6 ms·

Serious question: as we make opiods and now bezos increasingly difficult to prescribe, what are the alternatives for people with chronic pain or chronic anxiety

by jnovek 8y ago

Serious question: as we make opiods and now bezos increasingly difficult to prescribe, what are the alternatives for people with chronic pain or chronic anxiety? I have friends and family members with chronic pain and, through them and their communities, have become aware of many people who use opiods on a long-term, occasional basis to manage their pain. A family member of mine who suffers from chronic migraine lives in fear that she won't be able to get an opiod which she uses as a last-ditch rescue treatment before she ends up at the ER (not to mention that she gets treated like a drug seeker when she does end up there). I don't really see an alternative for acute intense pain; likewise an alternative for acute, intense anxiety. Meanwhile the crackdowns on these drugs also create a chilling effect for physicians. What do we do for people who fall in those categories? (Edit: not to claim that abuse of these drugs is not a problem... It just seems like the people these drugs are inteded to help are being sidelined in the dialog on the topic.)

OldSchoolJohnny 8y ago
Cannabis in both cases works well for a great many people.
- jnovek 8y ago
  Cannabis derived treatments do seem promising... someday. Imagine that marijuana is (at a minimum) federally rescheduled to schedule 2 in the US. How long will it take to research canniboid-based painkillers once drug companies can legally do so? How pong for FDA approval? It will be a long time until there is an alternative that is taken seriously by anyone other than the most progressive physicians in the realm of cannabis, unfortunately.
  - penagwin 8y ago
    I agree with this. I'm personally rather upset that it's schedule 1, meaning it has no medical benefit whatsoever, which is clearly BS and it makes it hard to research.
- Karrot_Kream 8y ago
  With anxiety, cannabis has pretty mixed effects, and we haven't been able to create reliable medications derived from cannabis that help. I've seen cannabis exacerbate as much anxiety as I have seen it help.
  - mrsteveman1 8y ago
    Vaporized CBD (isolated by itself) is apparently quite effective for many people who have trouble getting to sleep because they can't stop worrying about every possible outcome of an upcoming meeting or date, or replaying stressful conversations or situations that happened days, weeks, or even 5 years ago. The "broad spectrum" products that have multiple active components are far more variable, clearly.
  - jstarfish 8y ago
    Sure, if you smoke sativa. Indica does wonders for anxiety, but until recently most people were stuck just smoking whatever they could get their hands on, even if it resulted in a bad high.
- odiroot 8y ago
  Funny, I stopped smoking years ago because weed makes me anxious.
spamizbad 8y ago
For benzos: There really is no drug alternative to benzos other than maybe SSRIs but most people perscribed them probably tried SSRIs in the past to no effect. Your other alternative is extensive psychotherapy, which your insurance is unlikely to cover. Perhaps in the future marijuana, MDMA or ketamine might prove useful. Benzos generally require you to taper off them, as I believe the withdrawal side-effects include seizures. You cannot safely "cold turkey" them.... so I hope they don't get all heavy-handed with them like they are for people who rely on opiods to treat chronic pain.
- copperx 8y ago
  The other long-term side effect of benzos is that they have shown to speed up dementia in older people. This may be motivation enough to quit for some people.
  - icantdrive55 8y ago
    6% increase in older women. And I don't think there was more than one study?
- tnecniv 8y ago
  > There really is no drug alternative to benzos other than maybe SSRIs but most people perscribed them probably tried SSRIs in the past to no effect. Actually the two really serve different purposes. Benzos are commonly prescribed as a way to manage panic attacks or other acute occurrences of anxiety. SSRIs can help reduce your anxiety over time, but take a long time to build up in your system. Often people are prescribed both simultaneously.
  - DanBC 8y ago
    > Benzos are commonly prescribed as a way to manage panic attacks or other acute occurrences of anxiety. That's how they're supposed to be prescribed, but in this threaad we see a few people who take a daily benzo and have done for several months.
- jnovek 8y ago
jdietrich 8y ago
Benzodiazepines are a useful option for the short-term management of acute anxiety crises, but there's very little evidence that they're useful in the long-term. Clinical guidance in the UK says that they shouldn't be prescribed for more than two weeks, because the harms rapidly outweigh the benefits. There is good evidence for the efficacy of SSRIs and CBT in the treatment of anxiety disorders. Opioids are a more difficult problem. Some patients do need opioids, but we're not sure which. There is some evidence to suggest that opioids may worsen the long-term prognosis for many chronic pain patients. We need more research and better availability of psychosocial interventions and physiotherapy.
elihu 8y ago
I don't know about pain, but for anxiety there are other drugs that are intended for long term use. The ones I'm aware of (mirtazapine and venlafaxine) are also used as anti-depressants.
- jnovek 8y ago
  Benzos generally treat acute anxiety where serotonin/norepinephrine reuptake inhibitors treat chronic anxiety. Further, some folks don't tolerate SS(N)RI's very well, they have wide-ranging and difficult side-effects.
  - elihu 8y ago
    Yeah, I can see where there'd be cases where SSRIs and SNRIs wouldn't work out; everyone's situation is a little different. It seems like there's a problem in the general case though, if you have doctors that are a little too quick to prescribe benzos and refer the prescribing of antidepressants to a specialist. For those that live in an area with a shortage of mental health professionals, it might take a month or two to see a psychiatrist (and then maybe only after talking to a therapist or something first), and then maybe a few weeks more before the antidepressants start working, which is longer than anyone ought to be on benzos if they can at all help it.
alkonaut 8y ago
> what are the alternatives for people with chronic pain or chronic anxiety? If you look around the world, what is the solution there? The US is unique in the prescription of these drugs, but also unique in its reluctance to look around and say "what's everyone else doing that's working"? I think here the answer is that it's fundamentally a different view on chronic pain (Acute pain is a different story- you don't prescribe a ton of opiates to someone who needs to keep it for emergencies).
- peteretep 8y ago
  > The US is unique in the prescription of these drugs The US is in no way unique for prescribing anxiolytics, benzos or otherwise
  - alkonaut 8y ago
    The discussion is usually about opioids where the US is an outlier. For benzos I can't seem to find a good comparison, but this statistic stands out: "In 2008, approximately 5.2% of US adults aged 18 to 80 years used benzodiazepines." [1] Here "used" means filled at least one prescription during the year. This to me looks like an extremely high number, but I can't find a good number for comparable countries. I'd be very surpised if the rest of the OECD had a figure of even 1% [1] https://www.researchgate.net/publication/269766767_Benzodiazepine_Use_in_the_United_States https://www.researchgate.net/publication/269766767_Benzodiaz...
toomanybeersies 8y ago
There are newer benzos (and analogs) that have less negative effects than Valium or Xanax, but they don't seem to be popular in the developed world for whatever reason. Etizolam is one such drug. It's prescribed in Japan and India, but not really anywhere else as far as I can tell. It has a lower potential for dependance than classical benzodiazepines and tolerance builds up a lot slower. Anecdotally from people I know who've taken it, its acute effects feel much more mild than Xanax or Valium. In my limited experience, Valium feels like you've been lobotomised, and Etizolam feels like you've been given a big hug.
DanBC 8y ago
> have become aware of many people who use opiods on a long-term, occasional basis to manage their pain This is the correct way to use opioids for long term pain, but it's only useful for a small number of people. https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar... "A small proportion of patients may obtain good pain relief with opioids in the long term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation". This "small proportion" is in the UK context, where we are already prescribing much less opioids. The mistake people make is to think that opioids are effective to treat long term pain. For most people they do not work to treat long term pain. The patient develops tolerance, needs increasing doses, and eventually they're taking dangerously high doses and also not getting pain relief. We need to understand that there are limited treatments for chronic pain. Some people will need to lose weight and exercise. Some people may find a psychological treatment useful to either treat the pain or come to terms to live with the pain. https://www.rcoa.ac.uk/node/21134 https://www.rcoa.ac.uk/node/21134 "Chronic pain can cause low mood, irritability, poor sleep and reduced ability to move around. Unlike acute pain, chronic pain is difficult to treat with most types of treatment helping less than a third of patients. Most treatments aim to help you self-manage your pain and improve what you can do. Different treatments work for different people. Medicines generally and opioids in particular are often not very effective for chronic pain. Other non-medicine treatments may be used such as electrical stimulating techniques (TENS machine), acupuncture, advice about activity and increasing physical fitness, and psychological treatments such as Cognitive Behaviour Therapy and meditation techniques such as mindfulness. Helping you understand about chronic pain is important and in particular helping you understand that physical activity does not usually cause further injury and is therefore safe. It is important that you understand that treatments tend not to be very effective and that the aim is to support you in functioning as well as possible." "Neuropathic pain is a type of chronic pain associated with injury to nerves or the nervous system. Types of neuropathic pain include, sciatica following disc prolapse, nerve injury following spinal surgery, pain after infection such as shingles or HIV/AIDS, pain associated with diabetes, pain after amputation (phantom limb pain or stump pain) and pain associated with multiple sclerosis or stroke. Neuropathic pain is usually severe and unpleasant. Medicines may be used to treat neuropathic pain but are usually not very effective and work for a small proportion of people. You may not benefit from the first drug tried so you may need to try more than one drug to try and improve symptoms." I get the feeling that you're not aware of the scale of over-prescribing in the US. The US prescribes hugely more opioids than other countries. For example, for a while the US was using 99% of the world supply of hydrocodone. The US could correctly treat the small number of people who'd get benefit from occasionaly tightly controlled opioid prescribing while also massively reducing the total number of opioidprescriptions. And for anxiety the story is similar. The evidence for efficacy of benzos isn't great. https://www.nice.org.uk/guidance/cg113/chapter/Key-priorities-for-implementation https://www.nice.org.uk/guidance/cg113/chapter/Key-prioritie... You need a stepped approach: individual non-facilited self help individual guided self help psycho-educational groups (for one example see Recovery Colleges https://www.health.org.uk/recovery-college https://www.health.org.uk/recovery-college If these don't work you offer a high intensity psychological intervention, or a medication. Notice that for medication they say "Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context." Every time the patient collects their benzos from the pharmacy there will be a patient information leaflet. Here's an example for diazepam: https://www.medicines.org.uk/emc/medicine/18061 https://www.medicines.org.uk/emc/medicine/18061 I get the feeling that benzos are far more readily prescribed in the US, and for long times.

by jnovek 8y ago

OldSchoolJohnny 8y ago

Cannabis in both cases works well for a great many people.

jnovek 8y ago
Cannabis derived treatments do seem promising... someday. Imagine that marijuana is (at a minimum) federally rescheduled to schedule 2 in the US. How long will it take to research canniboid-based painkillers once drug companies can legally do so? How pong for FDA approval? It will be a long time until there is an alternative that is taken seriously by anyone other than the most progressive physicians in the realm of cannabis, unfortunately.
- penagwin 8y ago
  I agree with this. I'm personally rather upset that it's schedule 1, meaning it has no medical benefit whatsoever, which is clearly BS and it makes it hard to research.
Karrot_Kream 8y ago
With anxiety, cannabis has pretty mixed effects, and we haven't been able to create reliable medications derived from cannabis that help. I've seen cannabis exacerbate as much anxiety as I have seen it help.
- mrsteveman1 8y ago
  Vaporized CBD (isolated by itself) is apparently quite effective for many people who have trouble getting to sleep because they can't stop worrying about every possible outcome of an upcoming meeting or date, or replaying stressful conversations or situations that happened days, weeks, or even 5 years ago. The "broad spectrum" products that have multiple active components are far more variable, clearly.
- jstarfish 8y ago
  Sure, if you smoke sativa. Indica does wonders for anxiety, but until recently most people were stuck just smoking whatever they could get their hands on, even if it resulted in a bad high.
odiroot 8y ago
Funny, I stopped smoking years ago because weed makes me anxious.

spamizbad 8y ago

For benzos: There really is no drug alternative to benzos other than maybe SSRIs but most people perscribed them probably tried SSRIs in the past to no effect. Your other alternative is extensive psychotherapy, which your insurance is unlikely to cover. Perhaps in the future marijuana, MDMA or ketamine might prove useful. Benzos generally require you to taper off them, as I believe the withdrawal side-effects include seizures. You cannot safely "cold turkey" them.... so I hope they don't get all heavy-handed with them like they are for people who rely on opiods to treat chronic pain.

copperx 8y ago
The other long-term side effect of benzos is that they have shown to speed up dementia in older people. This may be motivation enough to quit for some people.
- icantdrive55 8y ago
  6% increase in older women. And I don't think there was more than one study?
tnecniv 8y ago
> There really is no drug alternative to benzos other than maybe SSRIs but most people perscribed them probably tried SSRIs in the past to no effect. Actually the two really serve different purposes. Benzos are commonly prescribed as a way to manage panic attacks or other acute occurrences of anxiety. SSRIs can help reduce your anxiety over time, but take a long time to build up in your system. Often people are prescribed both simultaneously.
- DanBC 8y ago
  > Benzos are commonly prescribed as a way to manage panic attacks or other acute occurrences of anxiety. That's how they're supposed to be prescribed, but in this threaad we see a few people who take a daily benzo and have done for several months.
jnovek 8y ago

jdietrich 8y ago

Benzodiazepines are a useful option for the short-term management of acute anxiety crises, but there's very little evidence that they're useful in the long-term. Clinical guidance in the UK says that they shouldn't be prescribed for more than two weeks, because the harms rapidly outweigh the benefits. There is good evidence for the efficacy of SSRIs and CBT in the treatment of anxiety disorders. Opioids are a more difficult problem. Some patients do need opioids, but we're not sure which. There is some evidence to suggest that opioids may worsen the long-term prognosis for many chronic pain patients. We need more research and better availability of psychosocial interventions and physiotherapy.

elihu 8y ago

I don't know about pain, but for anxiety there are other drugs that are intended for long term use. The ones I'm aware of (mirtazapine and venlafaxine) are also used as anti-depressants.

jnovek 8y ago
Benzos generally treat acute anxiety where serotonin/norepinephrine reuptake inhibitors treat chronic anxiety. Further, some folks don't tolerate SS(N)RI's very well, they have wide-ranging and difficult side-effects.
- elihu 8y ago
  Yeah, I can see where there'd be cases where SSRIs and SNRIs wouldn't work out; everyone's situation is a little different. It seems like there's a problem in the general case though, if you have doctors that are a little too quick to prescribe benzos and refer the prescribing of antidepressants to a specialist. For those that live in an area with a shortage of mental health professionals, it might take a month or two to see a psychiatrist (and then maybe only after talking to a therapist or something first), and then maybe a few weeks more before the antidepressants start working, which is longer than anyone ought to be on benzos if they can at all help it.

alkonaut 8y ago

> what are the alternatives for people with chronic pain or chronic anxiety? If you look around the world, what is the solution there? The US is unique in the prescription of these drugs, but also unique in its reluctance to look around and say "what's everyone else doing that's working"? I think here the answer is that it's fundamentally a different view on chronic pain (Acute pain is a different story- you don't prescribe a ton of opiates to someone who needs to keep it for emergencies).

peteretep 8y ago
> The US is unique in the prescription of these drugs The US is in no way unique for prescribing anxiolytics, benzos or otherwise
- alkonaut 8y ago
  The discussion is usually about opioids where the US is an outlier. For benzos I can't seem to find a good comparison, but this statistic stands out: "In 2008, approximately 5.2% of US adults aged 18 to 80 years used benzodiazepines." [1] Here "used" means filled at least one prescription during the year. This to me looks like an extremely high number, but I can't find a good number for comparable countries. I'd be very surpised if the rest of the OECD had a figure of even 1% [1] https://www.researchgate.net/publication/269766767_Benzodiazepine_Use_in_the_United_States https://www.researchgate.net/publication/269766767_Benzodiaz...

toomanybeersies 8y ago

There are newer benzos (and analogs) that have less negative effects than Valium or Xanax, but they don't seem to be popular in the developed world for whatever reason. Etizolam is one such drug. It's prescribed in Japan and India, but not really anywhere else as far as I can tell. It has a lower potential for dependance than classical benzodiazepines and tolerance builds up a lot slower. Anecdotally from people I know who've taken it, its acute effects feel much more mild than Xanax or Valium. In my limited experience, Valium feels like you've been lobotomised, and Etizolam feels like you've been given a big hug.

DanBC 8y ago

> have become aware of many people who use opiods on a long-term, occasional basis to manage their pain This is the correct way to use opioids for long term pain, but it's only useful for a small number of people. https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar... "A small proportion of patients may obtain good pain relief with opioids in the long term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation". This "small proportion" is in the UK context, where we are already prescribing much less opioids. The mistake people make is to think that opioids are effective to treat long term pain. For most people they do not work to treat long term pain. The patient develops tolerance, needs increasing doses, and eventually they're taking dangerously high doses and also not getting pain relief. We need to understand that there are limited treatments for chronic pain. Some people will need to lose weight and exercise. Some people may find a psychological treatment useful to either treat the pain or come to terms to live with the pain. https://www.rcoa.ac.uk/node/21134 https://www.rcoa.ac.uk/node/21134 "Chronic pain can cause low mood, irritability, poor sleep and reduced ability to move around. Unlike acute pain, chronic pain is difficult to treat with most types of treatment helping less than a third of patients. Most treatments aim to help you self-manage your pain and improve what you can do. Different treatments work for different people. Medicines generally and opioids in particular are often not very effective for chronic pain. Other non-medicine treatments may be used such as electrical stimulating techniques (TENS machine), acupuncture, advice about activity and increasing physical fitness, and psychological treatments such as Cognitive Behaviour Therapy and meditation techniques such as mindfulness. Helping you understand about chronic pain is important and in particular helping you understand that physical activity does not usually cause further injury and is therefore safe. It is important that you understand that treatments tend not to be very effective and that the aim is to support you in functioning as well as possible." "Neuropathic pain is a type of chronic pain associated with injury to nerves or the nervous system. Types of neuropathic pain include, sciatica following disc prolapse, nerve injury following spinal surgery, pain after infection such as shingles or HIV/AIDS, pain associated with diabetes, pain after amputation (phantom limb pain or stump pain) and pain associated with multiple sclerosis or stroke. Neuropathic pain is usually severe and unpleasant. Medicines may be used to treat neuropathic pain but are usually not very effective and work for a small proportion of people. You may not benefit from the first drug tried so you may need to try more than one drug to try and improve symptoms." I get the feeling that you're not aware of the scale of over-prescribing in the US. The US prescribes hugely more opioids than other countries. For example, for a while the US was using 99% of the world supply of hydrocodone. The US could correctly treat the small number of people who'd get benefit from occasionaly tightly controlled opioid prescribing while also massively reducing the total number of opioidprescriptions. And for anxiety the story is similar. The evidence for efficacy of benzos isn't great. https://www.nice.org.uk/guidance/cg113/chapter/Key-priorities-for-implementation https://www.nice.org.uk/guidance/cg113/chapter/Key-prioritie... You need a stepped approach: individual non-facilited self help individual guided self help psycho-educational groups (for one example see Recovery Colleges https://www.health.org.uk/recovery-college https://www.health.org.uk/recovery-college If these don't work you offer a high intensity psychological intervention, or a medication. Notice that for medication they say "Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context." Every time the patient collects their benzos from the pharmacy there will be a patient information leaflet. Here's an example for diazepam: https://www.medicines.org.uk/emc/medicine/18061 https://www.medicines.org.uk/emc/medicine/18061 I get the feeling that benzos are far more readily prescribed in the US, and for long times.