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Klonopin (clonazepam) tolerance at high dose and symptoms
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Klonopin (clonazepam) tolerance at high dose and symptoms

Hi,
    I'm having an extreme panic disorder with agoraphobia, social phobia and some OCD related to my heart. I take a high dose of Klonopin (Clonazepam) 8 mg day divided into 16 doses of 0.5 mg for 1 hour and 0.25 the hour after and do this all day long + 1 mg of Xanax (Alprazolam)/day, 0.5 mg in the morning and 0.25 afternoon and 0.25 at night. I take the 8 mg of Klonopin since june 2009, I was previously on a low dose of Valium 20 mg day but I start having panic attacks again so my PDoc put me on the Klonopin, who I had already took in the past from 2005 until 2007 when I withdraw it with the help of the Valium...

Since 1 1/2, my panic increase from a normal situational state of panic with the usual panic attacks who happen at first at the gym because of the fast pulse rate and some weeks later happening while I had to drive my car. In 2009 and for half of 2010, I was still able to get out of the house and drive and see my friends and have a "normal" life, even if I had many panic attakcs a day, especially when I was out of the house.

In the middle of 2010, I start having agoraphobia and my panic disorder get into a newer level never reach before. I had to stop driving my car, taking a shower was almost impossible because I was feeling like I will faint (I actually faint 3 times around the same period of time), light up the first cigarette in the morning was and is still horrible and since then i'm homebound.

I start having what my PDoc call a cardiophobia problem, can take my pulse rate 1000 times a day, take my blood pressure 30 times and more a day. Of course, I was sent into Therapy, who didin't improve my state at all, did 3 Therapies in less than 1 year (12 weeks each) + 1 group therapy.

Also, in the middle of 2010, I start seeking for more tests, I first saw a neurologist who just told me to take some neurotin or topamax for my headache. I also saw 2 different Cardiologists, the first one for the slow pulse rate I had in the begining of 2010 until the middle of 2010, I had a holter 24 hours monitor who was perfect, had a stress-test with an electrocardiogram who was also perfect so the first Cardiologist just send me home with no answer about the low pulse rate.

Like I wrote before, in july 2010 my panic reach a new level and I start having once in a while strong chest pain on the left side, very fast pulse rate in the morning and late evening, unstable blood pressure (high when I was out of the house and normal-low at home), so I saw another Cardiologist and had other tests for my heart, holter monitor 24 hours, blood pressure 24 hours, stress-test on a treadmill, everything was ok apparently and he RX a first beta-blocker to take as needed before a stressfull event or daily if I wanted... I had to try 4-5 different beta-blockers before finding the good one to reduce my fast pulse rate, who is not working anymore. I ending on a low dose of Inderal 5 to 10 mg a day to control the fast heart beat, I still take 2.5 mg of Inderal, but it's just to give to me some peace of mind like "yeah, I take something for my heart and I will not die from it", but I know that that dose is so small that it have no effect on me.

In february 2011, the panic and anxiety reach a new level again, this time very debilitating level of anxiety. That's when my PDoc choose to add 0.5 mg of Xanax in the norming because it's the faster acting benzo med and it's seem that I need something who act fast soon after I get up. Now, I can't be in a car, even if I don't drive, if I really need to go somewhere like a Doc or PDoc, I need to take some Xanax and double my Inderal dose 1-2 hours before I leave the house, I start having IBS symptoms (bloating, intestine pain, severe constipation) all the time especially in the evening (me who had a gastric by-pass to loose weight and who had diarrhea up to 8 times a day before), the headache is now chronic and is worse when my blood pressure is on the low side with a pulsating veins that I can see on the left temple of my head, also and I can't take painkillers cause they make my heart race and increase my blood pressure. I start having also extreme jaw and teeth pain, neck-shoulder-upper back and left side chest pain all day long, I start having muscles twitching and spasm (especially in my arms, legs and in my buttocks, I have those muscles spasm all day long also who is a sign that I MAY have developped a high tolerance to the benzo meds cause they are normally good to relieve muscles spasms (it's seem that I have some paradoxical effects from the Klonopin), my blood pressure is unstable and can be low for 2-3 months and be bordeline 2-3 months and return to the low side, I have an irregular heart everyday, goes to the ER several times for tachycardia (supraventricular tachycardia episodes) but all the EKG + blood tests + X-ray of my lungs was ok, i'm all the time dizzy, I have exercise intolerance and can't do anything physical like just walking without having a very fast pulse rate and strong chest pain (the chest pain happen more often at rest and is apparently not related to my heart, that's what my Cardiologist said to me when I saw him again last march), my eyes hurt and burn, I have extreme jaw pain and teeth pain all the time, neck pain, back pain, poor memory, feel like I will become crazy, constant depersonalisation, derealisation, and the list goes on...

Since i'm on a high dose of benzo, I should not have those symptoms, that's why I wonder if I don't build up a tolerance to their effects? When the PDoc add the Xanax, I was feeling more normal and less anxious in the first 3 weeks but it's seem that I build up a tolerance to the Xanax faster and really don't want to increase it. Same for the Klonopin, I try to increase it with no improve on my anxiety so I reduce it to the initial 8 mg...

Since i'm now med sensitives and can't start the Paxil, who is the only one AD who sork to stop the panic disorder on me, and since I have a lot of cardiovascular symptoms, what I should do with all of this? Should I start a slow withdrawal schedules for the Xanax first with the help of Valium (Professor C Heather Ashton technic)? And when I will be off the Xanax, should I start to do the same with the Klonopin? My anxiety is very high, for me each day is like the last day I will live and I want to avoid an increase of anxiety...

Someone else have build-up a high dose tolerance of benzo here? And if so, how you can deal with that? Is it normal to have withdrawal symptoms even if i'm on high dose? What I can do to reduce those symptoms? Adding some neurotin or Lyrica?

Thanks for your help ;-)
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9 Comments Post a Comment
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480448_tn?1403547723
All I can say is...WOW.

I'd be willing to bet that a vast majority of your issues is to due to the ridiculous way the Klonopin was prescribed.  Klonopin is a LONG acting benzo...you're redosing constantly before it has even STARTED working.  Not only is it not going to be productive, it's actually counterproductive and could have even been dangerous.

The only advice I can give you is to seek out a new doctor immediately.  It's going to take a while to undo this process and get you on a reasonable medication regimen, and you'll require a very deliberate and SLOW taper down from the Klonopin.  Most likely a benzo won't even be an optimal option for you due to the high tolerance you have.  That will go for most other benzos too, as there is a cross tolerance issue that arises with high dose benzo use.

I'm not trying to be negative, but sincerely...run, don't walk to a new doctor.  I would seek out someone who is very well versed in bemzo use.  Call and explain the situation and that you need to be reevaluated, starting from scratch.

Quite honestly, you may require an inpatient stay to get this sorted out.

Did your Pharmacy NOT question this Rx?  I'm just amazed.
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480448_tn?1403547723
I forgot to mention that typically, Klonopin is dosed twice a day, 12 hours apart, due to the long acting nature and long half life.  3 doses a day, 8 hours apart is about the most frequently one would take Klonopin.  Anything more frequent than that is just adding to tolerance issues and will not help the anxiolytic effects of the meds whatsoever...quite the opposite actually.
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Avatar_m_tn
Hi,
   Well, the Klonopin is dosing in that way cause I had a gastric by-pass who make it harder to be absorb in my intestine. I was on 2 mg x 4 times a day in the past but it was not effective in that way... when choose to redosing it each hour with low dose, it worked well for 6 months and then things get worse...

It will be a REAL pleasure to run and find another PDoc, but I can't... I live in the Canada, Quebec city and we have a public health system and we can't choose the PDoc we want... Right now he do nothing to help me, he just told me to take my benzo meds and stop complaining about my many symptoms!

I always build up a tolerance to the Klonopin after 6 months of use, it's work very well the first months and after it's a disaster... On the Valium I was maybe a little bit more anxious, but never had any symptoms like the ones I have now...

And I can't go inpatient here... I ask many times my PDoc to enter at the hospital as an inpatient to be put on the Paxil and sorted out the benzo meds thing, but he can't... they don't admit inpatient if you are not suicidal or dangerous for the society... it's the way it's working in a public system... Also, we don't have private hospital or special clinics here to treat those kind of problems...and since I don't work and have no money, I can't travel to the USA and find a good PDoc and go in a private clinic...
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480448_tn?1403547723
There would be many other better alternatives with the gastric bypass factor, orally dissolving tablets would be one example.  The fact that you had bypass surgery actually increases your risks for complications due to you dosing so frequently.  How do you sleep at night, or do you not take them overnight?

I'm not familiar with your medical system, but I would get the ball rolling on finding another doctor.  I know it isn't easy, especially when financially you don't have a lot of options.  I sincerely worry, though, that your regimen is compounding your symptoms bigtime and going to end up leaving you with very few med options.  Please try to seek out a new doc if you can.

In the meantime,  how about therapy?  Have you tried that at all?  

Wish I could give you more input, but your situation is tough.
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Avatar_m_tn
I forget to ask, why it will be more dangerous to take the Klonopin every hour instead of taking a larger dose of 2 mg 4 times a day? I ending with the same level of Klonopin in the system at the end of the day anyway. That's what my PDoc explain to me many time... taking a lower dose but more often will be, in my case (fast  metabolizer of meds), more productive for my anxiety than taking 2 mg who will peak only 2-4 times later, who will sedate me more and who will not help me more for the anxiety... With the dosing every hour, I get the same level of Klonopin in the blood, avoid the sedation from larger dose...

My pharmacist say it's ok, explain to me it was the same as taking it 4 times a day at larger dose. He just mention that I will may developp a stronger psychological addiction cause if I miss a dose I will feel bad and can increase my anxiety.

Also, the Klonopin half-life is between 18-50 hours, and is not a long acting benzo, the Valium is the longest active benzo because of the many active metabolites inside it. The Klonopin in my case is out of my system after 6 hours and the feel effect only last 3 hours, take 1 hour to start...with the Xanax I feel it after 10 minutes and it's lasting only 1 1/2 hours... well I don't really feel it because it's not decreasing the anxiety now, but at the begining it was working like that...

Maybe trying first to dosing my Klonopin every 2 hours for some weeks and then dosing it every 4 hours will help me? Have to remember to do it in slow step cause right now my anxiety level is so high that I feel that I will die from a heart attack...
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Avatar_m_tn
Hummm ok... well the by-pass I had is not the same they normally do in the USA... mine work with the malabsorbtion of food cause they by-pass 2/3 of the intestine, who make the meds not as effective as before the by-pass...

Also, I always let disolve under my tongue the Klonopin, to be honnest I don't see any difference between swallow it and let it disolve under my tongue... And of course, in the Canada we don't have the orally disolve tablets of Klonopin and we don't have the Xanax-XR... who don't help me and give not a lot of options of course...

I done 3 therapies in 1 year... 12 weeks each... the last one I had was a group therapy and I had to stop after 4 weeks cause it was making me too much anxious, had to go there each day by car, it was too much at the same time for me... Overall, the last therapist I had told me I had a somatoform disorder and since it's a public system and we don't pay for therapy, she show me the door saying that I was a harder case to treat and that I needed meds first... right now I can't have another Therapist, they send to me a letter saying that they will not take me anymore, only if my PDoc can prove that my anxiety state improve and will answer to CBT therapy...

At night I don't take them... I always put a 0.5 mg pill of Klonopin near my bed in case I wake up in a panic attack state, like it happen often... but normally between 12AM and 7 AM I don't take benzo meds... For the Xanax it's only 0.5 mg as soon as i'm awake... and 0.25 mg as needed at daytime, I never take more than 1 mg total a day... don't want to take more because I know I will built a high tolerance to it also... but my PDoc RX 3 mg day as needed...

I know that the Paxil will be the only thing who will save my life, but i'm so med sensitive that I can't take even a low dose of 1 mg of it right now without ending at the ER with a very fast pulse rate who last hours and hours... Who is really weird cause in the past I never had difficulty starting a SSRI's and was not sensitive to meds... I attribute it to the high anxiety state...

Will ask my Family Doc next time I see him in 2 weeks... will sorted out the benzo meds... maybe a 2-3 hours dosing schedule insistead of 1 hour... and see what to do next... maybe withdrawal the Xanax first with the Valium... or cut a part of the Klonopin and replace it with the Valium...

Thanks again for your advises ;-)
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480448_tn?1403547723
Average Klonopin half life is 30-40 hours.  It certainly is a long acting benzo, when compared to Xanax, Ativan.  You are correct that Valium is a longer acting benzo than Klonopin, but Valium is not optimal for treating panic disorder and severe anxiety.

In your case, you have decreased ability to absorb the medication (which could have been easily remedied with dissolving wafers).  You would really never be able to know how much of the Klonopin you are absorbing, and it will vary significantly dose to dose.  I say it is dangerous because with the constant redosing you run the risk of several doses peaking at one time, not to mention the increased burden on your liver.  Klonopin has a maximum plasma concentration duration of 1-4 hours for a person without gastric bypass.  Since the peak plasma concentration is going to vary anyway, you are adding another factor of inconsistent levels to the mix.

As far as hepatic risk,  you're having many doses of varying strengths hit your liver almost constantly, and the liver is the organ responsible for metablozing the medication.  The gastric bypass also places you at higher risk for liver problems, even without the Klonopin figured in.

You're left with constantly fluctuating levels of Klonopin, which defeats the purpose of the medication to begin with.  Klonopin, being a long acting benzo is most effective when allowed to build up in the plasma.  You would still have some ups and down dosing less frequently, but they wouldn't be as severe.  That's also why I suspect your panic is so poorly managed.   Plus, this is killing your tolerance, and then Xanax has been added to the mix.  It's not an optimal set up, I'm sorry.

Rather than having to take a a pill every hour or so, why not ask about the orally dissolving wafers?  That would be a much better option.  Also, have you asked the doc who did your bypass who to approach taking certain medications?  I bet if you asked him/her....he or she would not agree with your regimen at all.
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480448_tn?1403547723
We must have been typing at the same time...I see that the wafers are not available to you.  Taking the med sublingually would definitely help a little.  The fact that a good part of your intestine is involved with the nature of your bypass makes the absorption a little more difficult, although the majority of Klonopin is absorped after it's journey in the stomach (for normal people).

I getting the bypass surgeon involved is a good idea.  I've cared for a lot of gastric bypass patients, and while there is certainly special considerations with medications, I've never seen anything like your regimen.  

Very best of luck...let us know how it's going!!
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Avatar_m_tn
Ok, I understand now what you mean by dangerous... If you don't mind, I will print your message and show it to my Doc... ;-)

For the absorbation of the meds with the gastric by-pass, my Surgeon is aware of my Klonopin and Xanax dosing and said it was ok, she said to find a good way for me to take them, that's it... nothing much... she said that some meds like the XR will not be well absorb but that regular meds are well absorb, I try many times to explain to her that I had no effect or little effect on meds that I took before the gastric by-pass, so it must have an effect on the absorbtion of the regular med too!!! I think they don't even know what the surgery do really... no wonder why I have a lot of high dose vitamins to take daily, especially the fat solube ones... and since a lot of meds need to be absorb where the fat is absorb in the intestine, a part that is now by-pass in my intestine, I guess meds are not working good because of this...

Also, I ask my PDoc about the Klonopin, call Rivotril in the Canada, who dissolve under the tongue and they don't have them... they only one benzo they have in a wafers form is the Ativan, and it's one of the worse benzo I try in my life, affecting too much my memory, make me dizzy and sick... Also my family Doc who work take only patients who have depression and anxiety disorders told me that the difference between the waffers benzo and regular is small since it's absorb rapidly from the stomach and even before it's reaching the stomach and that's him who told me to let them disolve under my tongue... The Klonopin taste is good but the Xanax is awfull. And yes, adding the Xanax is not an optimal plan, I know, but I needed something strong for my anxiety in the morning, something who is really fast acting and the Xanax is the best benzo to achieve this... and since I had an addiction problem with the Xanax in 2008, that's why I don't want to increase my dose, even if I know it will help me 2-3 weeks until I reach again a tolerance effect... I will ending with bigger problems at the end...

I know that i'm now a fast metaboliser of some meds cause I had a blood test to see if I was a fast metaboliser of meds, I don't remember exactly the name of that blood test but the result show that I was a fast metaboliser...

For the liver and the kidney, they are ok... well I had blood tests in april and it was ok... have done newer blood tests 2 weeks ago and will receive my results the 29th august. I will ask about the liver and kidney... Also, I loose some blood because of some internal hemmoroids (hemorrhoids), maybe my iron level is down again, but I doubt it's the problem cause I had anemia in the past with low hemoglobin level and never had that kind of symtpoms...

What do you think about trying myself to dosing every 2 hours for 1 week? Like taking 0.75 mg every 2 hours insistead of taking 0.5 mg and 0.25 one hour later? Maybe I will see a difference?

The bigger problem is that with the dosing every hour method, I developp a strong psychological addiction and when I miss a dose I start having panic symptoms... And just to make you see how it's psychological, sometimes I will talk on the phone with a friend and totally forget to take a dose and will don't have any kind of withdrawal effect...

Anyway, tell me what you think about the 2 hours dosing...or 3 hours... do you think it will make my anxiety worse or help me? Adding some neurontin will help you think, even if I try that option 2-3 times without success in the past, when I only had a social phobia disorder...

Thanks ;-)

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