Abuse of Xanax Leads a Clinic to Halt Supply

LOUISVILLE, Ky. — Gayle Mink, a nurse practitioner at a community mental health center here, had tired of the constant stream of patients seeking Xanax, an anti-anxiety drug coveted for its swift calming effect.
“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”

Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end. The experiment will be closely watched in a state that has wrestled with widespread prescription drug abuse for more than a decade and is grasping for solutions as it claims more lives by the week. While Kentucky and other states have focused largely on narcotic painkiller addiction, experts say that benzodiazepines, the class of sedatives that includes Xanax, are also widely misused or abused, often with grim consequences. While the patients at Seven Counties are mostly poor, experts say the appeal of Xanax cuts across socioeconomic lines. Alprazolam was the eighth most prescribed drug in the nation last year, according to SDI, a data firm that tracks drug sales. Even more than the figures suggest, Xanax has become part of the popular lexicon, as well known as a panic antidote as Prozac is for depression. The Centers for Disease Control and Prevention last year reported an 89 percent increase in emergency room visits nationwide related to nonmedical benzodiazepine use between 2004 and 2008. And here in Kentucky, the combination of opiate painkillers and benzodiazepines, especially Xanax, is common in fatal overdoses, according to the state medical examiner. Seven Counties is not the first health care provider to cut off prescriptions for controlled substances — at least several others around the country have stopped giving patients certain opiates and benzodiazepines — but the practice remains contentious. Some doctors say that refusing to prescribe certain drugs under any circumstance is overly rigid, noting that Xanax helps many people who use it responsibly. “What they’re doing is a noble idea,” said Dr. Laurence H. Miller, who heads a committee on public and community psychiatry for the American Psychiatric Association. But he added: “I could never say never to anything. There are some people who may have done very well on it, are on a small dose and manage their lives on it, and that’s probably O.K.” But Dr. Scott Hedges, senior vice president for medical services at Seven Counties, said he felt certain that Xanax did not need to be among the options offered there. “The literature strongly suggests there are lots of really good ways to treat panic and anxiety disorders without using this particular medication,” Dr. Hedges said. “And the risk to the community, if we continue to use this medication, is very high.” Xanax poses a particular risk for abuse and withdrawal, doctors say, because its effects are felt almost immediately, but last only a few hours. Users often quickly want more, experts say, and as their tolerance builds, they want increasingly higher doses. Dr. Hedges said that while Seven Counties bore some blame for prescribing Xanax in the first place, many patients initially got it from primary care doctors. Alprazolam is one of the three most-prescribed controlled substances in Kentucky, along with hydrocodone and oxycodone, according to the state’s Cabinet for Health and Family Services. “We pick these folks up way down the road,” said Dr. Robert Caudill, a Seven Counties psychiatrist, “where they’re already on a big dose and don’t want to give it up because they’ve been given no skills along the way” for otherwise dealing with panic and anxiety. For people dependent on opiates, Xanax can be especially alluring because the fear of withdrawing from the opiates is so huge. After someone has experienced opiate withdrawal, Dr. Caudill said, “they really are scared to go into it again because it’s so horrible.” “They will panic,” he added, “literally.” At Seven Counties, some of the roughly 3,000 patients who were on Xanax have been switched to clonazepam, a longer-acting benzodiazepine that does not kick in as quickly and is thought to pose less risk of addiction. “They don’t get the high that’s associated with Xanax,” Dr. Hedges said, “nor the withdrawal associated with it.” The eventual goal is to wean patients off clonazepam, too, he said. People with severe anxiety should ideally take an antidepressant as well as a benzodiazepine, he said, and learn coping mechanisms with cognitive behavioral therapy. The doctors and nurses at Seven Counties have encouraged patients on Xanax to consider these options in addition to clonazepam or instead of it. But the transition has been cautious and slow, Dr. Hedges said, with Xanax doses generally being reduced in half-milligram increments over a number of months. “It’s a very slow and intentional process of weaning down,” Dr. Hedges said, “precisely because we don’t want to create all this anxiety and panic over, ‘Well, I’m not going to get it anymore.’ ” After the policy change was announced in March, everyone from the doctors to the receptionists at Seven Counties anticipated some tense moments as patients got used to the idea. It was not lost on them that a doctor in rural eastern Kentucky was shot to death by a patient in 2009 after refusing to prescribe a painkiller. Indeed, some transitions have been rough. Tina Graham, 44, a Seven Counties patient who suffers debilitating panic attacks, said her anxiety had sharply increased after switching from Xanax to clonazepam this summer. Clonazepam helps for about two hours after taking a pill, but for much of the day, she said, “I’m scared to do anything.” “I’m not saying I have to be back on Xanax,” Ms. Graham said. “But if this ain’t doing it, something’s got to change.” But Dr. Hedges said that such complaints had been relatively few, with about 90 percent of the patients who were taking Xanax already off it. “We haven’t had any episodes of violence, any acting out or difficult behavior in our clinics,” he said. “We tried to prepare for that, but in fact it hasn’t happened.” nytimes