For GAD..xanax, klonipan, or valium better?

[sleeplesss]

I've had panic attacks in the past.  Been on Xanax for over 18 years.  I've read on this forum that Klonipan is longer acting, but also, that it is more for panic attacks rather than general anxiety disorder.  Would valium be better for GAD....is it longer acting than Xanax?  After all these years the xanax isn't working as well.  been on the same dosage for over 18 years.  Don't understand why NOW it isn't working as well.  I know you can get tolerate to a dosage after months, but, I've never taken more or less than 1.5 mg a day of xanax....50 mg 3 times a day.
Thanks!

[JSGeare]

If you want a lot of different ideas and opinions, you've come to the right place. I'm not sure how any of it will help you -short of just being an interesting subject. And no one here can speak with authority on your situation. Have you thought about posing your question to a doctor -especially a psychiatrist? I am especially curious about the drop in effect of the Xanax -after all these years.

I can say that I have seen drugs which were designed for one thing used for something else. It all depends on some specific action the doctor is looking for.

Over the course of many years, other changes may also have taken effect. I urge you to get a consult soonest -and then tell us what the result was, please.

[Jade59]

Hey there!  I recently wrote down something Ryan said.  He states that Klonopin is for generalized anxiety states, whereas Valium would be for panic states.  

Hope this helps!

[RCA7591]

The inverse is true. Klonopin for panic, and Valium for generalized, free-floating, or tension states.

[sleeplesss]

Thank you for all your comments.  Does valium last longer than xanax?

[RCA7591]

"Does valium last longer than xanax?"

^quote

A seemingly, straight-forward question such as this one, actually requires a complex answer.

Xanax is a short-acting agent. The onset of action is within 15-20 minutes, and the drug peaks in the plasma within two hours. The duration of the clinical effect is four hours. Xanax never accumulates in the plasma, nor does it ever reach steady-state. The half-life of Xanax is six hours, and it is rapidly excreted from the body. Since it is a short-acting agent and does not accumulate, its usefulness over the long-term is limited. Xanax is indicated only for intermittent use. Long-term use of Xanax is associated with the development of tolerance to the clinical effects, and this renders the drug useless after an "X" amount of time. "X" may be as little as four months. "X" depends on the individual.

Since Xanax does not accumulate, it must be dosed frequently to prevent rebound phenomena and interdose anxiety. After long-term use, it must be taken to starve off withdrawal phenomena that result due to the development of tolerance.

Valium is a long-acting agent. The onset of action is within 30-45 minutes (up to an hour or more in some cases). The duration of the clinical effect is eight hours. Valium accumulates in the plasma, and reaches steady-state within one month, provided that it is dosed three times daily. After one month, Valium accumulates between 5-10 times that of the steady-state plasma level. The retainment of steady-state (and ultimately, the accumulation beyond steady-state) prevents the rebound phenomena, interdose anxiety, and development of tolerance that is typically seen with Ativan, Serax, and Xanax. Since Valium accumulates, it is indicated for long-term use.

Here's where things get tricky:

You cannot make a direct transition from Xanax to Valium, especially if you are on a large dosage of Xanax. Xanax works immediately and doesn't accumulate, where as Valium accumulates. For Valium to replace Xanax fully, it must reach steady-state. The process takes roughly one month, and this precludes the direct substitution of Xanax for Valium.

To transition from Xanax to Valium, a stepped program must be utilized. Failure to use a stepped program such as the one described below will result in severe withdrawal phenomena, and potentially, convulsions.

0.25 mg of Xanax is equal in potency to 5 mg of Valium. It is absolutely critical that this be borne in mind, and that the correct substitution dosage be implemented.

Example of a stepped program:

YOUR DAILY XANAX DOSAGE IS 0.25 MG, Q.I.D. (FOUR TIMES DAILY)

Weeks 1-4: The first 0.25 mg dose of Xanax will be replaced with 5 mg of Valium. Take 0.25 mg of Xanax in the morning, afternoon, and evening. Take the 5 mg of Valium nightly.

Weeks 4-8: Take 0.25 mg of Xanax in the morning and afternoon. Take 5 mg of Valium in the evening and nightly.

Weeks 8-12: Take 0.25 mg of Xanax in the morning. Take 5 mg of Valium in the afternoon, evening, and nightly.

Weeks 12-16: The Xanax is discontinued. Take Valium 5 mg, q.i.d. (four times daily) for the next four weeks. At this point, Valium has reached steady-state.

Week 16: Due to the tolerance you've developed towards Xanax, the Valium dosage will now be increased and altered to reestablish efficacy. The new dosage is 10 mg, t.i.d. (three times daily). You are now stabilized on 30 mg of Valium. It will never lose its efficacy, and no further change needs to be made.

This is a complex example demonstrating the proper substitution of Valium in place of Xanax. As with any program, it should be supervised under the direct supervision of a medical doctor.

Ryan

[xanweaner]

That is amazing re: the differences between xanax and valium.

Why, then does valium get its bad rap? Was it because it was being prescribed by so many other specialties other than psychiatry?

[RCA7591]

While Valium was released to the market in 1964, its widespread use didn't come into play until the early 1970's. There, it found use in a wide array of ailments - everything from tension, to muscle spasm, to hayfever (seriously). In short, it was over-prescribed and misused for every little ache and pain. That's where it got the bad reputation.

Prior to 1970, Miltown (Meprobamate), Nembutal, Librium, Seconal and Serax were the largest sellers, followed by the Phenothiazines (Compazine, Stelazine, Thorazine), and lastly, the Tricyclics of the era (Elavil, Sinequan, Tofranil).

By 1978, Valium fell out of favor when Ativan hit the market, as a new and supposedly "non-habit forming" replacement (what a joke). Yet again, history repeated itself. Ativan is ten-times stronger than Valium, and that posed a major problem. Prior to the introduction of Ativan, Benzodiazepines were relatively weak drugs.

In 1981, Ativan fell out of favor for Xanax, another supposedly "non-habit forming" replacement. The rest is history, and nothing has changed since. Xanax is twenty-times stronger than Valium, and its reputation is worse than Valium.

Of the Benzodiazepines, Librium, Tranxene and Valium are the weakest, carry the longest halve-lives, and are by far the safest three drugs ever devised for generalized anxiety. Unfortunately, they are rarely used anymore due to their weakness and ineffectiveness in panic states.

The Benzodiazepine that received the least attention was Klonopin, marketed in 1976 (originally sold under the name Clonopin). It preceded Ativan, but at the time, was only indicated for certain forms of epilepsy. In the early-to-mid 1980's, it found off-label use, in, what, at that time, was known as "panic-anxiety" (known today as panic disorder). The brighter psychiatrists' would prescribe Klonopin off-label for panic in place of Ativan or Xanax, due to the long half-life and prevention of tolerance. 22 years after Klonopin hit the market, it was finally FDA approved for the treatment of panic disorder. Like Xanax, it is twenty-times stronger than Valium, but unlike Xanax, carries a prolonged half-life and maintains its efficacy.

The name change from Clonopin to Klonopin occurred in 1985, as it was often confused with Clonidine (a high blood pressure med).

Today, the Benzodiazepines are better understood. Xanax has fallen out of favor for Klonopin, and Valium is making a comeback. The emphasis today is on the prevention of tolerance. The typical psychiatrist today would much rather prefer to prescribe Klonopin or Valium over Ativan or Xanax.

Also of interest is the fact that Ativan and Xanax are no longer listed in the PDR (ie: the big book of drugs). Klonopin and Valium are still listed after all these years. I think that's a pretty good indicator of their efficacy, and it makes me wonder why the makers of Ativan (Wyeth) and Xanax (Pfizer) opted out of includng their products. I think the reason why is obvious.

All is not lost, however. Below is the prescribing information for Xanax-XR, which is a very interesting read.

http://www.pfizer.com/files/products/uspi_xanax_xr.pdf

Ryan

[Jade59]

Hi Ryan!  Thank you for correcting me on the Klonopin/Valium issue.  I don't want to quote you incorrectly, so I appreciate that.  

Take care.......

[sleeplesss]

Thank you so much for the detailed response.  My dr. talked about switching me to Klonipan, but for GAD, sounds like valium is the better solution.  I rarely have actual panic attacks.  
Now I have to think of an approach about this with my dr. without trying to tell him how to do his job.  I like him alot, but I don't want to make him mad either.  

[xanweaner]

Ryan,

That was a great post on xanax and why valium got the bad rap. I wish I would have known that prior to starting on xanax in April 07. Fortunately, I'm weaning off and getting close to discontinuing my daily use.

Fortunately, xanax came in very handy when I needed it to stop the trembling that I had. It was fairly severe. Once I took the short-acting dose, it would stop it in about 5 minutes. However, when we started me on the long-acting, I also had to supplement with the short-acting, since the long-acting was not as effective. Obviously, my weaning off the long-acting was a bit challenging, but I did accomplish it.

After reading what many psychiatric experts write about xanax and its difficulty in withdrawal, I feel very lucky that I've gotten to this point in my weaning - but have been weaning off since Oct. 07 - 5 months....can't wait for the day when I no longer have to reach for my bottle or watch the clock to be sure that 4 hours haven't passed without my dose.

[Slappy3243]

Xanax and Xanax XR can be used long-term quite effectively as studies done in 2003 show. People will develop tolerance to its hypnotic effects but its anxiolytic effects can remain intact on a maintenance dose for years without having to increase. You are the perfect example. You used it for 18 years with great results. Another good thing about Xanax is that it does not build up in your plasma levels which lessens the chance of the drug causing depression. I have been on Xanax XR for over a year and have not required a dosage increase. While Ryan is certainly a wealth of information, people should not simply rule out Xanax XR for long-term treatment. My psychiatrist has been prescribing benzos for over 25 years and says he gets his best long-term results by treating patients with Xanax. Most doctors will also agree that withdrawal from Xanax becomes difficult at doses greater than 4 mg a day for a long period. This is not to say tha Valium may not be a better choice for people but a lot of it depends on the individual.

[RCA7591]

From Pfizer (the manufacturer of Xanax):

"CLINICAL EFFICACY TRIALS

The efficacy of XANAX XR Tablets in the treatment of panic disorder was established in
two 6-week, placebo-controlled studies of XANAX XR in patients with panic disorder.
In two 6-week, flexible-dose, placebo-controlled studies in patients meeting DSM-III criteria for panic disorder, patients were treated with XANAX XR in a dose range of 1 to 10 mg/day, on a once-a-day basis. The effectiveness of XANAX XR was assessed on the basis of changes in various measures of panic attack frequency, on various measures of the Clinical Global Impression, and on the Overall Phobia Scale. In all, there were seven primary efficacy measures in these studies, and XANAX XR was superior to placebo on all seven outcomes in both studies. The mean dose of XANAX XR at the last treatment visit was 4.2 mg/day in the first study and 4.6 mg/day in the second.

In addition, there were two 8-week, fixed-dose, placebo-controlled studies of XANAX XR in
patients with panic disorder, involving fixed XANAX XR doses of 4 and 6 mg/day, on a
once-a-day basis, that did not show a benefit for either dose of XANAX XR.
THE LONGER-TERM EFFICACY OF XANAX XR IN PANIC DISORDER HAS NOT BEEN SYSTEMATICALLY EVALUATED .Analyses of the relationship between treatment outcome and gender did not suggest any differential responsiveness on the basis of gender."

If studies were performed in 2003, I would expect to see the manufacturer touting the long-term efficacy of Xanax. The above is a quote from the official prescribing information, and there is no mention of any long-term study. The study was limited to eight weeks. In fact, Pfizer states quite clearly that the long-term efficacy has not been systematically evaluated.

Tolerance to the hypnotic effect of any Benzodiazepine is both typical and desirable. This does not indicate tolerance to the anxiolytic effect, which is maintained with the long-acting agents (of which Xanax is not).

Depression is an exceedingly rare side effect of any Benzodiazepine, and when it occurs, there was likely a predisposition to depression, or an underlying depressive state. All Benzodiazepines worsen depressive states, with the possible exception of Xanax. This has nothing to due with the half-life of Xanax or accumulation, but its triazolo-ring. The three-ring structure is similar to that of a Tricyclic antidepressant. This is why Xanax is unlikely to precipitate depression - even in those who are predisposed to it.

One could raise the argument that those who develop depression (or whose depression worsens) with Benzodiazepine treatment actually suffer primarily from a depressive state. In this case, an antidepressant such as Elavil would likely be more efficacious. Differentiating between anxiety and depression is critical, especially if they coexist, as treating the dominating disorder will also treat the secondary disorder. This is almost always the case. Unfortunately, given the triazolo-ring that Xanax possesses, Xanax may easily mask a mild, underlying depressive state and give a false-positive dominating diagnosis of anxiety, when, in fact, it is depression that dominates the clinical picture.

Ryan

[Summer123]

I'm not sure how someone would go about differentiating between anxiety and depression when they coexist.  I am both anxious and depressed.  Actually, I think I'm quite depressed about my anxiety.  It is very depressing to not be able to function outside of the home without a stupid little pill.   So where I am depressed about my anxiety, I am not anxious about my depression, just anxious about everything else.  Does that mean that my primary diagnosis is the anxiety?

I have also used xanex for 20 years and only in the last 6 months did I need more xanex to function well.  This scared me and I proceeded to lower my dose down to 25% of the functional dose.   This dose guarantees me that I will be able to function well in any situation if I increase the dose back up to the 100% mark for a period of time

[xanweaner]

Again, thank you for that additional info. It is comforting for me since I take it along with an antidepressant since my depression has a strong anxiety component to it.

[Slappy3243]

Ryan,

I am a bit confused in regards to your post. Since Pfizer did not do a study in regards to the long-term efficacy of Xanax, that means it cannot work long-term? To me, it sounds like they themselves did not do a long-term study just like pretty much all of the other Benzo manufacturers. Could you point me to a study that shows the long acting benzos like Valium keep their anxiolytic where Xanax doesn't in the long-term? I would like to learn as much as I can.

Here is a quick summary of the 2003 study: "However, in 1992 Romach and colleagues reported that dose escalation was not a characteristic of long-term alprazolam users, and the majority of patients indicated that alprazolam continued to be effective.[13] A 2003 study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.[14]In a 1-year follow-up study of patients with panic disorder continuing treatment with clonazepam, 90% maintained a positive response without developing significant tolerance. In a 2.5-year follow-up study of alprazolam therapy, little evidence of tolerance emerged.[15]"

Link to one of the studies http://www.ncbi.nlm.nih.gov/pubmed/1970813

Quoted from that link is this: "In a 2.5-year follow-up study of alprazolam therapy, little evidence of tolerance emerged and initial therapeutic gains were maintained, even among patients who decreased or discontinued medication. As with antidepressants, many patients remain on high-potency benzodiazepine medication after short-term treatment; the choice of maintenance agent should reflect side effects of treatment as well as the ease of discontinuation. The high-potency benzodiazepines are a reasonable alternative to antidepressants, which involve problems of morbidity, noncompliance, and risk for overdose. Discontinuation may be less difficult with the longer-acting high-potency benzodiazepines, which thus may be advantageous for long-term treatment. It is necessary to determine the contributions of all aspects of treatment, both behavioral and pharmacologic, to the longitudinal course of patients with panic disorders."

So as far as withdrawals go, a longer acting benzo may be better but Xanax is still a very viable alternative.

-Adam

[Slappy3243]

Also, the fact that the thread starter has been on the same dose of Xanax for 18 years without having any issues is also evidence that Xanax can be useful in the long-term treatment of anxiety.

[david85]

Clinical aspects of chronic use of alprazolam and lorazepam.

Romach M, Busto U, Somer G, Kaplan HL, Sellers E

Clinical Research and Treatment Institute, Addiction Research
Foundation, Toronto, Ont., Canada.

OBJECTIVE: The authors' goal was to determine the clinical
characteristics of persistent users of
alprazolam or lorazepam who wished to discontinue their medication.
METHOD: Long-term users
(daily use for more than 3 months) of alprazolam (N = 34) or lorazepam
(N = 97) who entered an
outpatient treatment program for discontinuation of benzodiazepines were
carefully assessed.
Detailed histories of benzodiazepine use were obtained; a structured
interview was used to make
psychiatric diagnoses based on DSM-III-R criteria. RESULTS: The majority
of patients were using
low therapeutic doses of medication (lorazepam: mean = 2.7 mg/day;
alprazolam: mean = 1.2
mg/day) and had either maintained their initial daily dose over time or
decreased it. Individuals
tended to shift their use of medication from an as-prescribed to an
as-needed pattern. Forty-seven
percent of the patients were diagnosed with at least one current anxiety
disorder, most commonly
generalized anxiety. At least one diagnosable personality disorder was
found in 45% of the patients,
most commonly obsessive-compulsive personality disorder. Patterns of
benzodiazepine use were
influenced by age, gender, and past history of alcohol dependence.
CONCLUSIONS: Long-term
users of alprazolam/lorazepam seeking treatment for discontinuation had
clinically important past and
current psychiatric histories. They used a constant or decreasing dose
of medication and made
attempts to stop their use. Persistent use of alprazolam/lorazepam for
therapeutic purposes did not
represent abuse or addiction as the terms are usually understood. A
substantial proportion of these
patients may be receiving appropriate maintenance therapy for a chronic
psychiatric condition.

[treefarmer1]

Hi Sleepless,I see you are having problems with anxiety,and panic attacks,I tried all the meds your are taking.Cymbalta also.I am taking the herb Bacopin right now.I found out I have HepatitisC 2 years ago.I really do not want to damage my liver anymore with script meds.Check ouy www.protazen.com I am thinking about trying this product,This might help you out.Good luck Treefarmer1  

[david85]

Xanax is actually the #1 choice for Panic disorder.

[sleeplesss]

Thank you for all your comments.  I really think that part of the reason my xanax wasn't working after 18 years is the fact that I was on vicodin for 6 months for a back problem.  I tapered off the vicodin, and the anxiety increased.  I can't help but think that this was not a coincidence.  Any thoughts on my theory?  In fact, now that I've been off the vicodin for weeks now, the anxiety seems to be better.  It was mostly bad during the time I was tapering.

[Slappy3243]

I totally feel that tapering off a drug like Vicodin can give you anxiety. It is a powerful narcotic that has withdrawal effects like any other drug in its class which includes anxiety. These are just some of the withdrawal effects of the drug:

The symptoms of Vicodin withdrawal include but are not limited to:

restlessness

muscle pain

bone pain

insomnia

diarrhea

vomiting

cold flashes

goose bumps

involuntary leg movements

watery eyes

runny nose

loss of appetite

irritability

panic

nausea

chills

sweating


Hope that helps you.

[level]

I was on klonopin for 8 years and was able to taper down slowly from 1.5mg a day to 0 but anxiety came back full force about a year later and had to get back on a benzo. Went with valium and have been on that for 7 years now.

If I don't take valium the withdrawals start kicking in real real bad about the 3rd day. I have tried to switch over to ativan, serax, and xanax and just dump the valium all together to give the other ones a go but I can't do it because the valium withdrawals start kicking in.

The only drug I have been able to completely switch back over is klonopin where I did a valium taper and added klonopin over a period of a few weeks and I didn't notice any withdrawals from valium doing that. However, I just hated how I felt on the klonopin-out of it, little depressed, drugged up, and it didn't seem to help my GAD either.

So now, I supplement a xanax or a serax or an ativan every now and then because the valium just doesn't really seem to be doing that great for my GAD anymore. I really wanted to just get off it and just try xanax by itself to really evaluate it but again I haven't been able to successfully do that because I get valium withdrawals each time. I guess I would have to do a complete valium taper then pick up one of the shorter acting ones but the valium withdrawals are not pleasant at all and you do feel them-it just takes a day or two longer. I am interested in just going on the xanax even though it might not be the right decision but again I just haven't been able to just dump the valium and do a straight crossover to it without the withdrawals from valium.