Table of Contents

Volume 1, Issue 11                                                                                 November, 2015


Curbside consults



Question:

What are your thoughts on the common combination of amphetamines and benzodiazepines? This is so very common and even worse in patients with substance abuse. 

The PL answer:

This common combination makes sense, in a rather absurd way. Amphetamines cause anxiety, which is then treated with benzodiazepines. Another relevant reason for the combination is that anxiety states, as discussed above, often cause  impaired concentration.  Such patients then get mistakenly diagnosed with adult ADD, and treated with amphetamines, which worsen the underlying anxiety that caused the inattention to begin with, hence the addition of benzodiazepines.  In short, the effect is mistaken for the cause, and inattention is treated with amphetamines which worsen the causal anxiety, leading to further treatment with benzodiazepines.  

Both classes of agents are addictive potentially, but at least in animal models, amphetamines appear to produce more addictive behavior than benzodiazepines. Certainly the former have more evidence of neurotoxicity harm, as reviewed in last month’s PL issue, than the latter.

Thus, the PL perspective is that if a patient has an anxiety condition, that is not due to some other diagnosis like a mood illness, then it is reasonable to treat that anxiety condition with benzodiazepines.  If such anxiety states cause poor concentration, then those inattention symptoms should improve with benzodiazepines alone, without the need to add amphetamines.  The use of amphetamines in persons with anxiety conditions is self-defeating, as is the case with using those agents in bipolar illness. Amphetamines worsen anxiety and manic states, hence they worsen anxiety and bipolar illnesses. The only condition which they do not worsen is pure depression, where they had been used for years as primary antidepressants.  

As reviewed in the classic article, it is reasonable to conclude that most apparent cases of adult ADD in fact represent inattention symptoms caused by other diseases, most commonly bipolar illness, but also anxiety conditions. Thus, if anxiety diagnoses are made, the PL recommendation is that adult ADD should not be diagnosed, and the anxiety condition be treated, with benzodiazepines or in some cases with serotonin reuptake inhibitors.  In most cases, attentional symptoms then resolve with treatment of the underlying cause, without ever needing to use amphetamines. 

PL Reflection

The young physician starts life with twenty drugs for each disease, and the old physician ends life with one drug for twenty diseases. 

 

William Osler

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