In The Sun Also Rises, Hemingway’s character Mike described becoming bankrupt in two ways – gradually and then suddenly. That line is validated in finance, healthcare, social sciences, and technology. Earlier posts in this blog, continuing a narrative that began on my practice homepage, describe my getting sick two ways. I slowly lost stamina over the past two or three years, and then I deteriorated by the day in early summer. To paraphrase the same quote, I got sick gradually and then all at once.
I thought of that process today during an appointment with one of my patients. He takes buprenorphine and typically does very well. But today he tested positive for benzodiazepines. He admitted that he takes a tablet of Xanax now and then when he feels anxious. Yes, he has had problems with benzos in the past, but this time he believes an occasional tab is warranted by his stressful situation. “I don’t plan on using them very long” he said.
By the way, his urine was negative for fentanyl. I always check for fentanyl these days in people using illicit benzos. Most people reading my posts know that millions of tablets stamped to look like Xanax but consisting of fentanyl are carried into the US across our southern border, courtesy of drug cartels, immigration mules, and our Chinese friends who supply fentanyl precursors for the cartels. Fentanyl caused most of the 106,000 deaths of mostly young people over the past year. Nobody currently in power wants to do anything about the fentanyl problem, though, so I’ll move on.
I asked the patient how he first ran into problems with benzodiazepines. “I had severe social anxiety in high school. But I ended up using them too much and ended up dropping out of school. Then I found oxy.”
“Did you plan on dropping out when you started taking benzos?” I asked.
“No. but I didn’t know how addictive they were. Now I’m more careful.”
I asked, “back then, did you start by taking them every day?”
“No, I was going to use them for the worst days, but then I had a lot of anxiety and needed to take them more. Then my anxiety got so bad that I missed classes and started getting F’s so I dropped out.”
“So you took them more and more for your anxiety, but your anxiety got worse? Wouldn’t your anxiety start getting better once you had all that Xanax to use?”
People with addictions often became addicted by surprise, but not because of ignorance. All of the facts are right there in front of them, and the warning signs are usually flashing in their heads. Maybe out of hubris, people ignore the things they know, and ignore the warning signs. That’s way decades of education about addiction haven’t done much to discourage drug use.
I talked with the patient about tolerance and the seductiveness of benzos, a discussion that I’ve had hundreds of times that always leaves me feeling unheard.
“Tolerance to benzos happens very fast. The receptors for GABA, the main ‘slow-down’ chemical in your brain, stop responding as well to benzos AND to GABA. So your brain becomes unbalanced, with only the excitatory chemicals working well. That’s why people always end up having more anxiety after they take benzos for a few weeks.”
“This time I’m only going to use them now and then so I don’t get tolerant” he replied.
“But you know what will happen. How will you not take it, when it is so nice to take a day off from worry, and not care about anything? You will end up taking it every day, and then when you don’t have it you will feel tons of ‘anxiety’ from benzo withdrawal. And when you take it, you won’t care about anything. Take enough and you’ll stand in the street, not caring that a truck is heading toward you.”
“I’m not planning on taking it every day” he said.
“DUDE! You know what you’re doing! You’re not stupid — I know that you see what I do, that you’re doing the exact same thing that got you into trouble before! Things will get worse and worse, day by day, and eventually the crap will hit the fan. Why do you want to do it again?!”
He stopped and thought. “I don’t know. I have anxiety.”
There it is — the reason I get angry about psychiatry, and about the emphasis, these days, on the emotions every young person experiences rather than on the strengths that they each possess. I will do my best to explain that to the patient; that everyone has ‘anxiety’, and that the best ‘treatment’ is developing a sense of self and self esteem — things that are never found in a benzodiazepine. But he will return to a world filled with sympathy for his situation, and my message is unlikley to take root.
Sometimes I wonder if many of today’s problems are caused by our own misguided approaches to solving them. It seems like so many things have gotten worse slowly, and now all at once.
And that’s a shame.