When does DEPENDENCY begin?

[Politicalchalk]

Just a quick note on swim's cat's history: buperenorphine 16mg (suboxone), 2mgs lorazepam x3/day, not to mention lithium, depakote, and hydroxyzine.
Swim is prescribed the lorazepam for tourette's, as well as tremors and spasms, etc.

Initial therapy began in November w/ clonazepam, 1.5mg a day. After not tolerating, was switch to Ativan, and climbed to current dose. Now, SWIM's cat notices withdrawl effects beginning if the bupe isn't taken until middle of the day. But lately, the cat's been complaining of gettin' the sweats, one of it's known symptoms, but while taking the bupe first thing in the morning.

Could it be that SWIM's cat could be becoming dependant on the lorazepam? She's not hunting it per se, and seems like she has become aware of, if not tolerant to, the effects of the benzodiazepine.

Note: Suboxone brand buprenorphine is a sublingual formulation, high-dose, indicated for opiate dependency.

[moda00]

Hmm, it's possible, but since lorazepam is a short acting benzo, and if it is being taken three times throughout the day (obviously not while sleeping) swim thinks if this were causing it, it would more likely manifest either during the night (causing waking/night sweats as the benzos wore off) or equally in the afternoon and evening if there are equal time intervals between the doses? edit: Ohh are you saying the symptoms are felt in the morning, after going all night without a dose? Or after having already taken one's first dose of the day? I think swim may have misunderstood what swiyou were saying.

In the case of tolerance, this is certainly a possibility, but swim thinks that tolerance symptoms would be more likely to result in increased anxiety or agitation/decreased response to therapeutic effects on Tourette's and the spasms before it would result in actual withdrawal.. but she is unsure. Has one noticed return of any symptoms either during the day or at the times one gets the sweats? What time frames is one taking the buprenorphine and the lorazepam throughout the day, and is it the same times and intervals each day? Perhaps chart the dosing times and see if one notices a pattern and whether this could be caused by either of the drugs' timing or tolerance/withdrawal?

edit: see above.. if one is feeling withdrawals upon waking it could be likely it is the lorazepam, as it is a short acting benzo, taken three times throughout the day and then obviously none at night.. I don't know much about how benzo addiction works in terms of short vs. long acting, but will see if I can find some more info. I do know that shorter acting benzos are often considered more addictive, and I suppose it makes sense that if one is having to re-dose on a shorter acting benzo it would be less stabilizing than being on a longer acting benzo in terms of blood concentrations and whatnot peaking and leveling out over time.. but I do advise noting the time frame in a journal of sorts and observing any patterns to conclusively determine what may be causing this.

[Politicalchalk]

SWIM's cat has a whole world of troubles, and lives in Bipolar land. In Bipolar land, sometimes you stay up just because...hence, lorazepam 2mg, maximum 3 tablets a day. Unfortunately no night time dose has been prescribed, so if the cat wakes up at dawn, it will likely exceed the 3-a-day-limit. One supposes a dose could be saved for the evening, or halved, or whathaveyou. The doctor advised SWIM's cat to take it every day, because it's so manic and comes off like a light-hearted leopard lately. Manic manic manic. All the time, so much energy.

SWIM's cat doesn't like to admit it, but if the "sleep desperation" kicks in enough, sometimes the cat will sedate themselves to sleep with other depressants, like sedating antihistamines, muscle relaxants, etc.

So, initially the benzo was prescribed because A)SWIM's cat can't take anti-psychotics, typical or atypical B) tourette's manifestations, and the bonus part was C) helping control the mania. The cat has been on a benzo since about December.

Now, to address to Buprenorphine. The cat's been on that for about a year, even wants to titrate down because the taste is like moldy, chemical oranges. Anyways, it is consumed anywhere from when the cat first gets up, to half-way through the day. Some days the cat technically doesn't need a dose, per se: half-life 72 hrs, as well as a ceiling effect at 32mg. So, once a stable blood level is in place, one might "forget" to take it and not even notice until the next day! It's happened, or at least the cat's had days when he doesn't request his daily dose of bupe. Not to mention in can take up to (sometimes) 45 min! Usually about 30 for the cat. Sorry for

I will try charting it out like you suggest, however, in bipolar land, time doesn't move in the same direction, making it difficult to keep the timing right. But what gets SWIM is it shouldn't matter! The blood levels are about as high as they'll get (16mg, every day, for a year).

It's almost like on certain days, the bupe just doesn't do it for SWIM's cat. Anyone else's cat have a similar dilemma?

Fun Fact: When we get the cats neutered/spayed with the animal rescue my family does, they send us home with 2 syringes, no needle, with Buprenorphine. Funny, eh?

[doublezero]

swim would take 4mg of subs as soon as waking and the 12mg lft at the normal time, might stop the sweats

[staples]

Originally Posted by buffalogreen

Could it be that SWIM's cat could be becoming dependant on the lorazepam?

How long has this cat been taking lorazepam?

Originally Posted by moda00

Hmm, it's possible, but since lorazepam is a short acting benzo

? I thought lorazepam was a relatively longer-lasting, slow-acting benzo. Clonazepam should've acted faster.. or are there a subset of benzos that are even longer-lasting?

[moda00]

Originally Posted by staples

How long has this cat been taking lorazepam?

? I thought lorazepam was a relatively longer-lasting, slow-acting benzo. Clonazepam should've acted faster.. or are there a subset of benzos that are even longer-lasting?

No, to the best of my knowledge clonazepam would have been one of the longest half-life benzos. This is a common misconception. I believe lorazepam is a short to medium acting benzo, a bit longer than triazolam (really short) and alprazolam (short) but I couldn't quote the hours or anything.. I will look it up and get back to you this is an important issue for determining how dosing of a drug could lead to dependence, tolerance, and/or withdrawals.

Originally Posted by buffalogreen

SWIM's cat has a whole world of troubles, and lives in Bipolar land. In Bipolar land, sometimes you stay up just because...hence, lorazepam 2mg, maximum 3 tablets a day. Unfortunately no night time dose has been prescribed, so if the cat wakes up at dawn, it will likely exceed the 3-a-day-limit. One supposes a dose could be saved for the evening, or halved, or whathaveyou. The doctor advised SWIM's cat to take it every day, because it's so manic and comes off like a light-hearted leopard lately. Manic manic manic. All the time, so much energy.

SWIM's cat doesn't like to admit it, but if the "sleep desperation" kicks in enough, sometimes the cat will sedate themselves to sleep with other depressants, like sedating antihistamines, muscle relaxants, etc.

So, initially the benzo was prescribed because A)SWIM's cat can't take anti-psychotics, typical or atypical B) tourette's manifestations, and the bonus part was C) helping control the mania. The cat has been on a benzo since about December.

Now, to address to Buprenorphine. The cat's been on that for about a year, even wants to titrate down because the taste is like moldy, chemical oranges. Anyways, it is consumed anywhere from when the cat first gets up, to half-way through the day. Some days the cat technically doesn't need a dose, per se: half-life 72 hrs, as well as a ceiling effect at 32mg. So, once a stable blood level is in place, one might "forget" to take it and not even notice until the next day! It's happened, or at least the cat's had days when he doesn't request his daily dose of bupe. Not to mention in can take up to (sometimes) 45 min! Usually about 30 for the cat. Sorry for

I will try charting it out like you suggest, however, in bipolar land, time doesn't move in the same direction, making it difficult to keep the timing right. But what gets SWIM is it shouldn't matter! The blood levels are about as high as they'll get (16mg, every day, for a year).

It's almost like on certain days, the bupe just doesn't do it for SWIM's cat. Anyone else's cat have a similar dilemma?

Fun Fact: When we get the cats neutered/spayed with the animal rescue my family does, they send us home with 2 syringes, no needle, with Buprenorphine. Funny, eh?

Yes, charting it seems the best idea.. swim has had a sleep disorder and found the only way she could possibly figure out what was going on in her body was to chart it, because she was so groggy or literally asleep all the time and couldn't remember what to tell the doctors except I am too tired and I can't function- well they want to know how many hours you are sleeping in a row, how the pattern works, etc. I mean they do polysomnograms to figure that all out, but to give them a starting point in that case they needed some starting point. Swim's been on buprenorphine and methadone and has found it to work quite similarly, and the docs usually seem quite willing to work with one if you can give them some sort of starting point. But it is understandable about the bipolar, just do what youcan, and even if you don't have a record you do know what is going on in your body and it is worthwhile to bring it up with the prescribing doctor and ask for their input and ways to attempt to address the issue.

Now, I know suboxone does have a very long half-life, so it is not something one would need or want to take at four hour intervals, but when swim was on it she did find that the way she metabolized it, it wasn't holding her until the night. She eventually wound up taking 12mg every 12 hours- she had the same issues with methadone, blood tests (peak/trough- unsure if they could do the same with bupe?) showed the same, and she was also is required to take that at 12 hour intervals, as some people do, rather than the standard 24 hours. Now, it seems with the issues that you are dealing with, it could be more of a hassle to try and take it twice a day, but perhaps that would make a difference? Is there someone who could help you remember, an alarm maybe? I know taking pills can be a pain- I don't have bipolar disorder but I still fuck up trying to take meds, so I can imagine how difficult it can be, especially when you don't start feeling withdrawal right away due to long half-life.. sometimes swim doesn't remember to take her second dose of methadone until she wakes up in the middle of the night with the sweats.. ugh. But she's getting better about it, so it's worth considering if one thinks it could be feasible.

Another option could be a dose increase. I know it is a strong drug for those without opioid tolerance,and 16mg is a decent dose, but everyone has their own "sweet spot" where things are just right, no ill effects and all withdrawals abated. Perhaps a solution could bo a dose increase? With something like buprenorphine, even a small increase can make a big difference, and since it has a lower potential for tolerance and overdose, and a ceiling on effects, I don't think it would be considered harmful to go up and see if that helps, but certainly consult with your doctor (swim was on from 8-24mg when she tried it, she thinks the cieling for dosing is at arounf 32-40mg, and if that doesn't help there is usually not much more the bupe can do, but if this is indeed related to the bupe, which is sounds like could be, I think splitting the dose and/or small increases until one finds the right spot, are good options.

As for the lorazepam, I think it seems much more likely that this is opioid related, given the dosing schedule and symptoms you describe, and it sounds like the pros definitely outweigh the cons at this point as other meds haven't worked- good luck and hope things smooth out with the manic episodes.

And that is hilarious about the kitties! I did notice when we got my cat spayed that that the medication sheet listed buprenorphine as part of the induction but we certainly weren't given any of it

[staples]

Originally Posted by moda00

No, to the best of my knowledge clonazepam would have been one of the longest half-life benzos. This is a common misconception. I believe lorazepam is a short to medium acting benzo, a bit longer than triazolam (really short) and alprazolam (short) but I couldn't quote the hours or anything.. I will look it up and get back to you this is an important issue for determining how dosing of a drug could lead to dependence, tolerance, and/or withdrawals.

Ah, I found where I was confused: Although clonazepam has a much higher half-life than lorazepam, it reaches peak concentration faster.

As for tolerance and dependence, both of these are developed with habitual doses for almost anything, this is where it becomes important not to take more than prescribed, because staying at a prescribed dosage each day lets tolerance and dependence only develop to a certain extent. Also, one medication can sometimes interfere with how you build a tolerance to another.

[0utrider]

swim would be interested in swiy opinion about how long benzo w/d lasts. he knows someone who took some for a few weeks, didnt have physical w/d symptoms, well, not really, except for "different" sleep but he feels quite without energy for a few days now, when will that stop? he has no other history with them except for this (or atleast with benzo abuse). the poor guy just took about 40mg in 3-4 weeks, more or less 1-2 daily

[sarbanes]

Isn't there a widely held beliefe among physicians that many potentially addictive drugs (which otherwise induce tolerance / their own metabolism), barbs, benzos, etc., at certain low dose, will not induce tolerance and addiction even if taken every day? That you need some threshold dose to have this effect. In other words, you can take a low (theraputic) dose of diazepam every night (5mg) indefinately, and still not have appreciable tolerance? Seems I read this in Merck Manual.

[moda00]

Isn't there a widely held beliefe among physicians that many potentially addictive drugs (which otherwise induce tolerance / their own metabolism), barbs, benzos, etc., at certain low dose, will not induce tolerance and addiction even if taken every day? That you need some threshold dose to have this effect. In other words, you can take a low (theraputic) dose of diazepam every night (5mg) indefinately, and still not have appreciable tolerance? Seems I read this in Merck Manual.

I think it does make sense that daily dosing does not necessarily mean dependence, tolerance, and/or withdrawal will arise, but it likely depends as you say on the dose of the particular drug as well as the properties of the drug and the timing of it's half-life and dose. For example, with GHB, taking two large doses for sleep (at bedtime and again four hours later, so two doses in eight hours and then 16 hours without) daily for years at a time doesn't cause withdrawal upon stopping (in Xyrem trials) BUT if someone is dosing every 2-4 hours around the clock withdrawal can develop. So I think while the dose amount is related, it's also the timing. Ie. if the dose is 9 g in a 24 hour period of GHB, taken in two 4.5 g doses for sleep (note: these are doses for individuals with narcolepsy, NOT usual recreational doses) it doesn't seem to produce a dependence, BUT if that 9 g is taken in half gram to gram amounts throughout the day it can produce dependence fairly easily. While GHB is obviously not a benzo, they are both related to GABA, and I think the concept applies to many substances. So since most drugs are (obviously) not taken when sleeping, perhaps the body has enough time without the drug each night to prevent ongoing dependence to shorter lasting benzos? This is just speculation, however. And I think the issue of tolerance itself is still a potential issue no matter how the dosing is done, if it is a potentially addictive substance and is being taken daily, and even if there were to be a dosing cutoff the premise is generally to use the lowest possible dose that successfully and fully treats the condition and has the desired results.. But would be interested in hearing more, as it is an interesting concept.. perhaps not applicable to the longer lasting buprenorphine maintenance if that is what is causing the OP's symptoms, but important to know regarding daily use of benzodiazepine drugs and others..

[Politicalchalk]

The 2mg tablets taken three times a day are around the clock, ie: not PRN ("as needed").

SWIM agrees with Moda00 above, among the many factors, timing is very important. The chemicals actually alter brain chemistry over time, getting used to having what it assumes is just another neurotrasmitter/modulator to deal with. So, if one's brain has enough time to "catch up" (like a neural hangover), it decreases the chances that it's chemistry gets too altered and can return to a normal state of function. However, if one keeps throwing these foreign neuropathic signals (by chemical induction), the brain will have to adapt, as that's what it does (in most cases).

It's like that episode of King of the Hill, where Hank starts fishing with crack, and is quite successful...at first. Incidentally, Hank gets busted when trying to buy more crack, but gets busted. An unusual judge hears Hank's plea of "I thought it was fishing bait," and being a fisherman himself, offers to go fishing with Hank. If he catches a fish with crack, no jail. Upon arrival, however, the fish don't bite. The drug dealer had sold Hank "stronger" crack, to attract the fish; this proves useless. The fish don't bite. They end up catching a very small fish with a worm.

[moda00]

^^I see staples, that makes sense. Thanks for clarifying that

How are things going with you buffalogreen? Any more insight on the symptoms? Let us know how things are going, and if you are able to find any distinct pattern in them or discuss options with one's doc!

[Politicalchalk]

Recently, Swim spoke to the neurologist, or at least his receptionist. Swim asked if there was anything he could do (in terms of exercise, physical therapy, etc) to help keep his hands steady. First year in college is coming, and Swim couldn't even finish writing out the bank slip the other day. He hears back from the receptionist, saying that Doc said to "Cut back on the lorazepam! You need to use less, and he reffered you to your prescribing doctor. He will not prescribe it for you." And he wasn't even looking for a prescription! He just wants to be able to take notes in class, something he hasn't had to do for 5 years or so...

Swim was quite saddened to hear that the doctor has him pegged out as nothing but a drug-seeking addict who exaggerates his symptoms in order to get the drugs he wants. Now, one acknowledges that one thought some time ago that benzos may be quite useful, and they are. Swim continues to use Lorazepam, but the specific type of tremor is caused by one, if not both of the following: Swim is a chronic lithium user, and depakote was added a few months ago after a scary psychotic episode (which, turned out to be too much lithium accumulating in the body). The other is there's a lesion on my brain. Swim hopes for the former.

All things considered, things are well. After taking a 2 or 3 week holiday, he believes the lorazepam to be helping. Swim can't take a holiday from the buprenorphine for obvious reasons.

it is amazing how leery doctors are about controlled substances. Swim's dose is relatively high, 2mg 3 times a day (all the time, not "as needed") -- in lowering the lithium, he's going ape-shit manic (sorry for the language) all the time. Sometimes the only real sleep he gets is by knocking himself out with Ambien CR (zolpidem tartrate-controlled release which, surprise surprise, is rapidly metabolized into zolpidem!), another difficult thing to obtain. Swim doesn't use it often at all, but more as a last resort, esp. if there's a lot to do the next day. Could it be that Swim HAS sleep problems often associated with Bipolar disorder???? Of course not! He's just an addict trying to get drugs! Did he REALLY have dystonic reactions to every anti-psychotic he's ever been on? Couldn't have been! He's just an addict....

[roseenglish]

Doctors "now" wont or shouldnt prescribe any benzo for more than 4 weeks.
Thats the best indictor.
Sadly that didnt hit my doctors morning post until 2 yrs after he put me on a repeat prescription for diazepam and zolpidem for Despression ( of all things! talk about out of the frying pan into the fire )

[drug-bot]

just throwing this out there for moda00-

Benzodiazepine Comparative


camparitive dose time to peak plasma level half life
------------------------------------------------------------------------------------

Alprazolam .5 1 - 2 9 - 20
Bromazepam 3.0 .5 - 4 8 - 30
Chlordiazepoxide 25 1 - 4 24 - 100
Clonazepam .25 1 - 4 19 - 60
Clorazepate 10 variable 1.3 - 1* (unreliableabsorption)
Diazepam 5 1 - 2 30 - 200 *
Estazolam 1 .5 - .6 8 - 24
Flurazepam 15 .5 - 1 40 - 250 *
Halazepam 40 1 - 3 30 - 96 *
Ketazolam 7.5 3.2 30 - 200
Lorazepam 1 2 -4 8 - 24
Nitrazepam 2.5 .5 - 7 15 - 48
Oxazepam 15 2 - 3 3 - 25
Prazepam 10 2.5 - 6 30 - 100
Quazepam 7.5 1.5 39 - 120 *
Temazepam 10 2.5 3 - 25
Triazolam .25 1 - 2 1.5 - 5

* metabolites

from a bulletin board site
the copy and paste fucked up the chart, it can still be figured out, but just going to the link will be make it much easier to understand.




wikipedia says the half life of lorazepam is 9-16 hours, while dr. bobs site says its half-life is 8-24 hours, either way its a short to medium lasting benzo.

hope swim helped some, sorry dr. bob's chart got all fucked, he tried to make it easier to read manually but when he saved it, it went right back to the way it was, when swim pasted it, its out of his control.