Dr. Feilgoode or: How I Learned to Stop Worrying and Love My Medications

There are likely a number of really good reasons for a primary care physician to elect to hold off receiving assistance from a psychologist or psychotherapist in monitoring their patient's medications; but, prescribing drugs with a high potential for addiction and/or death is not one of them. For example, happening more times than I feel comfortable admitting is the trend of seeing patients or clients who were already prescribed Alprazolam, referred for psychotherapy several months after taking the anxiolytic drug, or after the patient had a period of many months or several years of pain treatment with an opioid-based drug, making the patient very resistant to discontinuing the drug. One case comes to mind. 

A middle-aged woman was referred to my office for an evaluation by the Department of Health and Human Services to confirm the presence of depression and anxiety stemming from a significant injury. The woman was self-employed but struggling with grief that is not uncommon with the death of a spouse. She was forced by circumstance to tend to their business alone and unfortunately, shortly after her husband’s death, she incurred another challenge when she injured her lower back. The pain from the injury, which occurred several years prior to the current restrictions on prescribing opioid medications, was treated with the drug Tramadol, with initial alleviating effects. 

But as with most cases, after a few years, her pain had become less responsive to the medication, and she began to experience panic-like symptoms, such as shortness of breath, tingling fingers, nervousness, and agitation that surfaced when the pain was unmanageable or when off the medication. On two occasions, the symptoms were so intense that her concerned family rushed her to the emergency room. On the second visit, she was given Alprazolam, which had the sedating effect she needed to manage her fear related to the pain. When she came to my office for the evaluation, she had not worked for months. Further, her panic attacks increased in frequency and intensity, her use of Alprazolam also increased to 2 mg per day, and she had already had the Tramadol increased to 400 mg. Her meeting with me was the only contact she ever had with a psychologist, after almost a decade taking the drugs. 

The evaluation itself was problematic because of the difficulty separating the effects of grief and loss, the physiological effects of an opioid drug, and the sedating effects of an anxiolytic when determining the etiology of a clearly depressed and anxious woman. My impression was that the drugs did not cause the depression, but they surely made it worse when she was not taking the drugs. My impression of her situation also holds for many in our community who share similar circumstances.

People who take whatever medication is prescribed without being given the time to understand the potential long-term consequences of the drug. One such problem is a drug’s potential for overdose, such as Tramadol with forty (40) overdose deaths a day. The problem with Tramadol has very recently been addressed by The Centers for Disease Control and Prevention (CDC), offering their final recommendations for prescribing opioids like Tramadol for chronic pain. Simply put, the CDC said “Don’t do it.” They added to that statement the consideration for non-medication interventions such as exercise and Cognitive Behavioral Therapy (CBT) – two approaches which have been utilized for decades by clinical and counseling psychologists. For instance, CBT is the most utilized psychotherapeutic approach used by psychologists and, along with hypnosis, is a safe and effective method for addressing chronic pain and depression. Unfortunately, fewer patients wish to address their chronic pain and depression through these methods, especially if they have already used opioid-based drugs, and primary care physicians are largely unaware of these non-medication benefits of psychotherapeutic approaches.

A second problem is the potential for dangerous accumulative effects when paired together with other drugs prescribed by different physicians who do not have adequate information related to all the medications taken by the patient. The problem is this: most, if not all medications, were not scientifically vetted to determine the potential for harm when paired with two, three, five, and, as with many of my patients, twelve medications, when winning FDA approval for their individual drug, and individually there are potential risks. Studies on the effects of Alprazolam, for example, conducted in the 1980’s, held that there was little risk for addiction, and were found to be effective in the management of panic disorder. However, a later study found that 43% of people who took Alprazolam (Xanax) for more than eight months experienced significant withdrawal symptoms when stopping the drug, and those who had taken the drug for less than eight-weeks, 65% of subjects experienced significant anxiety rebound when stopping the drug. The addictive effect was with the single drug. Also, there was no long-term benefit. 

As with Tramadol, Alprazolam does not need to be the first line of treatment. The use of CBT and behavioral interventions, taught in psychotherapy, are equally effective in treating panic disorder and have the greatest long-term benefits. Unfortunately, non-psychiatrists have been overly ambitious in prescribing Alprazolam over the past fifteen years - as my former client described above had experienced - but without the monitoring by a mental health professional needed to manage the risk for addiction.

As with all medications, a patient needs to ask questions and needs to feel free to ask questions to their medical provider. Here are some suggestions to ask your doctor. 1. Ask if the drug is necessary. 2. Ask if there are alternatives and the potential risks. 3. Ask about the average dosage for the average patient for the drug prescribed. 4. For the drugs with greater risks, ask if the drug will relieve the pain and if there is no risk in getting addicted. 6. Ask the length of time the drug will be needed to be taken and the goals the doctor wishes to accomplish by using this drug. 7. Ask to have a clinical psychologist become involved in helping with your care, and if they can refer you to one.

As with any medication, there are risks, but you have the right to question any professional who is receiving payment for service, especially if a service that has life-long potential consequences on your well-being. You also may have options that do not involve medications and that have long-term benefits. So, explore them all.