I am thrilled to have Dr. Olivera Bogunovic and Holly Hardman with me on the show today. Dr. Bogunovic is an assistant professor of psychiatry at Harvard Medical School and the medical director of the alcohol, drug, and addiction outpatient program at the McLean Hospital, and Holly directed the documentary As Prescribed.
In today’s discussion, we dive into the ongoing benzodiazepine crisis in the United States, with over 92 million prescriptions written each year for medications like Ativan, Valium, Xanax, and Klonopin. We discuss the origin of those drugs in the 1970s as treatments for anxiety and how they lead to tremendous physical dependency. Holly shares her experience with the neurological effects she suffered after long-term use of Klonopin, and we examine challenges in psychiatric care, the need for informed consent, and the impact of social media.
We also cover the role of lifestyle, the need for psychotherapy and psychosocial support, and the significance of hope.
This conversation is truly invaluable! Given how frequently benzodiazepines get prescribed, everyone must understand their associated risks and considerations.
IN THIS EPISODE YOU WILL LEARN:
How prescribing practices have evolved over the last two decades
The significant consequences older adults face when they suddenly stop using benzodiazepines
Holly shares how doctors misinformed her when she began taking Klonopin.
Holly describes the benzodiazepine-induced symptoms and cognitive issues she experienced
Why people must get informed about the long-term effects of benzodiazepines when consenting to take them
How benzodiazepines work in the body and impact the brain
Why benzodiazepines are ineffective when used long-term for insomnia
The challenges certain people face when accessing psychiatric care
What is BIND, and what are its symptoms?
The significance of diet and holistic approaches for managing mental health and why community support is essential in the recovery process
Why As Prescribed is an educational documentary for everyone
“Like any medications, the goal with opiates is to use them only when needed.” (
-Dr. Olivera Bogunovic
Connect with Cynthia Thurlow
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Submit your questions to support@cynthiathurlow.com
Connect with Dr. Olivera Bogunovic
The McLean Hospital (in Boston)
Director Holly Hardman’s acclaimed documentary on the benzodiazepine crisis As Prescribed is now available to view across major streamer platforms including Apple, Amazon Prime, Google, Tubi, and more.
For more information on As Prescribed and how to stream the documentary, visit the film’s website at https://asprescribedfilm.com/. You can also follow on Instagram, Facebook, and X.
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Dr. Olivera Bogunovic who's an assistant professor of Psychiatry at Harvard Medical School and the Medical director of the McLean Hospital's Alcohol, Drug and Addiction Outpatient Program, as well as the director of As Prescribed, Holly Hardman.
[00:00:47] Today, we spoke extensively about the scope of the current benzodiazepine crisis. For listeners, these are drugs like Ativan, Valium, Xanax, and Klonopin. There are over 92 million prescriptions for these drugs every year in the United States. We spoke about the role of the development of these drugs in the 1970s and how they were initially designed to help control anxiety, but they do incur tremendous physical dependency.
[00:01:13] We spoke about Holly's story, her 17-year-history of taking Klonopin for chronic fatigue syndrome and how that led to significant long-term neurologic symptoms, how taking benzodiazepines are “a silent killer.” Issues surrounding current models of care about psychiatric illnesses, the roots of opiate addiction, the role of tolerance and how many benzodiazepines are prescribed for sleep disturbances but only work for about 28 days, the role of fully informed consent, BIND, which is benzo-induced neurologic symptoms, the role of accessibility to mental health care and the stigma surrounding it, the impact of social media as well as polypharmacy which means multiple drugs being given that are exacerbating side effects, and lastly the need for psychosocial support, psychotherapy, the impact of hope and the role of lifestyle.
[00:02:12] I feel like this is a truly invaluable conversation. I saw so much benzodiazepine use when I was working in a traditional allopathic model and this is something that I think all listeners need to be made aware of so that they can navigate making good choices for themselves and for their loved ones.
[00:02:33] I've been so looking forward to interviewing you both. Thank you for coming on Everyday Wellness. I think that for many, many listeners they probably are familiarized with benzodiazepines, this class of medications like Ativan, Valium, and Xanax. But I think for many individuals they don't fully understand the scope of the current benzodiazepine crisis. I think that when I was doing research for this conversation, the statistic I saw was between 1996 and 2013, the number of benzodiazepines prescribed for adults increased by 67% to 135 million prescriptions per year. And the quantity prescribed per patient more than tripled during that period. And so that's 10-year-old data, but yet it's still applicable even today. I'd love to really initiate the conversation today. You both have two very different voices, but equally powerful. And I'm so glad that we're going to be able to familiarize my community with this class of drugs and the personal and professional experiences you've had with them.
Dr. Olivera Bogunovic: [00:03:36] Thanks.
Cynthia Thurlow: [00:03:38] Could you give us a scope of, you know, obviously you work in this environment, you're a clinical psychiatrist. Let's speak to the prescribing practices that you have watched evolve over the last 20+ years of clinical experience working directly with patients.
Dr. Olivera Bogunovic: [00:03:54] Also just what is very important to know is this class of medication, the benzodiazepines, has been with us for a very long time. The first prescription started in 1970s and as the same thing that happened with the opiates, we really did not know much about the medication. It's a new medication. We don't know the side effects, we don't know the long-term side effects. What we knew then at that point was that it was helping decrease the anxiety, but we did not know on the long term what the effects are. And it is a miracle drug in an initial phase of anxiety, so the anxiety just is gone for most of the people, but on a long-term basis, like the opiates, this is a medication that produces a physiological dependence, so your body gets very used to these medications and coming off them is a problem for a number of folks.
[00:04:53] Some folks do not struggle, but obviously this medication cannot be stopped abruptly. If it's stopped abruptly, it can have consequences, it can cause significant medical morbidity that folks are not aware. You can have a seizure. It's linked with increased mortality with older folks that stop abruptly. So those are all the things we did not know, we saw initially, “Oh, it took good care of the anxiety and it's a good medication.” But as we all learned, like with the opiates, it's dangerous, we go out on the dangerous path.
[00:05:27] And like any medications, the goal is really to use it only when it's needed, correct? Like for the antibiotics, why we don't prescribe antibiotics all the time for anything that we don't have a confirmed diagnosis? It can cause resistance. These medications cause a physical dependence and cannot be stopped abruptly. So, I think educating just everybody, really, even people who struggle with the anxiety. We live in a very fast paced environment. Kids are very much prone and exposed to all sorts of social media. We see a spark in the diagnosis of anxiety disorders. As we get older, certainly, that has been for a long time very well known that the anxiety disorders are more prevalent. But what we also know is that the best treatment for anxiety is psychotherapy. It doesn't take away it immediately, but it teaches us how to live with the anxiety, and because the consequences of a long-term prescriptions are significant for everybody, especially older folks.
Cynthia Thurlow: [00:06:38] Yeah, so it's so interesting to me and listeners know that my background for 16 years was in clinical cardiology. And so, I had many, many patients that came to me either in the hospital or in the office that had been on benzodiazepines, usually Xanax or Ativan for 20, 30 years. And they would talk to me about the fact that they knew that they could not stop the medication and when they tried to decrease it, it was really problematic. So obviously in cardiology or inpatient medicine, sometimes you're prescribing appropriately a couple doses of Valium prior to a procedure. Maybe you're prescribing some Ativan. But we're really speaking to the people that are taking this long term. And you know, how 50 years ago we didn't fully understand the long-term ramifications of taking these drugs over time.
[00:07:25] Now Holly, you have such an inspiring story. When I watched the film As Prescribed, I was really drawn into your story and I would love for you to share your experiences, kind of the trajectory of your experiences working with these medications.
Holly Hardman: [00:07:43] It was true. I did put my own story into the film and having other people vocalize and discovering much more than I had already known from my own experience, which was milder than many of the people I started encountering while I was researching and then even during filming. But it's funny because I don't know if either of you recall a woman named Karen Ann Quinlan-
Cynthia Thurlow: [00:08:09] Yes.
Holly Hardman: [00:08:10] -who went into a coma in the 1970s. And there was a lot of information at the time about the dangers of Valium. And so, I said, “Well, I'm never going to take anything like Valium.” And then I developed in the early 1990s chronic fatigue syndrome. Now it's called MECFS, And I was given Klonopin to treat that. And I looked at the insert, and I saw something that prompted me to think, “Could this be something like Valium?” And I asked the doctor, and she said, “Oh, right. It's the same class of drug. The difference is these were developed because Valium does have a lot of problems, and these are great. You can take this for the rest of your life. It's all good.” And then I even asked at some point, “Well, what about the warnings in the insert?” And she said, “Oh, the pharmaceutical companies just have to do that to protect themselves from frivolous lawsuits.”
[00:09:04] Yes, so there I found myself just really believing what my doctor was telling me, of course. It took many years for me to understand that once I got past the chronic fatigue syndrome, which I did, and a lot of that had to do with diet. But once I made it through that, I was still having these mysterious symptoms. I was still sick in ways that I could not understand and had pain in ways like-- Well, I was in deep tolerance and I was seeking a diagnosis. And I was told things like, I had lead and mercury toxicity, anything but benzodiazepine.
[00:09:44] So, years later, I just happened to have this thought that I'm still taking this medication. It does help me sleep. I'm not sure. I just don't know if it's a good idea because any doctor I went to would always say, “I see this on your records, you want a prescription?” There was only one time that a doctor said, “These are great,” but where he almost killed me, but he said, “Take one of my Nutraceuticals.”
[00:10:13] He [unintelligible 00:10:11] “Take this instead of the Klonopin, this Nutraceutical.” So, I was like, “sure.” And so, I did. So I stopped the Klonopin and a week later, I was dying. I was dying, I was taking his Nutraceutical. And I thought, “He just wanted to sell me something.” So, thank God I did start to take the benzodiazepine again, the clonazepam. And so, time went on, and I just didn't love the idea of taking a medication, which at that point, I didn't really understand why I was taking it, so I stopped.
[00:10:47] And I kept track of it that time because I was intolerant for years, but never really keeping track of periods of time where I wasn't taking the medication. This was a time where I knew that what started happening over those four days was connected to the benzodiazepine. So, I googled simply stopping Klonopin and found so much information about how dangerous this was. And I found the Ashton Manual that day too. So that was the beginning of my escape from the benzodiazepine and also my determination to make a film about this.
Cynthia Thurlow: [00:11:24] Yeah. So how long were you taking the Klonopin before that realization came to you?
Holly Hardman: [00:11:30] It was about 17 years.
Cynthia Thurlow: [00:11:32] Wow. So, long, long time. And for the four days that you were not taking the Klonopin and you were taking this Nutraceutical. What types of--
Holly Hardman: [00:11:38] Well I had stopped the Nutraceutical.
Cynthia Thurlow: [00:11:40] Okay.
Holly Hardman: [00:11:41] Because I thought, “Oh, he just wants to sell me something. It's not as safe as the Klonopin. It's not as effective.” It had been probably as much as eight or nine years earlier. We're like eight, nine years later.
Cynthia Thurlow: [00:11:56] Okay.
Holly Hardman: [00:11:57] And I'm seeing a doctor who's telling me, “Oh, you want a refill for your Klonopin,” that sort of thing. And I'm sure it helps me sleep, but as I say, I got to a point where I thought, “Well, I just don't really like taking a medication when I'm not even sure why I'm still taking it.”
Cynthia Thurlow: [00:12:14] Which are appropriate questions to have in terms of investigating, you know, is this the right medication for me? Were you having symptoms related to the Klonopin during that 17-year time? What kinds of symptoms did you experience?
Holly Hardman: [00:12:28] I had so many symptoms of tolerance and now we call it benzodiazepine-induced neurological dysfunction. I was an avid reader and, well, still am in a different way, but just an avid reader of wonderful literature. And, all of a sudden, I couldn't read pages. And I would be given contracts to sign. And some days I would go through very thoroughly understand everything, and the next day I would look at a page and I couldn't process it visually. It was frightening.
[00:13:04] And then I started noticing I didn't think this was the Klonopin, I just thought I was falling apart. Oh, I was having terrible driving issues, which I just thought were a more extreme form of anxiety. I had lived in Los Angeles, I had lived in New York, I drove here, there and everywhere, and then all of a sudden, I was terrified of taking any simple left turn. And then pains, mystery pains, why? There was no reason to have some of these horrible sensations I was experiencing. I mean, I could just Go on and on. When people go through this--
[00:13:41] I have a friend in the benzodiazepine community who has counted 100 symptoms. I counted just about 50, that's when I started tapering because all hell breaks loose when you're tapering, unfortunately, but you're just so happy, you're finally understanding what's going on and you have support around you and you're going to get through it.
Cynthia Thurlow: [00:14:02] And Dr. Bogunovic, in your clinical experience, how quickly does someone develop tolerance to this class of medications and what are the more common symptoms that they will report to you?
Dr. Olivera Bogunovic: [00:14:14] So like opiates, we know that after two weeks you can develop the tolerance. The benzodiazepines is kind of almost this silent killer. So, it takes almost six weeks that you to develop the symptoms. And it's just that you need more and more medication for the same effect. And the problem with it is that you were increasing the dose and this is a medication meant to be used for short-term use, up to three months the most. And then as you can imagine, if you have it prescribed longer and longer, the more your brain gets used to it. So, it's much more difficult. Your receptors in the brain are learned and are waiting for it every morning. So, once it's not there, you become more anxious, it becomes very intolerable.
[00:15:02] And one of the things that is also important to know, I did mention that anxiety is treated with psychotherapy, the best. But a distinction between depression and anxiety, people learn to live with the depression and they can go forever if they're okay with staying in bed all day. And anxiety is a really state where you're not able tolerate it for longer periods of time. So, you're really grasping for something that is going to make a change, and that's the biggest problem, correct? Psychotherapy takes a while, there's some other medications that take a while, but just learning to overcome it is also a big task. And as I said, we all want it to go away immediately. And I think just doctors should deliver that message, “It's uncomfortable, we understand you, we know how you're feeling, but you're going to get through it.”
[00:15:59] And the other problem is that most of the medications, we live in a busy world where we have a lot of busy practitioners. The visits are really kind of crammed in 15-minute visits warranted by the insurance companies. The doctor doesn't know the patient that they're treating, correct? Well, because what can you tell them in 15 minutes? That you come and see the doctor for many problems and you're just grasping to get anything in as fast as possible. And then the problem is that you got a prescription, maybe when you were in the hospital, just to treat the insomnia for a night or two. It just gets carried. And what the pharmacists do, it's also kind of a consumer society. They want to get the money for the medication, so they send a request for a refill. You're a busy physician, you don't have a time. You just kind of approve it. And we get into a very vicious cycle.
[00:16:52] And as I said, it's a silent killer. And so, the older we get, we see the more serious effects of those benzodiazepines. We see the fogginess. We see the chronic fatigue that Holly was experiencing. We see more falls. There have been more motor vehicle accidents with patients prescribed benzodiazepines, that's another thing that should raise it to a public health alert. And there's also a subgroup of patients who don't do well with the tapering of this medication. And they can have problems for a number of years. And that's really not discussed because we discuss the majority of the patients, the majority of the patients feel it. It's uncomfortable, but they can get through it. But there's subgroup of patients that for a long time can and may experience debilitating symptoms.
Cynthia Thurlow: [00:17:50] Well, I think this is quite significant. You know, first and foremost, the differentiators between anxiety and depression. How people that are experiencing significant anxiety are struggling to see like the long term, like if they're we're running a marathon and not a race, they're looking for help right away because the symptoms are uncomfortable. I think there's also limitations to our current model of care. I certainly saw that working in clinical cardiology when were expected to see quite the volume of patients we were expected to see every day. It makes it challenging not just for the patients, but also for the providers as well.
[00:18:25] And one thing as I was preparing for this conversation was access to psychiatrist or specialized psychiatric nurse practitioners, how challenging that can be in our current medical model, and sometimes maybe internal medicine or primary care docs that aren't as familiarized with the long-term effects of benzodiazepines may be forced to prescribe medications that are ideally utilized very short term, they're being used long term because there just isn't the opportunity to get patients into the funnel of psychiatry as quickly as they need to be. Has that been your clinical experience?
Dr. Olivera Bogunovic: [00:19:02] This has been my Clinical experience all along. I've been sitting on a lot of advisory boards and panels where, you know, in the Midwest, the rural parts of the countries, people don't have an access to the psychiatrist. They have been on these medications for a number of years. As we remember, the opiate epidemic started in the Appalachian region, because when you don't have things, the life looks very grim. You're grasping at straws to make things better. It's the same with anxiety, and that's where-- the medications are actually prescribed because also the doctors don't have time, they're pushed, they don't have the support of the psychiatric community. It takes months to get referred to a psychiatrist or a therapist. And again, then we face the long-term effects as we get older, which are pretty significant.
Cynthia Thurlow: [00:19:56] And in terms of how the drugs act, like broad based kind of characterization. Let's speak to how the drugs actually work physiologically in the body and then we'll kind of pivot. But I think this is important to understand because there's a lot of discussion about, the neurotransmitter GABA and how beneficial it can be, especially when we're addressing anxiety. How do the drugs work mechanistically so that everyone that's listening will have a better understanding.
Dr. Olivera Bogunovic: [00:20:23] Like any medication, and our brain is a really special place, it has a lot of neuroreceptors, it has the receptors for the satisfaction, the dopamine, the reward system. But the GABA system is kind of really preliminary there to keep the balance for the anxiety. So, when the GABA receptors are activated-- And we are all dealing with much more stress in life than we deal with the past, they're really kind of like all up in the air. So, the benzodiazepines come, they attach themselves and they calm down, correct? And they stay attached for a while. And then, there's a half-life of medication, so we need to take it over and over again. So, this is how we actually continue to produce this tolerance, which then in effect does not work anymore.
[00:21:10] One other important thing to know about the benzodiazepines, they have been in the past very often prescribed for sleep. They lose their effectiveness for the treatment of sleep disorder after 28 days. It just wanes and it doesn't work for the treatment of insomnia. And the more and more where their senses is coming out about the treatment of insomnia and all the medications, similarly from the family of benzodiazepines like the Ambien, the Z-drugs that we call them, they also should not be prescribed on a long-term basis. So, we know for the regular benzos that their effectiveness stops for a month.
[00:21:50] But again, like the receptors also that are prescribed for anxiety, they want more and more for the folks that develop that tolerance. And as you can imagine, if we stop abruptly taking the benzos, all those receptors in the brain are lightened up and don't know how to calm themselves, so we have all that horrible feeling of anxiety, and we have other physiological symptoms of the benzodiazepine withdrawal. So, the problem is and this is what I tell people coming off the benzodiazepines, even for just regular people who will not experience that post-acute withdrawal can be difficult. Every time you decrease the dose, your brain needs to readjust now and find ways to find a different equilibrium.
Cynthia Thurlow: [00:22:39] It's really interesting because I know that-- And I was asking colleagues of mine when I was preparing for this podcast, I said, how many of you have patients that are menopausal who are prescribed benzodiazepines to help with sleep and anxiety post Women's Health Initiative, when a lot of patients were taken off of hormones, 28 days, that's huge. So, for someone taking one of these drugs, they may feel for the first week or two, “Okay, now I'm sleeping, this is great.” And then all of a sudden, they're going to have this time period in which it's no longer effective at that current dose. So, you can understand anyone who's taking these medications to try and sleep. And for so many of us, sleep is so foundational to our health. And then they stop working, it's like they're constantly chasing that desire to have better sleep.
[00:23:28] Now, when we're talking about the concept of informed consent, I'm sure that you talk to your patients about this, especially with this class of medications. But Holly, when you were working on the documentary, when you were talking to individuals who had developed significant tolerances to benzodiazepines, how many of them admitted that they had had informed consent, like true informed consent, about the potentiality of problems?
Holly Hardman: [00:23:53] None. And I'm sure it exists. And I think Dr. Bogunovic is somebody who would inform properly and does, but most people who find themselves dealing with what I said we call, BIND, benzodiazepine-induced neurological dysfunction, they had no idea. So many have been told things like, “Oh, it's as though diabetics need insulin. Well, this is just what you'll need for your ongoing anxiety.” They're prescribed for all sorts of reasons. Because the education is limited, but practitioners, what they know, it's limited. So even when they think, so many think they're giving a version of informed consent, it's not complete, it's not thorough. And they really do not understand the nature of this medication and just how damaging to the central nervous system they are.
[00:24:50] I mean, they start creating a different kind of adaptation within a week. I've been in touch with a number of people who do research specifically on GABA receptors and the effects of benzodiazepines. And there are some knowns now, but they're not well known about it among the medical community, because there's still a culture that believes--
[00:25:15] I mean, Dr. Bogunovic brought up the fact that we're in a consumer culture and doctors have such limited time to treat patients. So, it's difficult for doctors to know what they're prescribing because it's not just benzodiazepines. I'm kind of defending everybody who gets into this mess because we all have needed the information. We all need a better system of care. There's so much to this story. And I will just add so, you know, I really did experience something pretty wicked. My taper still took 22 months, almost two years. And it has changed my life. [crosstalk] I'm not 100%, I still have issues.
Cynthia Thurlow: [00:25:54] Yeah, it's interesting to me, and you're absolutely correct, Holly. I think most, if not all, licensed healthcare providers want to do what's best for our patients. They feel like they're a cog in the wheel. They're trying to do the very best with the time that they have. And that's why I'm hopeful that we can bring awareness to this issue. Because even as a clinician myself, I had never heard of BIND. I knew that there was tolerance that was readily and quickly associated with benzodiazepines, but I had not even heard of this disorder. And so, I think for the benefit of listeners speaking to what BIND is, it stands for benzodiazepine-induced neurologic-
Holly Hardman: [00:26:36] Dysfunction.
Cynthia Thurlow: [00:26:37] -dysfunction. I think that's something that I found troubling was that when I did some research and I looked at a 2023 survey, it was saying that symptoms that persisted for months or even years after complete discontinuation. So, it's not as if you stop and then you get over this hump. For some individuals, it can impact them for the rest of their lives, and that is quite significant.
Dr. Olivera Bogunovic: [00:27:00] It changes their lives. I think that is the most important thing. It does change your life and you have to adapt to it. And people who are prescribed benzodiazepines already are a vulnerable population that struggle with anxiety. And as I said, there's not too much time devoted for the treatment of mental health. We're just right now increasing our awareness of mental health and it's not so stigmatizing to talk about it. But still, people are very fearful to talk about it and feel a great deal of shame that they're dealing with.
[00:27:39] I always say, everybody will suffer from something. We're not spared from anything. We'll either have a medical illness, we'll have a psychiatric illness. There's really no difference. This is how our genetic make us and we have to accept it. And I think this is still the problem that people are experiencing it, they don't want to appear in front of the doctors, that they're like a pained. But then also the access to physicians and getting answers that you need is you have to jump through hoops to get answer from a physician. Now, you know, it's a concern, you're not feeling well, and you have to wait for a phone call back. It’s really not well organized. And, it's a subgroup of people that people say, “Well, they were always crazy. What's the big deal?” No, they're experiencing real symptoms that are related to a medication. And even if they're crazy, they need to get the treatment. We have to get away from this stigmatization of mental illness because you get the treatment, you're going to function as good as anybody else.
Cynthia Thurlow: [00:28:49] Where do you think that stems from? You know, in terms of-- if we're comparing symptoms that someone experiences, whether it's anxiety, depression, etc., versus someone comes in with chest pain. Why is it more acceptable to have a tangible issue, whether you broke a leg, you had a heart attack, versus something that's more emotional in nature but equally problematic and bothersome. What do you think contributes to that stigmatization?
Dr. Olivera Bogunovic: [00:29:18] It was always in the society, it was always the stigmatization of the mental illness. And it really still, we are still struck. We have made strides in many other fields, but getting the funding for the treatment of mental illness is still not, we don't have the equity there. And I always say all those conditions are treatable conditions, but we need to have access and we need to offer specialized treatment.
Cynthia Thurlow: [00:29:49] Well, I think one of the other things that really stands out to me, I know that when I was working in cardiology, I had a lot of older patients, I would say north of 60 years old, many of whom, whether they were experiencing, they had been widowed, maybe they had chronic long-term depression, maybe they had an acute episode of anxiety trying to find a psychiatrist. And I was practicing in Northern Virginia, so very large part of the East Coast, Washington, D.C. area, it was infinitely challenging to find a psychiatrist that was taking patients within three to six months, kind of challenging.
[00:30:28] And then on top of that, I understand why people do this. A lot of people were no longer taking insurance. So the burden of trying to find a provider, plus the challenges then of having to pay out of pocket for care, and that seems to be the direction a lot of mental health services are going in. And again, not a criticism, just kind of observational. And so, I can imagine if you're in a rural part of the United States, you're way outside of a big city, there may not be enough providers. And so, I'm curious if, post pandemic we're seeing more practice changes to going to telemedicine, maybe people benefiting even if they don't have a provider in their area, being able to have access to psychiatric services perhaps virtually as opposed to in person.
Dr. Olivera Bogunovic: [00:31:12] So, this has been a plus unfortunate plus a pandemic. But again, the telehealth is limited to the state where you're practicing. And I just think that even as I said, if we could raise more integrative health care, so working with the primary care physicians so that the psychiatrist can educate the primary care physicians and work together with them, it would offer more accessibility to the care.
[00:31:38] And as you point out, as you get older, we see more of the increased prevalence of anxiety disorders. But I also think we see all across an increased prevalence of anxiety disorders because of the exposure to the social media, because people just put up pictures that are not real-life representations. And then you really feel that you're alone, especially if you don't have the support. As we're getting older, you're more alone. I think the population also that struggles more with the benzodiazepine withdrawal are the elderly folks because they have been prescribed many other medications and the mix of medications is not helpful. They're not able to practice a holistic approach which includes healthy living habits including a diet, including exercise. And we really have to think as a society how to offer more help and care.
[00:32:36] As you point out, a lot of physicians do self-pay and it is a problem because people do not have the resources to pay. The rates at least in the northeast are somewhere $300 a session, correct. So, $300 to $500. I would say people need a weekly therapy, so it's already $2000, so you have to have like a budgeted amount every month.
Cynthia Thurlow: [00:33:09] Yeah, it gets expensive. And it's interesting, during the pandemic, what I saw were a lot of colleagues asking for resources for teenagers, for children, for young adults that were really struggling during the pandemic. And without question whether it was on social media, within mom groups asking like, “Who would you recommend for my son or daughter to see?” Was that cost piece even for places where people are perhaps it's more expensive to live. I think most people probably don't have thousands of dollars, kind of squared away to be able to pay for all those things out of pocket and on top of everything else. So, my hope, and by bringing greater awareness to all these issues, is that the amplification of the need for more mental health services.
[00:33:52] Now, Holly, when we're talking about BIND, help us understand what this is. The wide range of symptoms. I think I read. It was unbelievable when I looked at the volume of symptoms. You talked about someone had mentioned a hundred symptoms of withdrawal related to benzodiazepines. But when you were working on your project, I would imagine you were probably shocked at how many people were impacted by this.
Holly Hardman: [00:34:19] Oh, yes. At first, I thought I would just make a short film that's sort of lyrical and just gives an idea of this experience I had. And then I realized, “Wait a minute, this is not unique, this is not just some little story, this is huge and it's everywhere, and it never should have happened.” And, I just encountered so much more people who their stories were so compelling and they were so descriptive in ways that I could feel what they had gone through. And just knowing like, this is real, this is real. Every time somebody says they've had what to-- Somebody else might think some crazy, crazy experience that can't possibly happen from taking a pill like that. Oh, yes, it absolutely does.
[00:35:04] I mean, one of the worst physical symptoms I had from the benzodiazepine was really excruciating back pain. Then it would travel and then I kind of in my leg and my groin area and I was like, “What is this? What is this?” And then when I started connecting with people in these forums, “Oh, they were the group of people who shared the symptoms.” That's where you go, “Okay, it is connected,” because you're always trying to rule out, “Could it be something else? You know, is there something else that happened to my system or body that could have created this? Did I fall out of my bed and not know it?”
[00:35:44] And then one of the worst symptoms that many people find themselves living with and actually some people choose to take their lives and part of the tragedy of all this is I don't know if you're familiar with akathisia. And there's a spectrum of experiencing akathisia, but it is bloody torture. It is really torture. I made it through because about two weeks into my taper, I had a breakthrough, you go through waves and windows, we call them. And I realized that I hadn't been able to see color for a long time. Things you take for granted, just your living experience, it's just all of a sudden, I saw a blue sky. I said, “I haven't seen a blue sky in so long.” My processing was so off. So that was when I knew that, “Okay, I'm going to heal. I'm going to heal.”
[00:36:39] So even when I was experiencing akathisia, I was confident I was going to get past it, and I have. I think that akathisia was the worst. That's this feeling that you must escape yourself, you can't. And some people, it's affecting them to the degree that they pace nonstop. They're pacing, pacing, pacing. And you will find that suicide is common with people who experience akathisia a long term. This little pill could do that. It's just so cruel.
[00:37:10] There were tests on Roche. I think they were called Hoffman-La Roche at the time. They did extensive studies on Librium before they released like on thousands of people, really. And the unfortunate part is they only released to the public, including doctors, the medical profession, the good side, the good effects, because the good effects are amazing. And suppressed all this information and they've been--
[00:37:41] Now, it's not as well coordinated as it was originally to suppress that, but now we have a culture that just grew to believe these were safe medications. And it's just, “Oh, a few people who maybe have a problem.” So, it just never should have happened. And you brought up the opiate epidemic and you know the Purdue Pharma. And the Sackler family, well, the earlier generation, Arthur Sackler was a genius marketer, genius advertising man. And he is responsible for all this wonderful marketing, mother's little helper type marketing back in the 1960s. So, this goes way back. And it is outrageous that the original manufacturers knew how dangerous these medications could be. Helpful, yes, also terribly dangerous.
Cynthia Thurlow: [00:38:38] Yeah. There's a degree of corporate greed that I think is pervasive in the pharmaceutical industry. And equally on the flip side, there are wonderful advances that are made that benefit patients and their families quite significantly. Now, Dr. Bogunovic, when we're talking about BIND, how frequently are you seeing this in your patient population? Is it fairly common for you to see or is it less common?
Dr. Olivera Bogunovic: [00:39:03] It is less common. It's somewhat around 10%. But again, for the people who experience it, it's a debilitating experience. So, you're already vulnerable, you're struggling with an underlying psychiatric disorder, and then you experience these debilitating symptoms that really suck you into a rabbit hole.
Cynthia Thurlow: [00:39:27] Yeah, it's interesting, this one research survey that I was looking at, it said the study participants, over 80%, identified more than five serious life consequences which they attributed to benzodiazepine use. And these include things like low energy, difficulty focusing, memory loss, nervous, anxiety, sleep disturbances. So again, we go back to the fact that many of these drugs were designed to treat specific things that they then amplify later on over time.
Dr. Olivera Bogunovic: [00:39:54] Yeah, that is the unfortunate piece. It gets even much more amplified and people mistakenly don't recognize it because you started treatment for these symptoms, so, you are saying this is a rebound, but it's not a rebound, it's a separate condition that is very important to be recognized.
Cynthia Thurlow: [00:40:14] When you're working with patients. And you mentioned it's about 10% of the patients that take benzodiazepines will develop BIND. How do we go about navigating next steps with these patients. Obviously working with a clinician that is well versed, familiarized and experienced in benzodiazepine use and then withdrawal and how to do that safely. What should patients be looking for or listeners be looking for If they are in a position or a loved one is in a position and they feel like they need help and assistance?
Dr. Olivera Bogunovic: [00:40:50] It's really working with somebody who's very familiar with the treatment of it and the person that can actually offer that psychosocial support, because you don't want to treat that with another medication, so you really want to help them with therapy to overcome it. Again, the problem is it's not time limited, it's not a week, it's not two weeks, it's not a month, it can persist for a very, very long time. But like anything in life, the good part of is that life is not stagnant, it just moves along and just you have to try to keep on moving that person along and at some point, it will change.
[00:41:31] I think what is very important is working with people who are educated and versed and understand these symptoms, because it's very difficult, it's debilitating for the patient. Like most of the physicians, nurse practitioners, they want to fix everybody. And we want a quick fix ourselves because we want to feel like heroes. So, knowing that you're in for a long ride with this person, but then you will eventually things will get better is an important message to give.
Cynthia Thurlow: [00:42:02] Well, and I think that concept of marathon, not a sprint, is helpful because it acknowledges you'll probably have ups and downs. Holly, you certainly have experienced this. What are the things that you like to embed into those that are kind of navigating this journey right now? What message of hope?
Holly Hardman: [00:42:19] I would like to bring up the importance of diet. One of the effects of these medications is that they create in most people, even if you don't end up with BIND, they're terrible for the gastrointestinal system. If you've taken them long term, you're probably having issues. That was something I could relate to that I wouldn't have thought this little pill for sleep could have done. And of course, once you dig in a little, you see, “Oh, of course. Why did I even think otherwise?”
[00:42:51] And so one of the benefits of going through something like this is improving diet and becoming more serious about what is real food and, what else is wrong. Sometimes I see the difficulties people are having from actually healing, it's because they're still eating like ultra-processed food and that sort of thing. And it's like when it helped me to really start seeing food as medicine and you know, a cleaner diet. And for some people there's a diet called the MAPS diet that's very helpful. But that's one of the keys to healing, is also healing your gut, the gut-brain connection. And there's optimism there because we're learning more and more about “Oh, what have we done to our food culture and what can we do, where can we find food that actually supports healthy life, healthy body.” And so, I think along with more awareness about these medications that are being prescribed, you know, sometimes responsibly, but unfortunately oftentimes not that there are efforts going on to bring groups together who share a purpose to have a more holistic purpose about living life, and I think that ends up being one of the important answers to all this.
[00:44:16] And also, I'm going to just mention other-- Because life is full of suffering. Dr. Bogunovic was mentioning that. And it's true whether you're having a psychiatric issue or not. I mean life is, it's just the nature of living on this planet. And one of the things that I found is this was again grasping at anything that could help while I was tapering, I was introduced to TM and that was life changing. And I can't say that-- transcendental meditation. And I would never tell anybody that, “Oh, this is what you should be doing.” But I would suggest that most people would benefit psychologically from some sort of meditation, some sort of practice. Getting out in nature is part of it.
[00:45:01] There are discoveries about, “Oh, this really is a way to live life,” so that we can acknowledge that feeling anxiety is natural. And I feel uncomfortable-- See, I'm not in the medical field, so in my mind I don't necessarily use the language psychiatric issue. If I were a doctor, of course I would. Because I'm not in clinical practice, I'm seeing it more as these are life stages or life experiences and just there are just some exciting approaches to helping us find our way to health or back to health. And I think sharing all that information is helpful, of course.
Cynthia Thurlow: [00:45:47] Well, I love that you wove in really speaking to the gut microbiome, the healthier our gut health is healthier neurotransmitters, the role of nutrition, which is a huge emphasis of my work, and even speaking to things that are quieting the autonomic nervous system. So, getting us in that parasympathetic rest and repose where we are less likely to experience significant degrees of anxiety in conjunction with psychotherapy and working with a talented psychologist, psychiatrist, primary care provider, internist, whomever is helping you navigate these, but it goes without saying lifestyle is critically important.
[00:46:23] I think that one of the most important messages that we can share on this podcast is embedding a degree of hope so that people understand, even if they're in a tight or a tough time, tough space, that it is meant to be hopefully temporary and that over time, it's the marathon, not the race. We get to a point where we're more comfortable, we're better adapting, coping. I really loved your documentary, which is why I wanted to make sure that I brought you both on the podcast. I'd love for you to share, Holly, how to get access to the documentary, how to watch it, and Dr. Bogunovic, if you can let listeners know if they're in your area of the country, if they would like to work with you, how to go about reaching out.
Holly Hardman: [00:47:10] Well, I'm actually happy to say the film is widely available in the United States and Canada on Prime Video, Apple, Tubi, Canopy, and Google Play, so it's accessible. And we're working on international, but there's some international, I think, through YouTube or something, so the film is widely available.
Cynthia Thurlow: [00:47:36] Wonderful.
Holly Hardman: [00:47:37] As Prescribed.
Cynthia Thurlow: [00:47:39] The great [unintelligible 00:47:38].
Dr. Olivera Bogunovic: [00:47:42] I think it's a very educated. It's a documentary that is extremely educational for everybody for many reasons to see, just kind of to raise mental health awareness, to raise awareness about medications, about the effects of medications. And everybody can understand the movie. The movie has its own story about real life people who shared their life, their pain, their hopes. And I think, after all, it's very important to know that there is hope because life is not easy, but you're not always in a rabbit hole. We learn to deal with life, we learn to cope with life, and we learn to enjoy life. I work at McLean Hospital, so the best way to reach me is calling McLean Hospital, and they usually funnel the calls to me. McLean Hospital is located in the Boston area.
Holly Hardman: [00:48:39] And I'd like to thank McLean Hospital for allowing us to film you. Dr. Bogunovic, it was really a pleasure filming you. Thank you for participating in the film.
Dr. Olivera Bogunovic: [00:48:48] You're welcome.
Cynthia Thurlow: [00:48:50] Thank you ladies. This is really an honor for me to interview you you both. Like I mentioned, I really enjoyed the documentary and I think that this is information that most, if not all, individuals need to watch and to better understand what's going on behind the scenes. Unfortunately, I think unless someone works in the medical community, they may not have a sense of the scope of this problem. So, thank you again for the work that you do.
Holly Hardman: [00:49:14] Thank you. Thank you for having us and thank you for hosting this fabulous podcast.
Dr. Olivera Bogunovic: [00:49:18] I share all what Holly has said.
Cynthia Thurlow: [00:49:24] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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