"Ask your doctor if this medication is right for you."

Is that statement in TV ads driving you crazy too? I especially love it when they mention a bizarre sounding medicine’s name but they don’t tell you what it’s for. They just say, "ask your doctor if it is right for you." If they tell you what it is for the FDA requires that they tell you its main side effects. I love it when they use an old technique taught to lawyers: if you have to concede a point that is not in your favor do it in a tone of voice as though it was in your favor, or is no big deal. So, they will add nonchalantly that it may cause cancer, heart attacks, strokes, seizures, sexual dysfunction, etc. They will then reiterate how much better your life will be while showing a happy couple skipping off to fun and frolic.

Another thing I love is that they tell you not to mix it with other drugs like MAO inhibitors or Thioridazine, (meds that almost NO ONE takes), or tell you not to mix it with generics of the same thing, or not to take if you are allergic to it. All of this is reverse psychology - it seems to be providing fair balance but it’s mostly irrelevant.

I won’t make the obvious criticisms of the FDA - they have already taken enough heat lately, and their credibility is finally being challenged in various arenas.

What about pharmaceutical companies? They are also taking a lot of heat. They are being criticized for spending more money on marketing than on research. But this is America. Every private enterprise has profit as its goal and without profit they go out of business. Also, in their defense, pharmaceutical companies not only bring us new and better medications, they also play a huge role in educating doctors and the public about the nature of illnesses, dysfunction, and the role of various treatments in health and quality of life.

There’s a lot of criticism about the increasing use of prescription and over-the-counter medications. "Prescription nation" and "Parenting with Pills", are just two examples. The underlying message is that if you would eat right, exercise enough, and have a positive attitude you wouldn’t need medications. To a certain extent this is true. There is no doubt that stress related disorders such as anxiety, depression, hypertension, etc., are becoming more common, starting at an earlier age, and more severe. Everyone of us could do better stress management and have a healthier life style, but STRESS appears to be here to stay for a while. We can be thankful that we have a lot of tools available to help us deal with stress. Some of these tools are medications.

I am adding five permanent sections to my web site on medication. They will be regularly updated as we get new information. I consider these sections some of the most valuable information on my website.

Medication: Why Meds?

Medication: Best Meds

Medication: How to Take

Medication: Side Effects

Medication: How They Work

I have been prescribing medication since 1966. It is as much an art as it is science. When starting someone on a medication, I tell them, “I am not looking for you to say”, “doctor I think it is helping some.” What I’m looking for is “this medication is great! It has made my life better and it’s not causing any significant side effects.” Surprisingly, this is a fairly common response after a week or month or two. The harder challenge and the main goal I have is for a patient to be still saying that in 6 months, 1 year, 2 years or as long as needed. This is a much tougher test and only a few medications consistently live up to that standard. For most medications it is at best a trade off-some definite benefits but also annoying side effects.

The main factor that I use in ranking medications is my clinical experience. Everyone of my patients becomes a teacher-how does this medication help, what side effects does it have, how much difference does it make in their life, do their loved ones agree that they are doing as well as they think they are? I’m not just interested in how they feel overall, but even more importantly, how do they FUNCTION?
Many doctors get skewed feedback because the patients that don’t like the treatment just don’t come back. The ones that come back feel like the treatment is helping and so the perception is this is a good treatment. Managed care especially likes the patient that doesn’t come back. This is counted as a “one treatment cure”.

So what medications have the best batting average? This translates to what are the odds that I’m going to think this medication is great-both short term and long term?

The best medications consistently work great, have minimal side effects, and work as long as they are needed-which may mean indefinitely. I am especially biased because I don’t participate in any managed care programs. I have to get good results to keep my practice going.

Click here to see how Dr. Jones determines “Best Meds”
Sleep medications should only be used when good sleep habits don’t work. (See Sleep Do’s and Dont’s Handout) Because almost everybody has at least occasional sleep problems due to acute stress, early flights, late meetings, jet lag, shift work, etc., and because not sleeping well even one night has potentially adverse effects on functioning and or health, having a sleeping pill available when needed can be very helpful.
The problem with OTC sleep medications like Tylenol PM is they don’t provide a normal night’s sleep and really haven’t been shown to have no carry over affects the next day. All OTC sleep medications are antihistamines.
Many people use alcohol to sleep. This is actually a horrible idea because although alcohol may help you fall asleep, it wears off in 2-3 hours and disrupts the quality of sleep in the middle of the night. Alcohol should not be consumed in the 2-3 hours before bedtime.
Benzodiazepines are frequently used for sleep, including Xanax, Klonopin, Ativan, Valium, Dalmane, Restoril and others. They help you fall asleep but they decrease deep Stage 4 sleep-the most important type of sleep we get. (See Sleep Newsletter)
Trazodone, Seroquel and Zyprexa are sometimes used for sleep, but they haven’t been adequately studied for sleep and probably don’t provide completely normal sleep. Clonodine increases Stage 4 sleep, but affects on dream sleep (REM) aren’t clear. Tricyclics like Amitriptyline, Nortriptyline, Doxepin, and Imipramine are sometimes used-they increase Stage 4 sleep but decrease dream sleep (REM).
So, we are left with a few good choices. Neurontin appears to provide normal sleep. It also helps anxiety and certain kinds of pain but it may cause weight gain or sexual dysfunction so it’s not usually a first choice. Gabatril increases stage 4 sleep without interfering with REM sleep. In one study in elderly people, Gabatril doubled stage 4 sleep. It also helps anxiety but it’s not very sedating. It is not used first line, especially on an as needed basis.
So, now we are down to the best medications. They provide normal sleep. At the proper dose they don’t cause any next day drowsiness or impairment. You get a reliable good night’s sleep and you feel rested the next day. As of January 2005, we have 3 choices.
Sonata-This is the mildest option. It is usually taken as a 10mg capsule. Some people require 2 capsules. It is completely out of the system in 5 hours. This is sometimes an advantage because it can be taken during the night as long as you have 4 hours before you need to be up and alert. But for many people it is not strong enough, or they wake up too early, sometimes after 3-4 hours and don’t like having to repeat it during the night. Many people like it. At one capsule there is usually no impairment in thinking or functioning if there’s an emergency during the night. It is extremely unlikely that you will not remember the next morning if anything did happen during the night.
Ambien-This has been around for about 10 years and is the number 1 selling sleeping pill. It comes in a 10 mg tablet that is about 21/2 times stronger than Sonata. Because the tablets can be easily broken in half (which is still slightly stronger than Sonata 10mg) the 10mg tablet is more cost effective. It is more likely to keep you asleep for 61/2 hours or more-but some people wake up after 5-51/2 hours. Some people complain of having grogginess the next morning. It is an excellent medication and in my practice it’s about equally popular to Sonata.

Ambien CR-New on the market, this form of Ambien comes in 12.5mg and lasts longer than regular Ambien. It has a duel release (7.5mg immediately, and 5mg delayed) It also does not have short term restrictions so insurance should be easier.
Lunesta-This is the newest sleep medication to be approved in the U.S. It will be available in January 2005. It is actually an improved form of the most popular sleep medicine available in Europe for the past 15 years. The dose forms have been carefully chosen to optimize effectiveness while minimizing risk for next day drowsiness. Lunesta is the first sleeping pill to be approved in the U.S. not just for helping you get to sleep, but maintaining sleep. Sonata is just approved for helping you get to sleep. Ambien is approved for help in getting to sleep and increasing sleep duration (on average 61/2 hours). Lunesta helps you get to sleep and reduces time awake during the night by an average of 50%. At 3mg it increases total sleep time to 7-8 hours per night for 70% of people with chronic insomnia. This was documented with all night monitoring in a sleep lab, not just patient reporting.
Lunesta is also the first sleep medication approved in the U.S. that is not specifically restricted to 10-14 nights maximum usage. Although many physicians and patients know that Sonata and Ambien can be effective and tolerated for longer periods of time, insurance companies frequently use the time restriction in the PDR to limit coverage of the prescription supply to 2 weeks.
Lunesta has also demonstrated efficacy and tolerability in placebo controlled studies for up to 6 months and extended open studies to 1 year without loss of effectiveness or tolerability. The company studied 2,000 patients, which is encouraging. As always with a new medication, we will have to see how well it does in clinical practice. There are a few people who complain of a metallic taste in the AM but only 1-2% were bothered enough to discontinue it for that reason.
The bottom line is although Sonata and Ambien have worked well for many patients, there are still many patients they are not adequate for. We all welcome this new option, Lunesta.

Kim Bassinger was interviewed during an HBO special on Panic Disorder.  She described her recovery from Panic Disorder in an unusual but very successful way.  During her recovery period she developed a technique to change her negative thinking and attitudes.  She decided to talk to her fear.  She said, “how do you have so much power over me?”  Fear answered, “I get in your face and talk loud!”  Then she asked, “how can I defeat you?”  Fear replied, “don’t  believe a word I say!”

• In the U.S., 1.6% of adults (3 million) will have Panic Disorder in their lifetime.
• First degree relatives of those with PD are 17x more likely to have PD than the general population
• 30% of people with PD abuse alcohol
• Twice as many woman as men have PD
• Most panic attacks start in the mid 20’s
• Proper treatment reduces or prevents panic attacks in 70-90% of cases
• 29-44% of those with PD also have Irritable Bowel Syndrome
• 43% of ER patients with chest pain actually have PD
• Panic patients may see an average of 10 doctors before a correct diagnosis is made
• 50% of those with PD will have clinical depression during their lifetime.
• PD is abnormal activation of the part of the brain called the amygdala

Cognitive behavioral therapy for Panic Disorder focuses on fears of bodily symptoms, catastrophic thinking, and avoidance behavior.  This is done by identifying specific ways in which the patient can reduce anxiety.

Cognitive restructuring - Identifying and countering fear of bodily sensations and focusing thoughts away from the negative consequences of such sensations.

Individuals with PD often have distortions in thinking that cause a cycle of fear.  When the person experiences physical symptoms, such as racing heart, they react with catastrophic thinking, e.g., “I’m having a heart attack”.  Cognitive restructuring helps the person to recognize thoughts and feelings and to modify their fear response to them.  By changing catastrophic thought patterns the person gains more control over the symptoms, e.g., “it’s only uneasiness and it will pass”.   

Breathing retraining - Learning how to use anxiety management techniques and lifestyle changes (see page 2) to control physiologic reactions.  

Exposure therapy - Helps the person accept and face some fear and anxiety in order to cope with phobic situations.  This is done by facing the feared situation and actually doing it.  The person must enter real world situations that cause anxiety, e.g., driving a car on the expressway. Exposure therapy requires considerable time and discipline from the patient.  Exposure exercises must be practiced routinely and monitoring must be continuous.  The patient has to be willing to confront the feared situations. It is easier to establish a hierarchy from the least to the most difficult task.  It’s ok to pause, breathe, and/or take medication, but then proceed.

Avoidance behavior makes panic disorder worse. Resist the urge to stop or avoid those things that trigger fear and/or physical symptoms

Desensitization - Occurs with persistence and practice.  This involves exposing the patient to fear cues, specific things or situations that trigger panic attacks.

Practice paced breathing

Proper breathing is very important for control of anxiety and panic.  It is also the best relaxation technique for control of nervousness and panic.  Underbreathing (slow/shallow) increases carbon dioxide retention.  This triggers the suffocation response in panic prone people, leading to compensatory overbreathing.  Conversely, overbreathing (hyperventilation) decreases carbon dioxide and causes feelings of depersonalization (feeling detached from oneself), dizziness, numbness, and confusion.

When anxious or tense, it is easier to breathe out first:

• Step one:  Slowly exhale through the open mouth making a “s h h h h” sound.  Listen to the sound, or feel muscles relax, letting go of tension.
• Step two:  Breathe in through the nose slowly, (mouth closed) and count, 1—2—3—4
• Step three:  Hold to count of  1—2—3—4    
• REPEAT STEPS

Find distractions

Focus attention on something outside yourself.  This might include listening to music, going for a walk, or calling a friend.

Use conditioned relaxation response

Make relaxation a part of daily routine.  Set aside time to practice your favorite relaxation activity.  This might be working out, playing sports, games, cards, movies, listening to music.  When relaxation is regularly practiced, the body forms a memory of what it feels like to be relaxed.  This memory is a tool you can use when you feel anxious.  Practice relaxing in anxiety provoking situations.

Panic patients listen too closely to body sensations, feel anxious, have “what if” thoughts, and scan their environment for possible danger.

Panic patients are always in a state of hypervigilance-most especially they listen to their bodies and they “hear everything”.  They can almost feel ions crossing membranes!  They release adrenaline, preparing for “fight or flight”.  The adrenaline revs them up and it snowballs-then they are having a panic attack!

• Xanax (Alprazolam)   

• Niravam (Alprazolam orally disintegrating tablets)

• Klonopin Wafers (Clonazepam)

• Ativan (Lorazepam)

A common question asked is “how much should I take?”  “Take enough, not too much.” 

This is like a firefighter calling headquarters and saying, “I have a grass fire starting here, how much water should I put on it?”   “Put out the fire.  Don’t flood the valley.”

Earl Campbell (football legend) was in his truck driving to Austin, Texas. He was stopped at a light in the small town of LaGrange. All of a sudden and for no reason he felt chest tightness, racing pulse, and shakiness. He panicked. He thought, “am I having a heart attack, dying, or going crazy”? This is a classic panic attack!

Panic attacks are physical reactions associated with an inappropriate adrenaline response in the body and excessive noradrenaline release in the brain. Though brief, they are terrifying, especially because they come on for no apparent reason or precipitating cause. Panic attacks can be thought of as a “false alarm” in the brain. There is some evidence that two types of panic attacks exist. One relates to hypersensitivity to increased CO and the other to hypersensitivity of the inner ear. Symptoms are acute and intense and vary for each individual. Agoraphobia is usually caused by panic attacks. What the agoraphobic fears is panic or panic related symptoms. He or she may begin to avoid certain situations because of panic attacks.

Although they come out of the blue, panic attacks are almost always preceded by increased stress within the recent few months. Stress includes any significant life change (good or bad), and any loss, as well as conflicts and life demands. The worst stress is associated with a feeling of being helpless to control factors that affect an individual’s life.

Stressors are cumulative and additive. Symptoms tend to occur when the amount of stress in life is greater than stress management (exercise, recreation, relaxing activities, laughter, positive relationships).

Treatment includes patient education, desensitization (behavioral techniques to reverse the phobic process), relaxation techniques (especially proper breathing), and cognitive training. Frequently medication is necessary to aid treatment, or used to shorten the treatment by accelerating the recovery process.