Drew was in his early 30s. His medical history included alcohol
abuse, but he had been sober for several months when he became my patient.
His previous doctor had given him a prescription for Ativan, or lorazepam, which
is frequently used to allay tremors and seizures from alcohol withdrawal.
My first inclination was to wean him off the medication by lowering the dose and
telling him to take it less frequently. But inertia is strong in medical care,
and Drew prevailed upon me to continue providing lorazepam at his regular dose
for another month while he solidified his situation with a new job.
The next time I heard about him was a couple of weeks later when a colleague
read me Drew's obituary in the local paper. There was no cause of death listed.
But I knew he could have run into serious trouble if he had mixed alcohol or
other drugs with his lorazepam.
Lorazepam is a benzodiazepine, a class of medicines known as sedative-hypnotics.
They're used frequently in the U.S. to treat anxiety and insomnia. Other drugs
in the same category include Valium and Xanax.
The problem with benzos, as they're also known, is that they're highly addictive
medications, both physically and psychologically. Abruptly stopping them can
lead to withdrawal symptoms like the ones Drew hoped to avoid when he kicked
alcohol.
Moreover, with long-term use, our metabolism adjusts to benzos. We need higher
doses to achieve the same effects.
When taken regularly, benzos can have the unintended effect of impairing your
ability to sleep without them. When used for anxiety, their disruption or
withdrawal can lead to a wicked return of the symptoms they are intended to
treat.
Because of their addictive potential, benzos are controlled substances, whose
use is regulated and monitored by the Drug Enforcement Administration.
With so much of our attention now understandably directed at the nation's
insatiable appetite for those other controlled substances — opioids — it's no
wonder that the dangers of benzodiazepine overuse haven't drawn as much
scrutiny.
But that is starting to change.
A recent essay in the New England Journal of Medicine titled "Our Other
Prescription Drug Problem" highlights massive growth in the use and abuse of
benzos in the U.S., including the fact that the number of deaths attributed to
benzodiazepine overdose has risen sevenfold over the past two decades.
That's not altogether surprising when you consider that the number of
prescriptions written for benzodiazepines increased 67 percent to 13.5 million
per year in 2013 from 8.1 million in 1999.
While death rates and prescriptions for opioids still substantially outnumber
those for benzos, it's combinations of the two types of drugs that are
particularly fatal.
Three-quarters of deaths attributed to benzodiazepines also involve an opioid,
resulting in a stern warning from the Food and Drug Administration in 2016 about
the danger of combining the medicines.
Stanford psychiatrist Anna Lembke, lead author of the New England Journal of
Medicine essay, calls our overprescribing and overconsumption of benzos a
"hidden epidemic," because it remains underpublicized in the glare of the opioid
crisis. "Even if we get the opioid problem under control, the benzodiazepines
will still be there," she told me in an interview.
Her essay also mentions the growing problem of synthetic benzos manufactured in
clandestine laboratories and sold on the Internet without FDA approval, doctors'
prescriptions or pharmacy oversight.
One such designer drug is called clonazolam: a chemical combination of
clonazepam (brand name Klonopin) and alprazolam (brand name Xanax).
Clonazolam serves no medical purpose. It's a chemical devised for recreational
use and profit. But it's a hundred to a thousand times more potent than our
standard array of benzos, according to Lembke. This means its potential for
overdose is substantially higher, too.
In another recent piece about benzos, author Maia Szalavitz points out that
these medicines have exhibited explosive growth in use even without the
marketing that brought opioids to the fore in the 1990s and early 2000s. Most
benzos were already available as generics then and still are today — yet the
numbers of prescriptions continue to grow.
Journalist Paula Span, who writes regularly about aging for The New York Times,
published a recent feature about the widespread use and risks of benzos in the
elderly, for whom they pose a particular danger.
The American Geriatrics Society lists benzos as "inappropriate" for use in the
elderly, because of their potential for adverse drug interactions. In older
people, benzos also heighten the risk of falls and can hamper memory.
Unfortunately, since the quality of sleep diminishes as we age, many Americans
are prescribed benzos to help them doze.
As with Drew, I've had many other patients come to me already taking benzos
prescribed by another doctor.
With the growing awareness of our nation's opioid problem, many patients ask me
to help them taper off opioids or not to start them in the first place.
I wish the same could be said for benzodiazepines.
John Henning Schumann is an internal medicine doctor and serves as president of
the University of Oklahoma's Tulsa campus. He also hosts Studio Tulsa: Medical
Monday on KWGS Public Radio Tulsa, and is on Twitter @GlassHospital.
It’s hard
to believe that anyone but scholars of modern literature or paid critics have
read W.H. Auden’s dramatic poem “The Age of Anxiety” all the way through, even
though it won a Pulitzer Prize in 1948, the year after it was published. It is a
difficult work — allusive, allegorical, at times surreal. But more to the point,
it’s boring. The characters meet, drink, talk and walk around; then they drink,
talk and walk around some more. They do this for 138 pages; then they go home.
Auden’s
title, though: that people know. From the moment it appeared, the phrase has
been used to characterize the consciousness of our era, the awareness of
everything perilous about the modern world: the degradation of the environment,
nuclear energy, religious fundamentalism, threats to privacy and the family,
drugs, pornography, violence, terrorism. Since 1990, it has appeared in the
title or subtitle of at least two dozen books on subjects ranging from science
to politics to parenting to sex (“Mindblowing Sex in the Real World: Hot Tips
for Doing It in the Age of Anxiety”). As a sticker on the bumper of the Western
world, “the age of anxiety” has been ubiquitous for more than six decades now.
But is it accurate? As someone who has struggled with chronic anxiety for many
years, I have my doubts. For one thing, when you’ve endured anxiety’s insults
for long enough — the gnawed fingernails and sweat-drenched underarms, the
hyperventilating and crippling panic attacks — calling the 20th century “The Age
of Anxiety” starts to sound like calling the 17th century “The Age of the
Throbbing Migraine”: so metaphorical as to be meaningless.
From a sufferer’s perspective, anxiety is always and absolutely personal. It is
an experience: a coloration in the way one thinks, feels and acts. It is a petty
monster able to work such humdrum tricks as paralyzing you over your salad,
convincing you that a choice between blue cheese and vinaigrette is as dire as
that between life and death. When you are on intimate terms with something so
monumentally subjective, it is hard to think in terms of epochs.
And yet it is undeniable that ours is an age in which an enormous and growing
number of people suffer from anxiety. According to the National Institute of
Mental Health, anxiety disorders now affect 18 percent of the adult population
of the United States, or about 40 million people. By comparison, mood disorders
— depression and bipolar illness, primarily — affect 9.5 percent. That makes
anxiety the most common psychiatric complaint by a wide margin, and one for
which we are increasingly well-medicated. Last spring, the drug research firm
IMS Health released its annual report on pharmaceutical use in the United
States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax
— was the top psychiatric drug on the list, clocking in at 46.3 million
prescriptions in 2010.
Just because our anxiety is heavily diagnosed and medicated, however, doesn’t
mean that we are more anxious than our forebears. It might simply mean that we
are better treated — that we are, as individuals and a culture, more cognizant
of the mind’s tendency to spin out of control.
Earlier eras might have been even more jittery than ours. Fourteenth-century
Europe, for example, experienced devastating famines, waves of pillaging
mercenaries, peasant revolts, religious turmoil and a plague that wiped out as
much as half the population in four years. The evidence suggests that all this
resulted in mass convulsions of anxiety, a period of psychic torment in which,
as one historian has put it, “the more one knew, the less sense the world made.”
Nor did the monolithic presence of the Church necessarily help; it might even
have made things worse. A firm belief in God and heaven was near-universal, but
so was a firm belief in their opposites: the Devil and hell. And you could never
be certain in which direction you were headed.
It’s hard to imagine that we have it even close to as bad as that. Yet there is
an aspect of anxiety that we clearly have more of than ever before:
self-awareness. The inhabitants of earlier eras might have been wracked by
nerves, but none fixated like we do on the condition. Indeed, none even
considered anxiety a condition. Anxiety didn’t emerge as a cohesive psychiatric
concept until the early 20th century, when Freud highlighted it as “the nodal
point at which the most various and important questions converge, a riddle whose
solution would be bound to throw a flood of light upon our whole mental
existence.”
After that, the number of thinkers and artists who sought to solve this riddle
increased exponentially. By 1977, the psychoanalyst Rollo May was noting an
explosion in papers, books and studies on the subject. “Anxiety,” he wrote, “has
certainly come out of the dimness of the professional office into the bright
light of the marketplace.”
None of this is to say that ours is a serene age. Obviously it isn’t. It is to
say, however, that we shouldn’t be possessive about our uncertainties,
particularly as one of the dominant features of anxiety is its recursiveness.
Anxiety begins with a single worry, and the more you concentrate on that worry,
the more powerful it gets, and the more you worry. One of the best things you
can do is learn to let go: to disempower the worry altogether. If you start to
believe that anxiety is a foregone conclusion — if you start to believe the hype
about the times we live in — then you risk surrendering the battle before it’s
begun.
To receive immediate updates and new posts subscribe to the Anxiety RSS feed.
Daniel Smith is the author of the forthcoming book “Monkey Mind: A Memoir of
Anxiety” (Simon & Schuster, July 2012). His work has appeared in The Atlantic,
Granta, n+1, New York, The New York Times Magazine and elsewhere. He writes
regularly about anxiety at his Web site, The Monkey Mind Chronicles.
This post has
been revised
to reflect the following correction:
Correction: January 15, 2012
An opinion essay on Jan. 15
about the prevalence of anxiety disorders
erroneously attributed a distinction
to the anti-anxiety drug alprazolam, or
Xanax.
It was the only psychiatric medication among the top 15
— not the top 25
— prescription drugs
in the United States in 2010.
A summary accompanying the
article
also referred incorrectly to Xanax.
It was prescribed 46.3 million times
in the United States
CHICAGO (AP) -- The rapid pulse and shortness of breath of a
panic attack can feel like a heart attack, and it may signal heart trouble down
the road, a study of more than 3,000 older women suggests.
Women who reported at least one full-blown panic attack during a six-month
period were three times more likely to have a heart attack or stroke over the
next five years than women who didn't report a panic attack.
The researchers took into account other risk factors such as smoking, high blood
pressure, inactivity and depression and still found that panic attacks raised
risk.
The findings add panic attacks to a list of mental health issues -- depression,
fear, hostility and anxiety -- already linked in previous research to heart
problems, said study co-author Dr. Jordan Smoller of Boston's Massachusetts
General Hospital.
''Postmenopausal women who are experiencing panic attacks may be a subgroup with
elevated risk,'' Smoller said. ''Monitoring them and reducing their
cardiovascular risk may be important.''
The study, published in Monday's Archives of General Psychiatry, wasn't designed
to explain the link, Smoller said. He speculated that a panic attack may trigger
heart rhythm problems or that stress hormones released during an attack may harm
the heart.
The findings don't surprise Susie Rissler, 51, of Terre Haute, Ind. A panic
attack sufferer since childhood, she's also has had three mini-strokes.
''You feel like the whole world is caving in,'' Rissler said of her panic
attacks, which can include a racing heartbeat and chest pains. ''I've had
shaking, sweating, curling up in a ball totally afraid to even look around.
Panic attacks can really destroy a person in a lot of different ways.''
Some of the reported panic symptoms may have been heart problems in disguise,
Smoller said. Symptoms such as racing heart, chest pain or shortness of breath,
experienced as a panic attack, may have been caused by an undiagnosed heart
problem.
''One study doesn't settle a question,'' he cautioned. ''The number of events
seen in this sample is still relatively small.'' Forty-one of the 3,243 women in
the analysis had a heart attack or death from a heart problem. An additional 40
had strokes.
The study, which enrolled women from 1997-2000 and followed them for five years,
was funded by the drug company Glaxo Wellcome, which is now GlaxoSmithKline PLC.
The company makes Paxil, an anti-anxiety drug. Some of the study's co-authors
reported financial ties to that company and others.
The research relied on the women's memories, rather than doctors' diagnoses,
which could be considered a weakness of the study, said Dr. JoAnn Manson of
Harvard's Brigham and Women's Hospital. But Manson, who wasn't involved in the
study, said it's likely the findings point to a real connection between panic
and heart problems.
''It does tie together very well with what we know about the biology and
physiology of the stress hormones,'' Manson said. ''I think it does suggest that
this is something to discuss with your doctor'' for women prone to panic
attacks.
Previous research has found that panic attacks are more common in women than in
men. The researchers found that 330 of the women, ages 51 to 83 years at the
start of the study, reported a full-blown panic attack during the previous six
months. Of those, about 4 percent, went on to have a heart attack or stroke.
That compares with 2 percent of the women who reported no panic attacks but who
had heart attacks or strokes.
Once the researchers adjusted for other health factors, they found the heart and
stroke risk three times greater among women who had panic attacks.
A full-blown attack was defined as a sudden attack of fear, anxiety or
discomfort accompanied by at least four of 12 symptoms, such as shortness of
breath.
Laura Kubzansky of the Harvard School of Public Health, who wasn't involved in
the new study but does similar research, said stress hormones may cause
immediate heart damage or wear-and-tear over time. During panic, ''the body is
flooded with hormones that in the short run help the body cope with an
emergency, but in the long run take a toll,'' she said.
While treating panic with medication may help some people with the psychological
distress, there's no evidence yet that medication alone reduces heart risk,
Kubzansky said.
''We still don't know how best to address this or how reversible these effects
are,'' Kubzansky said.
