Michael Jackson and Xanax

July 10th, 2009

The following is something I say now whenever a patient who is not currently on Xanax
asks me for Xanax (alprazolam).

“I am a hardworking psychiatrist, in a new situation every few minutes, with more

reasons to be anxious on this job than anybody I know anywhere. I don’t get Xanax for
what I do, so I don’t see why you should.”

This is met with surprised silence, usually. Sometimes unsurprised silence.

In nearly thirty years of practice, I have not yet found a more effective way to stop people
from starting on Xanax.

No, I was not always this clever, nor did I always feel this way. Back when I was training
to be a psychiatrist, there were several lovely publications that said if someone came in
with panic disorder, the correct thing to do was to start them on Xanax. This would be a
temporary measure until another medication kicked in to diminish the frequency and
intensity of Xanax. The fashion was to use a Selective Serotonin Uptake Inhibitor, or
SSRI, Prozac, Zoloft, Paxil.

I never saw any of the patients I saw during my residency get off the Xanax. Period.
None. It was always just a little more or some other drug in the class or some begging
with big moon eyes and valid descriptions of the sort of anxiety that would get them the
prescription.

Sure, there were a few stalwart souls, as I started seeing more and more patients, who did
get off the Xanax by the end of the prescription, Even some who, after I told them about
dangers of addiction, seizure, and death, who kept the bottle around and took one or two
and then stopped. Many who refused it and never filled the prescription. A few, who I
think were particularly wonderful, filled the prescription, stared at the bottle, and never
took one, because the very idea of getting involved with such a potentially addictive drug
gave them a panic attack.

Most patients I know who have panic disorder have learned to handle it one way or
another, or it has disappeared. Although I am in no way diminishing how devastating this
disorder can be for a patient, I know this is usually a self-limiting, or it-ends-by itself
disorder, that often has something to do with specific stressors, and usually comes in
“spells” of several months that end just as suddenly as when they start.

Most of the patients who ask me for Xanax do not fit the criteria for panic disorder. They
have ill-defined anxiety that can be treated in a ton of other ways. Even those who cling
to the idea that mainstream drugs are a solution for problems some of the rest of us
consider real life can go in other directions, like antidepressants in many cases.
So when our intrepid investigators at CNN tell us that a document from 2004 revealed the
late Michael Jackson needed more than ten Xanax to sleep, and it is alleged other people
got him Xanax under their names, this is not what life is supposed to be like.

First, they do not say the strength of the Xanax. Most people with panic disorder get
0.25mg. or 0.50mg. a couple times daily, maximum. Strongest pill available is 2mg.,
which people are supposed to break up in little bits. No source known to me, certainly
none of the package inserts or official FDA stuff, has recommended over 4mg. daily.

Second, every publication about Xanax even by its proponents says it is for short term
use only. As far as I know, the studies that led to FDA approval in the first place were
short term studies. The most popular of the internet sources, Rx list, like all the others,
tells about tolerance, meaning you-need-more-to-do-the-same-thing. All medicines in
this class can have a lovely anticonvulsant effect. But that means, in this class, that
stopping them when someone is taking a high dose can mean seizure and maybe death.

Only once in my life do I remember seeing a woman on 4mg. daily. It had been obtained
from a doctor who had a justified reputation for giving people whatever they wanted. He
was out of practice, which explained my presence as a temporary fill-in doc in that rural
clinic.

This woman told me she had trouble staying awake enough to drive her car, even though
she had miraculously driven to the clinic. She said she couldn’t remember her last panic
attack, slept an awful lot (she could not tell me how much) and it was not clear that she
needed the dose she was on for any particular symptom. I was so scared for her safety I
got a relative to come over and drive her car home. Of course, that entailed being driven
by another relative (too far for a taxi in a rural setting). But we finally got her home.
With treatment, I slowly but surely got her off the stuff, woke her up, and got a therapist
to help her with her “anxiety,” which largely meant how to deal with her family. Last I
heard she was fine.

Back to Xanax. Without going into technical stuff, let’s just say that the way this group
of drugs, benzodiazepines, acts on the brain is an awful lot like the way alcohol acts on
the brain. This means that you can get withdrawals and seizures and death. Ever hear of
DTs, which means “delirium tremens,” or “shaking confusion?” Sounds pretty much the
same to me.

This class of drugs is not even a really good sleeping pill. Habituating nature is well
known, for one thing. But both alcohol and benzodiazepines seem to diminish if not
totally block REM or Rapid Eye Movement sleep. This is the part where you dream, that
takes up a lot of time in the sleep of babies but less as you age, and that seems somehow
connected to health and well-being. Well, if you ever drank until you were out cold and
suddenly woke up somewhere around 3 a.m. wondering why you are awake; you
probably did a very good job of blocking your REM sleep. You can generally catch up
the next night or so.
Michael Jackson allegedly took ten or so of these pills, of an undisclosed strength, to
sleep nightly. Presumably, this was a couple years ago, before he required general
anesthesia. Is there anyone who thinks this is not a problem?

I am not going to say that this whole class of drugs should be removed from the list of
drugs available in America. I have vivid memories of a respected university in a
downtown American city, where far above the other buildings the hospital where I
worked there was tower. There was a job, a lifesaving job, performed more by
permanently employed nurses who were trusted far more than us young docs in training.
People who had serious alcohol problems and risked withdrawal and death had skilled
attendants, at least one to a patient, occasionally me. Judicious intravenous “push” of
benzodiazepines kept these folks from seizing and kept them alive.

Xanax is the most addictive drug in this class, because it stays in the body for the shortest
period of time. Peaks fast in the blood, gets out of the blood fast. The getting out fast
sure feels like anxiety. Anxious people rarely stop to analyze their feelings, so this
feeling of anxiety is easily treated with another Xanax.

As for “getting off” Xanax, I now have the type of practice where people come to me for
this and most do very nicely. The mainstream medicine idea is to slowly change to a
drug that lasts a bit longer in the body and then diminish that dose.

I believe the best way to do this usually incorporates some of the ideas promoted by Dr.
Heather Ashton, who is the experienced clinician who is behind benzodiazepines.org,
having run the downtown London (England) clinic to get people off benzodiazepines for
many years.

I also feel very strongly the ONLY way to do things safely is to work one-on-one, face to
face with a doctor. There are LOTS of drug-drug interactions, lots of personal
differences in what people can “handle.”

Personally, I use as adjuncts a number of natural substances — amino acids and such —
that help people deal with anxiety and withdrawal. The specific needs are different for
every patient. They are no more one-size-fits-all than any other aspect of medical
treatment for anything.

There is another aspect of benzodiazepine addiction nobody discusses. The problem is

not just getting off benzodiazepines. It is learning to deal with whatever got a person on
them in the first place. Repeat problems are easily accepted in this field; too easily.
Helping someone stay off an addictive drug can require drugs or natural treatments,
psychotherapy, all kinds of creative techniques. But if it is not dealt with, getting off any
drug, especially benzodiazepines can have a multiplication of nightmares. Inpatient
treatment is still available, rarely sought or paid for by insurance. I try to refer
appropriate patients for it when I can, since I do not do it myself.
Addiction is a brain illness. Blaming, moralistic judgements are common in this field but
have no place whatsoever. They may prolong denial, hiding, all sorts of behaviors that do
not help the situation. We need to treat people who need treatment. If Michael Jackson
was doing this, he needed treatment. If he had less money, less power, he may have been
easier to give access to treatment. But none of us knows the drama that went on behind
closed doors, and nobody has the right to blame. If this is true, he needed treatment for
the illness of addiction as surely as some other patient would need treatment for a cancer,
or for a severe life-threatening infection.

As with all journeys, the first step is the toughest.