The one question almost everyone asks when starting a medication is: How long will I have to stay on this?
They fear that their drug treatment will be some kind of life sentence. One patient said, “It’s like going to Prozac prison, is there any hope of parole for good behavior?” While it’s true that some rules of thumb exist, the best way to determine how long a person with anxiety stays on medicine is their dedication to practice new behaviors.
The willingness to practice isn’t determined by your doctor. I bet you expect me to say that the willingness to practice is determined by you. Why should I say something you already know? Let’s go ahead and look at some things you may not be aware of when you’re taking anxiety medicine.
How the Drug Becomes Master
Anxiety medicines come in different varieties: some are liberating and some will enslave you. If it’s a drug you take “only as needed,” then it’s a setup for you to be the Master. Taking a medicine as needed may at first glance seem like a liberating experience that puts you in control. After all, what could be more freeing than taking a drug only when you need it?
Needing something seems pretty innocent. Deciding when you need to take your medication lets you feel like your calling the shots. But watch out, the word “need” also has some subtle meaning that can catch you by surprise. Taking “as needed” means:
- you can’t do without it, you NEED it.
- your have to tracking your anxiety levels in order to detect the right moment you need it
- you have to wait for the medicine to take effect
- there is only, “needing” and “not needing,” with nothing in between
- a pill is the only way you can manage your anxiety
2. Short Effect
“As needed” medicines are typically short-acting. That doesn’t always mean they stay in your system for a short time, it just means you feel the effect for a limited amount of time. That means you will need it again when the effect is over and you feel anxious again.
3. Vicious Cycle
The immediate calm feeling you get from taking a medicine “as needed” compared to the way you feel when the effect is over can cause you to need the medicine more often. In fact, when you are artificially calmed by a drug, the rebound effect can make you feel even more nervous. The difference will feel even more dramatic and the natural tendency will be to avoid the nervousness by taking the drug again. This is how addiction, or what is medically labeled “dependence”, gets started. You take the drug more often, so you need the drug more often. Then after a while, you need more of it to get the same effect, and that’s called “tolerance”. These are the building blocks to enslavement.
The best example of an enslaving anxiety medicine is Xanax (Alprazolam). If you meet anyone who takes this drug as needed you will see how their lives revolve around the medicine.
Let’s look at a quick example of what I’m describing:
Sarah takes Xanax “as needed” for panic. She started with this dosing because she preferred not to take daily medicines. She had her first experience with Xanax when she lwent to her local emergency room. She had been at work covering for an absent coworker and thought she was dying of a heart attack. Her exam was completely normal and the emergency room physician determined that she was having a panic attack. His treatment: Xanax to “calm her nerves.” By the time she took the medicine, the worst of it was already over but she remembered how relieved she felt when the Xanax kicked in. Later, she scheduled an appointment with a psychiatrist who was a great proponent of Xanax. He prescribed it for her “prn”, doctors lingo for “take as needed”. Because her panic attacks were rare , he believed it made sense to avoid using daily drugs if she didn’t need them. Note: I will write another post on the fallacy of this thinking later.
Sarah left the psychiatrist’s office with a prescription for Xanax .5 mg up to three times per day as needed for panic. She considered the prescription “overkill” because she only had one other panic attack since leaving the Emergency room. Then again, she was already worrying about the next attack so she was relieved to have the medication. Sarah’s work demands were particularly stressful her first day back to work. She thought she could feel her heart palpitating and her breathing was strained. She decided to take a Xanax to avoid another attack. After about 15 minutes, she noticed she was feeling calmer. It was a relief. “Thank God I ‘ve got this medicine.” she tells herself. It was 9:00 am when she took it. By 1:00 in the afternoon, she was starting to notice some nervousness again. Not panic, but some tremor and fast heartbeat. She tried calling her psychiatrist but he was in with another patient, and couldn’t take her call. Since the prescription was labeled up to three times per day, she decided to take another Xanax. It was 1:30. By 4:00, she started watching the clock, expecting to lose the effect and wondering if she should take the last Xanax allowed for that day.
Sarah’s story is a story of “drug enslavement.” She starts out with a real set of symptoms that disrupt her life. She also starts with many possible options to treat the panic, such as: behavior modification, lifestyle changes, and a host of other not-so-enslaving drugs which ironically, are taken every day. Drugs like the Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Lexapro, Celexa, etc), Selective Norepinephrine Reuptake Inhibitors (like Effexor XR and Cymbalta) and Remeron (mirtazapine) to name a few. The enslavement process doesn’t normally happen as quickly as I’ve dramatized here, but the phenomenon is real and it’s documented in every basic text in psychopharmacology. They don’t call it “enslavement”. It’s called dependence, clock watching, tolerance, and rebound. They are the downside of the “as needed” anti-anxiety medicines known as benzodiazepines.
Below is a list of benzodiazepines, commonly called sedatives, often used to treat panic disorder. The generic name is followed by one brand name after the colon. Consider their psychological costs when discussing your anxiety treatment options with your physician. You don’t have to be a slave if you understand your options.
alprazolam: Xanax clonazepam: Klonopin
lorazepam: Ativan diazepam: Valium
Tell us your experience with sedatives. Do you agree with my description of some drugs as “enslaving”? Or do you think I’m missing an important piece of the puzzle?