18 Comments
Oct 4, 2023Liked by Owen Scott Muir, M.D

As a patient I personally have found clonazepam to be an extremely beneficial drug with few side effects (though I am unquestionably physically dependent on the drug).

I was prescribed it for REM Sleep Behavior Disorder which sounds really lame and banal but is actually pretty dangerous. Your muscles doesn’t get paralyzed during REM sleep and so whatever body movements you make or anything you say while dreaming becomes sleepwalking/sleepwalking.

I always had it and it led to some weird situations but I didn’t seek medical treatment until I apparently told my gf I was going to murder her and pinned her down with one of my arms. That was pretty terrifying so I was down for whatever.

Melatonin is first line but it did nothing for me. So after I got a sleep study and confirmed it they prescribed clonazepam as it’s the only other medication used to treat REM SBD. I feel like other benzos would probably would too but idk.

I can’t really tell much difference between lorazepam and clonazepam. Diazepam felt much more sedating and euphoric but also cognitively impairing. I absolutely hate Xanax as I blackout at subtherapeutic doses (0.25 mg will annihilate my memory for the evening). I’ve never blacked out on clonazepam and unless I take it during the day I don’t feel tired or cognitively dull. I also have Bipolar and it def does help mania but I don’t think it’s the best drug for that purpose bc a lot of ppl find benzos so addictive.

I suppose I’m lucky in that I really don’t enjoy benzos much. It improves my sleep quality and prevents me from hurting myself or others - that’s all I was looking for and once I developed a tolerance that’s about all I get out of it. I strongly dislike taking a dosage so high that I’m even slightly impaired or intoxicated.

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REM sleep behavior disorder is one of the very few indications were clonazepam is a crucial drug. Thanks for pointing it out! We don't have other treatments for this condition, which can be quite disabling. It's also crucial in essential tremor, for many!

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Sep 11, 2023Liked by Owen Scott Muir, M.D

I simultaneously agree with nearly everything you said. And, I wish you would further emphasize the important role that benzos can play in treating acute mania. I work with seriously psychotic individuals who require weeks of multiple antipsychotics + benzo to break through their mania. Its real.

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I have more coming about to acute mania soon. It's a very difficult thing to manage.

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Sep 9, 2023Liked by Owen Scott Muir, M.D

I'm in strong agreement with the article. I have been saying for many years that the problem with benos is that they work so well as a prn, but so poorly as a standing med. My experience is that patients with issues of waking during the night, sometimes can use a tiny dose of Klonopin (0.25mg) to go back to sleep. Even that should only be a couple of times a week IMO. Anxiety, which is low level fear (as opposed to "terror"), is extremely painful. Fear evolved to save one from life threat -- it is the most punishing of the 9 basic hard-wired affects. It does it's job by making reducing or eliminating the source of the fear urgent as hell. Pound for pound, distress, the underlying affect of depression, while still punishing, is not as painful. This is not to say that depression doesn't suck, because it does. But moderate anxiety is a lot more punishing than moderate depression. Since I'm on my high horse, I'll add that a great deal of what is diagnosed as depression with anxiety, is really depression being caused by anxiety. I enjoy your postings, Owen.

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That's also a beautiful sentiment, David. It's a great understanding. More understand things are needed.

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I think you'll enjoy the next piece about Xanax in that case. It's gonna be a burner.

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Sep 9, 2023Liked by Owen Scott Muir, M.D

I very rarely prescribe benzos and never standing. The issue around learning is so critical, giving versed before surgery to calm one down and induce amnesia is great, a standing amnestic when someone needs intensive therapy-which involves intensive learning, is counterproductive.

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So much yes. Some things are better left aside.

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Sep 8, 2023Liked by Owen Scott Muir, M.D

I want a psychiatrist like you. Want you to know you seem very special. Thank you.

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author

This is very kind. It's also why I do supervision for trainees and peers.

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Sep 8, 2023Liked by Owen Scott Muir, M.D

Really nice article though. Interesting how it’s the most prescribed psychiatric med in Brooklyn. Something about needing to take the edge off living in the city that never sleeps 🤔

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It was pretty surprising to me. It's like the fourth most popular drug prescribed in the borough. The next site drug isn't till Zoloft at number eight.

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Sep 8, 2023Liked by Owen Scott Muir, M.D

GABA A receptors are chloride channels, not calcium channels

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Sep 9, 2023Liked by Owen Scott Muir, M.D

right, calcium would depolarize.

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Fixed and I dropped the appropriate reference thank you.

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This is what I get for dictating on my phone. Thank you.

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Thanks for the restack @Leon Macfayden

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