Not sure what to do about swapping meds for panic disorder. Experiences helpful.

In My Humble Opinion
1

After being blessed with lifelong depression, I’ve had the extra icing on the cake by adding panic disorder to my cocktail of problems. The first panic attack happened back in November of 2007 and they continued until I finally got some level of rest with Klonopin (clonazepam), 1mg taken 3x per day (so, 3mg per day). I also have Xanax (the regular kind) for emergencies.

Anyway, I’ve been on the klonopin for about a year now, and for the first seven months it worked quite well. The difference was noticeable–from a couple of attacks per week down to maybe one every couple of months. I still had anxiety that started to develop into attacks, but thanks to therapy I was able to stop 7 out of 10 incidents of anxiety from blossoming into full-blown awfulness (via breathing exercises, talking to myself, distracting myself, plunging my hands in cold water, all the tricks of the trade). For the remaining 3 incidents that weren’t helped by the above, I would take my emergency Xanax (1mg). That would help 2 out of the 3.

For the remaining incident, when nothing would stop it and my heart felt like it was going to explode and nothing was working, I go to the ER, because I’m certain it’s a heart attack. Of course there’s a part of me that knows the likelihood is that it’s just another panic attack, but I just can’t help being afraid that… what if I’m wrong? Every medical website I read says one shouldn’t second-guess and if you think something is wrong with your heart, call 911. Still, I hate doing that. I hate it. I feel like I’m wasting their time and it’s embarrassing to be going for just a mental situation.

Anyway. For the past four months or so, the anxiety has suddenly stepped up its game. I’ve been to the ER twice–once in October, and once just three weeks ago. Oh, I should mention that every time they run all the tests (echo, EKG, chest x-ray, multiple blood tests spaced a few hours apart, etc.) and other than tachycardia and temporary high blood pressure, I’m fine. They give me an Ativan or Valium and I’m free to go. Actually this last time the department head didn’t even run any tests other than the EKG, which he said “looked beautiful.” He was really certain nothing was wrong with my heart so he just rehydrated me (I was very dehydrated), gave me a Xanax and told me to follow up with my psychiatrist.

All right, that’s my boring history. The point of this is to say that I am fairly sure I’ve developed a tolerance to the clonazepam, because there’s nothing in my life that’s changed to explain why my anxiety has suddenly worsened. However, I’m not thrilled as it is to be on a benzo as addictive as this, and I know that the only real answer is to either step up my dosage–which I really really don’t want to do, because then where do I go once I reach my tolerance level again?–or to switch to something else.

Clonazepam is considered one of the worst drugs to step down on, and I know about the method that everyone talks about where you keep substituting levels of valium at a very slow rate until a billion months later you’re finally only on valium, which supposedly is much less of a problem.

That’s all well and good. However, my psychiatrist has decided that what he wants to do is switch me from the Clonazepam to Xanax XR. Apparently no step-down or anything–just swapping the drugs.

This has me very scared. (Imagine that, a hypochondriacal person with panic disorder is scared!) Firstly, isn’t Xanax even more addictive than Clonazepam? And is it possible to just go cold turkey from 3mg of Clonazepam to none, albeit with Xanax XR instead?

I’m going to contact my regular doctor to ask her about this. But I’m wondering if anyone has experience with swapping meds, especially Clonazepam (or Klonopin, whatever you call it), or if you have experience with Xanax XR and if it’s really a decent long-acting daily medication.

And for God’s sake, I know there are a couple of folks who are VIRULENTLY anti-benzos. Please don’t lecture me about this. I know they’re notoriously awful. But I very clearly need something. Therapy alone is not working for me. Some people recommend Paxil, but I can’t take SSRIs because they only make me more anxious. (This doesn’t help my depression, needless to say.)

I’m at my wit’s end. Every time I have a panic attack I have a rebound depressive incident that just devastates me, because… well, I really thought for those seven months I was getting better. Having more panic attacks just re-emphasizes that I’m not.

I feel like an abused spouse who’s tried to hide from her husband and thought I was safe for several months, and suddenly my husband knocks on my door: he’s found me again.

To quote Billie Holliday’s famous song:

*Good morning, heartache, here we go again
Good morning, heartache, you’re the one who knew me when
Might as well get used to you hangin’ around
Good morning, heartache, sit down *

Anyone have any advice on switching meds?

2

I have no personal experience with meds so I’m no help there, but I wanted to offer some feel good “hang in there” stuff anyway. Good luck to you. Anxiety is a bitch.

Also, dehydration isn’t helping. Drink lots of water.

3

Thanks so much, Silver Fire.

I know, I know, dehydration is terrible and I am so bad at keeping hydrated. Aside from being bad for your physical health, it only speeds up my heartrate and makes me dizzy, and those are two big triggers for me regarding my anxiety.

I probably should’ve mentioned that my panic isn’t brought on by anything. I mean, it’s not triggered by a phobia such as elevators or speaking to crowds or being outside or planes, etc. I could be just sitting on my bed watching something on Netflix when I’ll realize my muscles are sore and stretchy and feel as if aderenaline is going through my body, as if I’m on heightened alert preparing for a lion attack or something. Then my heart starts to race and I’m off. Sigh.

But anyway thank you for the good wishes and the reminder to drink!

4

Hi Choie. I have had some experience with anxiety issues. I have Bipolar 2, with ADD and anxiety.

I was on Clonazepam/Klonopin for several months, taken as needed. I found it made me very tired and, with doctor’s approval, went off of it.

For the past couple of years I’ve been on Xanax XR/Alprazolam ER. Not as needed - one every day. However my insurance would not cover the the extended release version beginning at the start of the year. So now I have switched to 1 mg of regular Xanax/Alprazolam twice a day.

So far, so good. I haven’t had any problems.

I will warn you though that if you get on Xanax, do not miss a day. Or, even worse, two days. You will feel it and it will not be pleasant. There have even been people who reported seizures. :frowning:

Good luck and I hope you find some meds that will work for you! :slight_smile:

5

Basically wait 90 days and see what happens. You seem well informed and you are following all the right steps so all you can do is take it day by day. Really. Trying to “solve” this problem just adds to the anxiety so keep working and see where you are at in 90 days.

6

Thank you very much, Mage-Girl, that’s very helpful. Sorry about your insurance refusing the XR version. You’re really helped as much by just the IR edition? For me it’s a good “quickie” solution (well, it starts working about 10 minutes after I take it), but it wouldn’t be a good all-day option.

One way I know I’ve gotten too tolerant of the Klonopin is that I’ve now started taking what was my “emergency” Xanax every night, just to get me to sleep. I never used to do that, and I don’t like it. I’m super-paranoid about getting addicted and taking more pills than I need is antithetical to me.

I hear you about being assiduous about taking the meds without fail. There have been two incidents where I stupidly ran out of Klonopin and went a couple of days without it, or at least one day, and after about 12 hours I started to feel very trembly. I couldn’t quite tell if it was physiological or psychological–as i said, I’m a ridiculous hypochondriac and just knowing I could have side effects/withdrawal is almost guaranteed to give me actual side effects or withdrawal.

Oh God, it’s amazing how wearying it all is. I actually long for the days when I was “just” morbidly depressed. I never knew how awful things could get before I had this panic disorder. Depression, I’m used to–have dealt with it all my life. Anxiety is what makes me feel like I’m actually crazy and losing my mind. How can I not be crazy when I’m feeling terrified of… something… but there’s nothing actually to be scared of, except in my own stupid brain?

I would love to go to some anxiety clinic somewhere beautiful and do nothing but treat this, but I don’t know of any places like this. Also, even if they exist, they ain’t gonna be free. :slight_smile:

Edited to add: Thanks, Robert163. I’m sorry, do you mean, wait 90 days from now, or wait 90 days from changing the meds? Because I’ve been at this increased level of anxiety since late October, and that’s basically 3 months already. It’s only getting worse, and it’s making my depression worse as well because I’m beginning to feel hopeless about the whole thing. So I’m reluctant to wait yet another three months, y’know? I’ve already been on Klonopin for a whole year, which is waaaay longer than many people recommend being on it (I’ve read it’s meant to be a short-term solution). My psychiatrist tends to keep me on the same meds forever. I ain’t getting any younger!

7

I totally understand the “…but NOTHING HAPPENED!!!” anxiety. The first really bad, omg I’m going to die, panic attack I ever had happened while I was… riding to Target with my mom. WHAT. I thought if I didn’t hold my breath I would never stop screaming and if I didn’t sit on my hands I’d jump out of her car. Absolutely nothing at all precipitated it but I was suddenly overwhelmed by OMFG, DOOM.

It was awful.

My therapist told me I have generalized anxiety and I’m tense and vaguely nervous kind of all the time, but I’ve only had maybe half a dozen such attacks and each time was during periods of relative calm and while I was engaged in totally mundane tasks.

8

I got addicted to Clonazepam at much lower doses than OP uses and had an utterly miserable time kicking it. So I’ll have to classify myself as “anti-benzo” although perhaps not too wildly virulently so. OP makes clear that she already understands most of the stuff I’d be inclined to “lecture” her about. Perhaps I can add a few details, from my experience.

One thing to beware of: It seemed to me that very few doctors were very knowledgeable about benzo addiction and withdrawal. Every doctor I went to, over a period of about a year, gave me different advice, and different meds, to help alleviate the withdrawal problems. None of them worked. Several meds worked well for only two or three days and then stopped working. (The thing I needed most was some help sleeping, as benzo withdrawal typically entails intense and brain-crunching insomnia. The various pills were supposed to help with that.)

Many meds will produce a “rebound” situation if you quit them, which means the original symptoms return even worse than originally. I am convinced that drug withdrawal is a similar phenomenon, just raised to extreme proportions.

So, choie, if you have a problem with panic, then any benzo withdrawal you suffer will likely involve extreme panic attacks. I had extreme panic attacks for at least six months that came on every night at promptly 02:00 am, as regular as clockwork. Each attack hit me like the proverbial ton of bricks and lasted at least four hours before subsiding at least a little bit.

Typical drug detox or rehab programs (like, for heroin, etc.) run for 4 weeks. I’ve seen it suggested that benzo detox programs need at least six weeks or more. It’s also claimed that about 10% to 15% of addiction cases will suffer from protracted withdrawal syndrome in which the withdrawal symptoms persist for months or years – typically from 6 months to 18 months, or possibly longer. That is what seems to have happened to me. Again, no doctor I met knew anything about this, which led to all sorts of other misleading and unhelpful diagnoses or theories from them.

Perhaps you already know about www.benzo.org.uk – a benzodiazepine recovery site. You might find some useful stuff there. But it is for the most part a full site of virulent anti-benzo rantings, so perhaps most of it isn’t what OP wants to read. But one part is very good: The Ashton Manual: Benzodiazepines: How They Work and How to Withdraw by Professor Heather Ashton, a professor of neurology (now retired, I suspect) at Newcastle University, who ran a benzo rehab clinic for a dozen years. The paper offers a good text on the workings of benzos and suggestions for how to deal with it. I recommend reading this.

9

More thoughts: Anyway, to address OP’s specific question: Yes, from what I’ve experienced and from what I’ve read, I’d be X-tremely dubious about your psychiatrist’s idea of abruptly switching from Clonazepam to Xanax – for exactly the reasons that OP already understands. From my experience, I’ve learned: DON’T TRUST ANY DOCTOR (INCLUDING PSYCHIATRISTS) TO HAVE A CLUE HOW TO DEAL WITH BENZO PROBLEMS. Surely, there must be some out there who know, but how do you find them? And how do you know if your doctor’s recommendation is any good?

Maybe you can do some on-line research (that benzo.org site I mentioned may have a lot of good material, if you can sift through the virulent stuff, and the Ashton Manual is a definite MUST-READ). You should definitely try to accumulate some knowledge about it, as much as you can scarf up, before you trust ANY doctor, especially someone who wants to do something radical like abruptly switch your meds. Especially to Xanax. I’ve often read that stepping down to Valium is the commonly prescribed method. (None of my doctors ever suggested any kind of swapping like that.)

By all accounts that I’ve ever read, Xanax (alprazolam) has a much shorter half-life than Klonopin, which in turn has a shorter half-life than Valium. The shorter the half-life, the more addictive. I’ve heard horror stories about Xanax. I’ve only used it sporadically myself, so I never had a problem with it. But it never did much for me one way or another anyway.

The problem, which remains unsolved as far as I can tell, is how to treat chronic long-term anxiety problems. What seems clear is that benzos may be very effective and helpful, but only for short-term usage like for six weeks or less. Any longer, and addiction and tolerance start to set in, and the drug snares you. I don’t know what help there is, other than things like talk-therapy, relaxation stuff, or meditation, for long-term help. Those kinds of treatment may work for some people but I don’t know how that will work for lots of other people.

10

Thanks very much, Silver Fire (again! :)) and Senegoid. Silver Fire, I think I’ve had “logical” things that frightened me that caused what I’d call anxiety attacks more than panic. Both times it was at parties where I didn’t know anyone, and started to feel embarrassed that I wasn’t fitting in, and then became aware of just how much I wasn’t fitting in, and obviously everyone was looking at me and why were there so many damn people all standing so close and oh god I just had to get out of there…

That was penny ante stuff compared to what you describe, and what I’d call a real panic attack. I think that’s why I get annoyed by all the materials one reads that call Panic Disorder one of the “easiest” problems to treat, usually via CBT where you gradually learn to face your triggers. Screw that; I don’t have anything that I need to “face” unless you call watching Netflix some kind of trigger. (Of course lots of cites claim that panic attacks only last ten minutes. As if. Two hours minimum for me. I suppose it could be rolling panic attacks, but I don’t notice any abatement in between.)

Senegoid, I really do sympathize, and yeah, I absolutely have been worried about what’ll eventually happen when I go off the meds. (Of course, part of me is like, “okay, so why do I ever have to go off them? I’ll likely be on some antidepressant all my life, so why can’t I be on antianxiety meds forever and ever? As long as I’m not continually going higher and higher doses or having unbearable side effects…” But I have no idea what risks exist of long term use.)

And yep Ashton is the method I was thinking of in my OP, where you vvveeeerrrrrrry slowly taper down off Clonazepam by swapping with Valium, like, for the first two weeks I’d take 2.5mg of Clonazepam and .5mg of Valium, then 2.0mg of Clonazepam and 1mg of Valium, etc. etc. etc. for several months until one has switched over completely to Valium. I’d be fine with that. I think my knowledge of that method is why I’m so concerned about suddenly just swapping Clonazepam for Xanax XR. I don’t think it’ll be that easy. I’m kinda glad I have a whole month’s supply of Clonazepam just refilled, because I think I would rather try the swapping method if possible. I do NOT want that blowback panic attack issue. Oy, that’s all I need!

To my memory, the best anti-anxiety drug I’ve ever taken was Ativan, which I was given at one of my ER visits–I remember that acting super-fast, it was like insta-sedative. Except I never feel sleepy on any of these benzos, isn’t that weird? None of them make me feel loggy or sluggish the way so many people describe. In fact the only medication that’s ever made me sleepy at all was Elavil (Amitriptyline), the antidepressant I was on before Nortriptyline. That was kinda awesome. I have insomnia so it was a joy taking a medication that put me to sleep so quickly.

Anyway, I do appreciate your warnings and I know it is a really rough road to get off the medication. I suppose I’m being short-sighted in just needing to find a solution to this horrible anxiety, and not thinking of the longer term consequences. But I’m at the point now, after six years, where if I don’t find some solution I am… well, I wouldn’t ever say suicidal because I have never ever been that way and I don’t think I ever will, but I do feel I will be losing all quality of life. I hardly have any as it is. I’m so afraid of my own beating heart that I don’t even like to walk, because my heart rate naturally climbs a little and that very sensation frightens me so much. I end up sleeping all day because it’s an escape from the fear.

So I just know I have to do something, because this is a form of what’s called “subtle suicide” and I can’t accept it. If it means benzos, if they will help me, then I’ll take them, because as bad as they may be, I think the alternative that I’m experiencing is worse.

But I do take your warnings seriously and I appreciate it, thank you, Senegoid.

Edited to add: Sorry, didn’t see your 2nd post. Just want to stress that this doc is suggesting Xanax XR, not the regular Xanax. Regular Xanax (aka Xanax IR, for Instant Release) is the short-acting drug I already take for emergencies; I believe it usually lasts about, 2 hours or so? Maybe shorter. Xanax XR is the long-acting version that has I believe a 12 hour window of calm, and you usually take it twice a day (once AM, once PM). It’s a newer form that I think came out in maybe 2011 or so?

That probably doesn’t change the concern and I definitely agree, I think my pdoc is waaaay too casual about my just swapping drugs. I have found that my GP is much more conservative regarding that, so I want to get her opinion on this.

11

i mean regardless of the current circumstance don’t give up and don’t get too worried. all you can do is take it one day at a time. if you keep trying to get your meds under control and at a more manageable level, that is all you can do. don’t make the mistake, however, of making the best effort possible and still second guessing yourself. your best effort is literally the best you can do.

12

One of my many doctors DID suggest that I might just have to take Klonopin for the rest of my life, gradually upping the dose as needed. He compared it to being diabetic and having to take insulin for the rest of my life. When I asked him what would happen when I reached the max possible dose and that stopped working, he said we have to cross that bridge when we come to it.

I was like :dubious: and didn’t accept that solution. I had already kicked the drug at the time, cold-turkey (BIG mistake!) and was determined to stay off it until the withdrawal went away. I didn’t know yet that it was going to be another year and a half (!) until I felt even functional – and even then, I didn’t feel quite right for another year or more after that!

Benzo withdrawal is torture. I made the observation (timely at the time) that Saddam Hussein and his evil sons could learn some excellent severe torture techniques by studying up on benzos. I felt that my doctor, by suggesting chronic benzo usage, would simply be writing a torture warrant when he wrote prescriptions – although for some time in the future, when he might be my doctor to have to deal with it.

From all I’ve read and experience, I’d guess the best hope would be the gradual – verrrrrrrrry gradual – tapering of the clonazepam, possibly (?) with the addition of some other less dreadful benzo to take its place, and then tapering that. I happen to know that Valium wouldn’t work for me, since I’ve used it also with bad effects. (It makes me extremely agitated, a known paradoxical effect in some people, which clonazepam never did.)

But, what of that chronic anxiety trouble that the drug was supposed to treat in the first place? To be sure, I was using clonazepam for both anxiety and depression (both of which treated very well, while it worked, until it didn’t) I’ve learned to just live with it somehow. I’ve just lowered my expectations of life and recognized that all the doctors’ toxic potions, however helpful they may be, can only be helpful for the short-term but are the devil’s own brew when used for the long term.

13

You may need to be on it the rest of your life. It sounds to me that you legitimately need medication to help with your anxiety, so take it.

You may think that there’s no trigger at all - and you may be right - but I’m sure there are things you can do to lessen the likelihood that you’ll have a panic attack. Staying hydrated could definitely make a difference. I always thought that people preaching about how important drinking water is for your health were full of it. Then I took the advice when I had a horrendous hangover and had to work and BAM all better. Now any time I’m feeling that nasty, shaky, uncomfortable in my own skin feeling (hangover or not) drinking a few cups of water helps greatly. Getting exercise - even if it’s only taking a walk in the park on a nice day - also makes a huge difference in your overall well-being.
How’s your blood pressure when you’re not in a panic attack? Beta blockers can help with anxiety. I was put on them for a bit when I dropped clonazepam and they seemed to help. I’m currently not on any prescription medication despite the numerous different meds I’ve taken for anxiety and depression over the years. I do take 100 mg of 5-HTP twice daily and it has done more for my depression and anxiety than anything I’ve ever been prescribed. Talk to your doctor about it and see if it’s something that you could take. I don’t know what all you’re prescribed and if it’s something that you could safely take alongside your other meds or if it would be helpful to your specific problems.

I don’t have any advice as to the switching of medications though. I never took Xanax XR. Stressing about the medications is not going to help your situation though, that’s for damn sure. If you have to take them for the rest of your life then that’s how it is. Worrying is not going to get you any closer to being without them.

I wish you the best of luck.

14

Yes, likewise, I know exactly nothing about how Xanax XR might work out, and have no experience with that. So I can’t even offer an honestly virulent tirade about it. :stuck_out_tongue:

15

Prescription drug tolerance is extremely common, and it does sound like you & your doctor have this part nipped in the bud. It’s true that “stepping down” from benzos can be paralyzing (and, in cases of severe abuse, potentially life-threatening) but if all you’re doing is swapping one medication for the other, you shouldn’t have too many problems.

Ativan’s amazing. :cool: I’ve recently swapped from Xanax to Ativan myself, and it’s like a whole new world – there’s barely any side effects, and it doesn’t mess with my head they way Xanax sometimes would. The only major issue is that my body’s not quite used to it, so if I skip a day I’ll start to “jones” pretty bad, but that’s something everyone needs to manage. (Technically I’m only supposed to take it “as needed”, but lately it’s become almost every day, because the Ongoing Family Drama which has been building since last September has become downright Apocalyptic lately.) As always, YMMV.

Remember, your doctor is there to serve your needs, not the other way 'round. If you don’t feel he’s helping you properly, let him know, and if he doesn’t listen, get a new doc ASAP.

But it does sounds to me like things are working out in your favor, so best of luck!