Alcohol and Klonopin . . . decision time

I have been putting this off for a while.  I have a nice lady who lives in difficult circumstance.  She has struggled with addictions most of her life, whether it is food, drugs, and now, alcohol.  Both her circumstance and her biology lead her to be tremendously anxious, depressed and to have mood swings that are sufficient to warrant an atypical bipolar disorder.  Getting these factors under control has been impossible, because her life circumstance has been so difficult . . . really heart-wrenchingly difficult.  Typical antidepressants have not worked.  Benzos have helped tremendously . . . but she is drinking.  Sometimes to great excess . . . while she is taking Klonopin.  But today . . . is decision day.  For both her and for me.  Today she must decide if she is going to choose health, or a continued pattern of behavior that is unhealthy and dangerous.   The danger in situations like this is that the patient will be consumed with hopelessness when faced with the decision.  Instead of choosing one path or another, they can choose to die.  Great care is needed.  And support.  I can be careful . . . but she has minimal support.  But the current situation must change.

The biology under my concern is how benzos like Klonopin interact with alcohol.  There is an ion channel in the brain called a chloride channel.  It decides when and how much chloride ion goes into a nerve cell.  The chloride ion is very negative (negatively charged, I mean . . . not pessimistic).  When it is concentrated inside the cell, the inside of the cell is very negatively charged and very stable.  When a nerve cell “fires”, the inside becomes positive for a very brief period of time before the chloride channel can once again restore the nerve cell to the negative state.  This channel has numerous receptors on it that interact with a variety of hormones, medicines, chemicals, etc.  This includes benzodiazepines like Klonopin, Valium, Xanax, barbiturates, and . . . alcohol.  When these substances are ingested, the chloride channel opens up and the cells become hyperpolarized . . . really negative compared to the outside.  This makes them more stable and less likely to reach threshold to “fire”.  While this may sound like a good thing . . . and in some situations (eg seizure disorders) it is.  But when they are too, too hyperpolarized . . . you stop breathing.  Not a good thing. 

So when my nice, but overwhelmed patient uses too much alcohol in addition to her Klonopin . . . she is at risk.

So today is decision time.

It’s either me and my benzos . . . or the alcohol. 

Both she and I know that the alcohol must go.  

But will she have the courage?

Think some kind thoughts for her today.

–Dan Hartman, MD