The Impossible Job: When Help becomes Harm

A 56 year old man, Roy, comes to see me after his family doctor raised concerns about his benzodiazepine use. He was taking 1 mg of Ativan most days, and when his panic attacks were particularly bad, he could take up to 4 mg. On top of this, he was drinking 5-6 glasses of wine most nights.

In my assessment, I confirmed that he had the diagnosis of Panic disorder. This means he would have symptoms of high anxiety (his specific symptoms included shortness of breath, feeling his heart racing, sweating, nausea and feeling out of control) for minutes to hours at a time. He described that this had been happening to him for years and the only thing that would work was taking Ativan. He had tried many therapies for his panic symptoms but did not find them helpful. he found that at times the panic attacks would come out of the blue, like in the middle of the night and startle him awake, or there could be a trigger. He noticed they came on most after he had finished a large meal. The feelings of indigestion would get his heart racing and he would then need to pace furiously for hours as if trying to run away from the symptoms he knew would overtake him.

Impressively, despite these symptoms, Roy was able to complete and retire from a very successful career as an accountant. He was even working part time when he came to see me. He described a life that sounded great, in fact. Every year, he and his wife would go to Portugal or abroad for several months where he found his panic symptoms were better overall. When he was back home, he would play golf almost daily with long time friends and he admitted that he was truly enjoying this phase of his life. He was relatively healthy, and he indulged his love of wine and rich foods with few consequences. He was aware that his family doctor was worried about how frequently he needed the Ativan, but he did not think it was a big deal. It was very effective in keeping his panic and anxiety symptoms low and allowing him to enjoy his life.

Ativan, also called Lorazepam, is a benzodiazepine. This class of medications can be highly addictive and can build dependence. When used appropriately, they are very effective for managing symptoms of anxiety. Because of this characteristics, benzodiazepines are only meant to be used for a short-term (ideally less than 1 month at a time). I use them most in times of crisis where I find the benzodiazepine can quickly alleviate distress as I am stabilizing them on safer, longer term, treatments. I have also prescribed 1-2 tablets at a time for patients who are highly anxious in specific situations like flights or prior to a medical procedure.

When we talk about addiction and dependence, what this means is that some patients are at risk of developing an unhealthy relationship with benzodiazepines. Initially, these patients will get benefit from the initial dose of the medication, but quickly over time, they will need higher and higher doses of the benzodiazepine to feel the same effect. Another possibility is that they may feel a euphoria or pleasure with these medications that lead to them using these drugs more frequently than what is prescribed. How a patient reacts to a benzodiazepine can not always be predicted. Patients with a history of addiction should not be prescribed these medications, but even those with no such history can be at risk. This is why it is important to prescribe as low of a dose as possible for as little time as possible.

Long term daily use of benzodiazepines put people, especially older patients at higher risk for cognitive impairment and falls. When on benzodiazepines for too long, stopping them can lead to very serious medical complications, even death. I have also found benzodiazepines can interfere with healthy sleep and lead people to avoid addressing core issues that may be perpetuating the distress in the first place.

So patients need to know that these medications are meant to be stopped eventually and though Roy understood this, he did not know why I was insisting that his reduction happen now and what the fuss was about. And I saw his point. In some ways he felt entitled to the medication because it staved off crippling and torturous feelings that came on for no reason. He had tried other things that were not as effective and he now had a life he enjoyed and loved. When I told him my job was to look after his mental health today, and 20 years from now, he appreciated this, but informed me, quite rightly, that I did not know what it felt like to have panic attacks. He described the doom of an attack hanging over him every minute of every day, and the sacrifice of hours of his life when they did come on.

What is the right approach? To optimize his present functioning when it is at the expense of his future? To keep prescribing ativan when it is becoming less safe? And then what can I offer instead for his panic attacks?

So it is an uneasy alliance I have with this patient at this time. I keep prescribing what he wants and we do not have any problems, however when I do not, and that day will come, I do not know what will happen. So far, with my encouragement and education, he has been able to cut down on his alcohol use and reduce the size of his meals to avoid the triggers of feeling too full to the point he can not breathe. He tells me he is using less ativan and his pharmacy records comfirm this. A prescription is now lasting twice as long.

Because, lest I forget, this patient is compromising with me also. He is learning to tolerate greater amounts of discomfort, reserving the Ativan only for the moments he really needs it. He knows I will limit his dose when the next prescription renewal is due and he has joined a meditation class to help him when this occurs. And perhaps this is the best it will get: that I can not get my patients to where I want them to be or where I feel safest. These patients deal with suffering and experiences I have not and therefore can not fully comprehend. If I can work with him to keep him within a range of ativan use that is "safe enough", that just might be good enough.