Why I hate Xanax

A lot of people like Xanax. It’s given out like candy. People get it from their friends, from their primary care doctors, even from their psychiatrist. I hate it. I might go so far as to say it’s evil, though really it’s just bringing out the worst aspects of our nature. In my professional opinion, it’s bad for you.

But no one wants to hear that.

Yes, it feels good when you take it. People take it for anxiety. They feel less anxious (usually) after taking it. Must be working, logic would dictate. Unfortunately this is short-sighted, in the same way that we as a collective society (and medical establishment) view pain as something to annihilate.

Xanax makes you feel good. It brings on euphoria. Heroin feels pretty good too. Feeling good from it doesn’t mean it’s good for you. In fact it is this hedonistic approach of minimizing anything uncomfortable [painful] and maximizing pleasure that leads to more problems with both pain and anxiety. I’ll discuss pain in another post, particularly the overtreatment of pain as a phenomenon which is leading to a significant number of deaths from prescription pain pill abuse and misuse. Here Xanax needs to be addressed.

“My doctor prescribed it for me, so it must be safe.”

“The FDA approved it, so it must be safe.”

In truth nothing is absolutely safe. Water will kill you if you drink enough of it. Seriously. Every medication has its potential benefits and potential drawbacks. You are not guaranteed to get either the benefits or the drawbacks. It’s really a numbers game. Do the benefits outweigh the risks? In Xanax we both overestimate the benefits and underestimate the risks. And those that prescribe it like candy have a fundamental misunderstanding of how anxiety works, in my opinion.

Over and over again I hear –
“But you have to give me Xanax. It’s the only thing that works for my Anxiety.”

Really it doesn’t. It’s giving you the illusion that it’s helping, because it seems to give temporary relief. And it does. It works really fast. It gets into your system quickly, and feels really good really fast.

And then it’s gone.

The anxiety returns. Even worse, there may be withdrawal anxiety as the medication comes out of your system, bringing up all the feelings that your body and mind are out of control. So you turn to the same thing that seemed to help, even if temporarily: more Xanax. As you take it on a regular basis, possibly with increasing amounts, your body becomes tolerant to it. Tolerant means the same amount doesn’t have the effect it used to have. So again you need more of it. If you start to worry about the possibility of anxiety (anticipatory anxiety), you can then make yourself more anxious. Then you’d need a Xanax just to prevent the possibility of something bad happening.

I wish this was a fanciful diatribe with no grounding in reality. I’ve seen hundreds of these patients in my relatively brief career, caught in exactly this cycle.

The basics
Xanax is a benzodiazepine (aka benzo). It’s a tranquilizer. The same drug “family” includes clonazepam (klonopin), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium), and others. Xanax is notorious because it has such a short half-life, meaning it lasts in your system a brief amount of time. Surely the longer acting tranquilizers must be the better approach? Perhaps. Some people do function on benzo’s. That isn’t really in debate. The question is whether they function better with them than without them, in the long-term, and if there isn’t a safer alternative. In my opinion, they’re a third or fourth line approach, at best.

Anxiety is uncomfortable, and people in our culture don’t want to be uncomfortable. At all. Ever. So logic would dictate we should try to annihilate it. If something helps a little, use it a lot.

This is the rationale that actually leads to anxiety becoming an unremitting problem. Trying to keep it in check, to hide from it, or to hold it at bay, all feeds the problem. Fear is the problem. Psychotherapy figured out the truth: the way to lessen anxiety is to face it, not avoid it.

I had a patient once who had panic attacks. I think of panic attacks as the worst kind of anxiety, so severe it can feel like a heart attack or like you’re dying. He grew up on the streets (homeless for much of his life), coming from a tough childhood. He never had anyone he could trust. He got over his panic attacks without medication, and even without therapy. He had tried Xanax and other meds, and was on the slippery slope of trying to manage the anticipation of anxiety by using more and more benzo’s.  He would think about how bad anxiety could get, and would get anxious about that, and so would end up taking benzo’s just to prevent possible anxiety.  He was getting more and more addicted.

Then one day he got fed up. He was having a panic attack, and felt the fear of dying.

He shouted at himself, while beating his chest, “just fucking do it! Just fucking die already.”

He welcomed the worst possible consequence. And immediately the panic attack went away. The fear fed the panic. When he stopped fearing it, it deflated. It was still uncomfortable, but it didn’t build up the same way. He cured himself.  He doesn’t have panic attacks anymore.

If you want a medication for anxiety, look at the whole picture.

“I only want to take something as needed.” Your anxiety is all day, though. You have brief periods of it getting worse, but the rest of the time there’s some anxiety. So really you need something that works all day. You’re falling into the fear of chemicals while still wanting some chemicals. The issue is that the ones you’re asking for perpetuate or worsen the problem, rather than improve it. It’s a lot harder to treat anxiety in someone already addicted to benzodiazepines than someone not. Thus the slippery slope of good intentions and short-term outcomes.  And I believe medical providers with our good intentions cause more iatrogenic problems with this than we do help people.

The other risks
Unlike other medications for anxiety, the risks with benzodiazepines are much higher. Primarily the risks are seizures and death. If you take too much, you could get oversedated and die. If you mix it with anything that makes you sleepy (or pain medications), you could get oversedated and die. Withdrawing off of benzodiazepines can bring about increased anxiety, but more importantly the risk of seizures. Alternative medications like SSRI’s while not perfect, have far fewer risks to them, and are thus a much safer choice.

–postscript.  Yes, I float between the 1st/2nd/3rd person.