injury. This is a very occasional thing, so tolerance and addiction aren’t an issue. I have no interest in increasing the doses I use in frequency or amount. Would you class this as use, mis-use, abuse or something else? If a patient told you this, would you be wary about prescribing other drugs to them? Obviously prescribing opiates for this sort of thing would be dangerous for the prescriber due to the politics surrounding the issue; aside from that, do you think opiates should be investigated as psychiatric drugs?

WOW!!!

I’ll address your first paragraph and then the second.  Self-adjustment of the dose of benzodiazepine (whether it is Klonopin, Xanax or Valium (the above mentioned diazepam), is as predictable as sunrise.  I would guess that a large majority of the patients who get a prescription for this class of medicine take a little more or a little less, depending on how they are doing.  Because of the nature of the medication, it can be changed in that manner and still provide benefit for the patient.  That strategy is not effective for, say, antidepressants, mood stabilizers or antipsychotics, because they need to be present in a consistent way to provide for the blood levels that provide the benefits.  This is not always true, however.  There is something to be said for consistent administration of the medicine.  Especially when it comes to Klonopin.  If I hear that someone has a repetitive pattern of feeling good and droping their dose of medicine and then runs into a string of days where they feel more anxious and have to take more, ddduuuuuhhhhh . . . take the medicine on a consistent basis.  Do I refuse to treat patients who self adjust their medicine? No.  Unless I feel that they are abusing it.  But that, again, is all about communication.  For example, if someone is prescribed Klonopin 1 mg at bedtime and comes back in and tells me that it didn’t work so he started taking it twice a day and it did work, I will prescribe him Klonopin 1 mg twice daily.  We will have a talk about self adjusting meds and the benefits of giving me a call . . . but I don’t yell.  If that same guy comes back in and says, it stopped working as well so he started taking three mg daily . . . I start to get worried.  I may go up . . . but I am worried and I will have a serious chat about my concerns.  Further adjustment upward after “the second talk” may be cause to discontinue the medicine and try something else. I don’t refuse to treat, I change MY treatment strategy.  As we have discussed on this site before, some people get transient benefit from these meds and start sponging them up without getting clinical benefit.  If that starts to happen, it is way better to catch it early and start diverting attention and patient expectations toward another avenue of treatment.  If not, you do end up with a hefty benzo addiction.  Discharge from my care will happen if you are lying to me (no therapeutic relationship there) or are getting additional benzos from another doctor (again, can’t split the thereapeutic relationship).  In cases like that, I am just being used for my prescribing ability . . . not as an agent for life improvement.  It is all about communication and honest, just like any other successful relationship.

Now, codeine for something other than pain . . .

I am intregued.  But nervous.  I did have one adult patient who suffered from chronic focus and concentration difficulties that were unresponsive to any medication that he was given.  On his own, he found he did better when he took narcotics for his (very ligitimate) back pain.  He went on to use the narcotics for both purposes, ended up getting hooked on them and then having to detox off.  This is a standard story for narcotics and pain management.  It is unlikely that narcotics, as they are now formulated, will ever hit mainstream psychiatric practice because of the liability of addiction that they have.  Would I feed into that and prescribe them? It all depends on the relationship.  If I have a relationship that is honest and trusting with my patient, and they are doing all that I ask them to do (from a conventional standpoint) and still use unconventional approaches occasionally because they work do I sacrifice the whole relationship for principle? Probably not.  I may go overboard in my documentation and make sure that there is good communication about the intervention between me, the family doctor, the patients family, etc, so that all are on board with the atypical intervention and all questions are answered etc.  Then I would monitor and document over time. 

Again, it is all about relationship.  Honest and open and trusting relationship.

–Dan Hartman, MD