Peter Andrey Smith

The visit lasted five minutes, and Tran walked out with a prescription for alprazolam, an antianxiety medication that is better known by its brand name: Xanax. On half a milligram twice daily, Tran felt comfortable going out. He made friends like never before and even went skydiving. This is like a God drug, Tran says.

Like Tran, nearly a third of all adults will be diagnosed with an anxiety disorder at some point in their life, according to the National Institute of Mental Health. A recent American Psychiatric Association poll revealed that 32 percent of Americans reported feeling more anxious than they did one year earlier. And thats not necessarily a bad thing. Anxiety motivates us to solve problems and take care of business, and it can boost productivity. But when the frequency, intensity, or duration of symptoms interrupts your life, it can become pathological anxiety. Persistent. Nightmarish. Mental-health experts now recognize anxietythe umbrella term that includes social anxiety and PTSDas a legitimate brain disorder, sharing some of the same underpinnings as depression.

People are more ready to have a medical diagnosis to describe their suffering, says Anna Lembke, M.D., a psychiatrist and researcher at Stanford. Theres a modern phenomenon of people being more anxious than they used to be. The uptick in diagnoses may have to do with increased isolation and stress combined with the pressures of social media and hustle culture. Plus, the eroding stigma around mental illness means more people feel comfortable talking about their anxiety.

Dr. Anna Lembke giving a Tedx Talk on the opioid epidemic.

Many of us want quick fixes. Several online start-ups offer meds for social and performance anxiety, delivering beta-blockers right to your doorstep. Professionals favor the use of antidepressants, particularly serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs), as a first-line treatment. But the most broadly prescribed pills are the benzodiazepines, or benzos, which have been around since the 1960s and include Xanax, Ativan, and Valium. Benzos work. Short-term, their effect in reducing anxiety is undeniable. But as boomers and millennials seek out pharmacological fixes, doctors are now prescribing benzos in more than a quarter of all office visits (27 out of every 100)nearly triple the number of benzos being dispensed in the mid-1990s. More than 48 million prescriptions were written in 2013 , and the use of benzos to treat chronic pain more than doubled between 2003 and 2015.

Benzodiazepines are not a panacea for every twinge of anxiety, says Timothy J. Wiegand, M.D., a medical toxicologist at the University of Rochester. Theyre habit-forming. The medications come with a high risk of overdose, especially when combined with opioids or alcohol, or in patients with breathing problems or sleep apnea. Chronic use can lead to neurological changes, resulting in mental cloudiness or loss of coordination. Several studies have reported that long-term use and high doses can accelerate the onset of dementia. Because its extremely difficult to stop taking them, a short-term bid to relieve anxiety can, for some patients, unwittingly turn into a vicious cycle.

For Tran, things started to unravel as he built up a tolerance. The effects of his medication wore off, and he felt increasingly irritable between doses. By 2017, he was spending less time thinking about his ambitions and more time worrying about his next dose. His memory and cognition sputtered. Still, he thought, being medicated felt better than any debilitating anxiety. It would be another year before he finally said to himself, Being tranquilized 24/7 is no way to live. Id rather suffer through the hard parts.

The decision presented him with a daunting, unforeseen challenge: How was he going to get off his meds? Cold turkey was not an option; the abrupt discontinuation of benzos can lead to seizures. Tran found an Internet forum called BenzoBuddies.org and learned about the Ashton Manual, a doctor--developed guide to the workings of benzos with methods for taperinggradually reducing the total dose over a set period of time.

Web forums offered what physicians had not: validation and support. By 2018, Tran came to believe that most doctors didnt want to hear from patients who wanted off, and so at his next visit, he asked for Valium, another benzo. At home, he used a volumetric doser to reduce his medicine by 10 percent every week. The withdrawal left him with constant severe nerve pain, as if his spinal cord had been plugged into an electrical outlet. The effects of withdrawal are lasting. He found it difficult to go outside, and the world seemed depersonalized, almost as if Tran were observing himself from outside his body.

At Dr. Lembkes clinic at Stanford, about half the patients she sees are deprescribing, wanting to stop taking medication that was given for a legitimate medical condition. I have a lot of high-functioning people who were prescribed small doses of benzodiazepines for decades, she says. But its very, very difficult to stop. Some people take 18 to 24 months to taper down, she says. And thats with a lot of psychological support and other treatments.

Alex Smith, a 33-year-old lawyer in Des Moines, learned firsthand that not all health-care providers recognize fatigue, full-body tremors, or even other, more obvious symptoms of benzo withdrawal. Hes had three seizures. Only after the third one, he says, in September 2019, was he informed that these resulted from not taking benzos. I was told Im lucky to be alive, he says. Smith does not crave his meds. Since he doesnt have a strong compulsion to use or extreme difficulty in abstaining, he doesnt meet the formal criteria for addiction. This is a subtle but important distinction: Support groups wont let him join because hes considered an active drug user. Had he known it would take him more than a year to stop the medication, he says, I would have never taken it to begin with.

Another issue is that most physicians receive more training on prescribing drugs than on safely tapering patients off them. Christy Huff, M.D., a cardiologist and the director of the Benzodiazepine Information Coalition, says doctorsherself includedcan be in the dark about potentially life-altering risks. Dr. Huff was prescribed benzos for insomnia and says withdrawal was the worst experience of her life. She suffered panic attacks, crushing fatigue, and akathisia (the inability to stay still). Having been off the medication for a year, she now has to contend with lasting neurological damage. The emergence of patient-led groups, she says, speaks to a greater unmet need: People definitely need more answers than are being provided by doctors. Her coalition was created to inform patients. Other experts make similar observations. People are finding out that, you know, traditional Western medicine is not always the place to get the best treatment, says Dr. Lembke.

Now health start-ups appear to be tapping into a subset of customers who want to stave off acute anxiety. Online providers Kick and Hims dont sell controlled substances, such as benzos; they do sell a drug called propranolol. (Pricing varies, although both offer a virtual consultation and the first shipment of pills for less than $100.) Propranolol, a beta-blocker, slows down your heart and reduces blood pressure. Short-term use of the drug for performance anxiety and social phobias is legal and permissible. By some estimates, millions of prescriptions for beta--blockers are written for the treatment of anxiety, but its considered an off-label use since these medications are cleared primarily for cardiac purposes by the FDA.

When taken for less than two weeks, benzos remain an evidence-based option for treating panic disorder, social anxiety disorder, and generalized anxiety disorder, especially when psychotherapy or serotonergic agents fail. Clinicians recommend SSRIs, like Prozac and Zoloft, although these can require two to four weeks, or longer, to take effect.

Stefan Hofmann, Ph.D., a professor of psychology at Boston University, recommends keeping an open mind about nonpharmacological treatments. Try psychotherapy, such as cognitive behavioral therapy, he says. It works for many people, and the potential adverse effects are considerably smaller compared to many of the pharmacotherapies. Still, not all alternative therapies are created equal. Hypnosis and yoga are promising, but more research is needed. Despite the hype around CBDthe nonpsychoactive ingredient in marijuanaand mobile health apps, neither has much scientific support. For her part, Dr. Lembke recommends exposure therapy, a specific type of psychotherapy in which patients expose themselves to the source of their anxiety. It takes considerable time and effort to see benefits but builds mental calluses that last a lifetime, she says.

Since May 2019, Tran has been off benzos. Once a month, he sees a therapist to focus on cognitive behavioral techniques. Hes learned the 4-7-8 breathing method (breathe in for a 4-count, hold it for a 7-count, and exhale for an 8-count), which has helped ease tense situations that might have otherwise induced a panic attack. And he does mindfulness meditation daily. Like some patients whove successfully tapered, Tran still feels anxious and still experiences the residual effects of withdrawal. To alleviate them, he uses many methods he first learned about online, and there are times when he climbs into bed, pulls up a 17-pound weighted blanket, and puts on noise-canceling headphones.

Life feels better nowharder, he says, but also more rewarding. If he could start treatment all over again, Tran wouldnt visit a general practitioner. I would definitely go talk to either a psychologist, a psychiatrist, someone who is more specialized in this field, he says. If I could go back now, I would try to avoid medication. Thats my biggest regret.

The Anxiety Spectrum Anytime medication is considered at any phase to treat anxiety, ask questions, says psychiatrist Gregory Scott Brown, M.D. Ask: How long should I be on this medication? Whats the intended effect? Is it addictive? Use the chart below to plot a sustainable path forward.

Situational Anxiety Symptoms Pounding heart, shaky voice. Rx Take a beta-blocker right before public speaking, a job interview, or another nonrecurring anxiety--producing situation. Mild Anxiety Symptoms Racing thoughts, heart palpitations, excessive worrying, tension in your body. Rx Have a doctor rule out underlying causes like hyperthyroidism; practice meditation using an app like Headspace, and consider yoga; try cognitive behavioral CBT).

Severe Anxiety Symptoms Inability to go to work or leave the house, substance abuse, suicidal thoughts. Rx Explore benzodiazepines in addition to SSRIs/SNRIs; get help for drugs and alcohol; use CBT and meditation; consider a short-term stay at a mental--health treatment facility.

Michael Tran always thought of himself as shy and a little anxious. But in 2012, he began having debilitating panic attacks. At the time, Tran was 19, a University of Maryland sophomore. Hed get tunnel vision. His heart rate would skyrocket. Hed lose the ability to walk, stand, or do much of anything. Tran stopped going to class and dropped out within a year. He eventually went to see a doctor. I get really nervous, he told his physician. I cant perform in front of people. I cant... I get rea...

Escape the Anxiety Trap

He had agreed to take in a friend’s son who was struggling with addiction, on the condition that no drugs be brought into his house. When Weil discovered a packet of white powder in the guest bedroom, he called 911. “Somebody’s messed up in my house,” he recalled saying. “He’s on drugs. I don’t know what he’s on. Can we get somebody here?”

When officers arrived, Weil tried to hand over the packet, but was told to drop it onto his gravel driveway. He did, but picked it up again out of concern, he later said, that his Yorkshire terrier, Schnoogabutch, or his free-range chickens would be exposed.

As he picked up the packet, some powder got on his index finger and he blew it off. Police later said that he blew “a large cloud” of the powder toward them, exposing one officer to fentanyl, an opioid whose use has driven up the number of overdose deaths nationwide to a record high.

Weil was charged with reckless conduct, something akin to waving a loaded gun in the air. Prosecutors argued that fentanyl was a deadly weapon.

As stories circulate of the lethality of powdered fentanyl and its cousin, carfentanil, similar cases have been brought in Maine, Michigan, Indiana, Ohio, Wisconsin, North Carolina and Kentucky, with charges ranging from wanton endangerment to assault.

At least two people are serving sentences of up to three years. In the widely reported case of an Ohio officer who was said to have nearly died after brushing some fentanyl off his shirt, a man pleaded guilty to assault and was sentenced to 18 months. More than 10 other cases are pending.

Medical professionals say that the risks from accidental exposure to opioids, even potent ones, are actually very low. The prosecutions have been driven by fear, they say — not science. None of the incidents has caused a death, or even symptoms of opioid overdose, a review of the available evidence shows.

Even so, fear is rampant: there has been no shortage of warnings that unidentified powders can kill. A 2016 video by the Drug Enforcement Administration warned law enforcement that touching fentanyl or breathing in just a few airborne particles could be fatal.

Dozens of police officers and medics have been given naloxone, a drug that reverses opioid overdoses, to treat suspected on-the-job exposures. Those affected have often complained of dizziness, nausea, and lightheadedness. Some pass out.

In Ohio, after a prisoner overdosed, 23 correction officers and four nurses were treated for possible opioid exposure, 31 inmates were relocated, and a nearby school was placed on modified lockdown.

“I never want to be in a position where I have to go see a family member, a wife, kids, and explain to them why their father or husband is not coming home that evening, or ever, for that matter,” Ryan Heath, the police chief in Alton, New Hampshire, where Weil was charged, said in an interview.

“Everybody knows it’s a dangerous substance,” Heath added. “I’ve seen it on the news.”

More recently, the Justice Department released another video, urging emergency medical workers to use precautions like gloves, eye protection and a face mask. In several cases, officers and emergency workers have conducted drug busts while wearing biohazard containment suits.

But such messages worry doctors, who contend that these precautions are unnecessary and could even do harm, stigmatizing patients — as happened in the early years of the AIDS crisis — and causing deadly delays while responders don protective gear.

“I want to tell first responders: ‘Look, you’re safe,'” said Dr. Jeremy S. Faust, an emergency physician at Brigham and Women’s Faulkner Hospital in Boston. “You can touch these people. You can interact with them. You can go on and do the heroic lifesaving work that you do for anyone else.”

True, a dose of powdered fentanyl the size of a few grains of sand can prove lethal, and carfentanil is even more potent. But the drugs must generally be deliberately ingested, not accidentally touched or inhaled, to cause a reaction.

“I would say it’s extraordinarily improbable that a first responder would be poisoned by an ultra-potent opioid,” Dr. David Juurlink, a clinical researcher at Sunnybrook Health Sciences Centre in Toronto, said. “I don’t say it can’t happen. But for it to happen would require extraordinary circumstances, and those extraordinary circumstances would be very hard to achieve.”

For exposure by inhalation, powdered drugs would have to be aerosolized; for absorption through the skin, they would have to be dissolved in liquid or formulated with a “permeation enhancer,” according to a scholarly article.

To counter the false alarm, toxicologists released a formal position paper last year, saying the risks involved in touching or inhaling powdered forms of fentanyl are “extremely low.”

If that were not the case, said Dr. Kenneth A. Williams, a professor of emergency medicine at Brown University in Providence, one would expect to see more reports of exposure involving people who use drugs, or ordinary civilian bystanders. But virtually all of the cases involve police and other emergency personnel.

Experts say the symptoms that are reported, like nausea and dizziness, may be real, but could stem from an expectation of harm, commonly known as the “nocebo” effect — the placebo effect’s evil twin.

In one Kentucky case, an emergency medical technician named Scottie Wightman radioed for help after he used a towel to dry off a patient who had overdosed. Wightman lost consciousness and was treated with naloxone, but his drug test was negative.

“What was going through my mind was, ‘Here I am trying to help someone and keep them alive, and I almost died doing that,'” Wightman said in an interview. “I’m supposed to be helping someone, yet in my mind, it’s like they just tried to kill me.”

As a result of the episode, three people — the patient who overdosed, his stepson and his stepson’s girlfriend — have each been charged with 10 counts of wanton endangerment. The patient recently pleaded guilty. The other two cases are pending.

The stepson, Scotty Hatton, said that he had lost custody of his own son because of the charges and that local officials had thrown out all his possessions over fears of contamination. “I would understand if they found a bunch of dope or had a test that said, ‘Yeah, that’s carfentanil,'” Hatton said. “But they had no test or anything.”

Had he not called 911, Hatton said, the patient could have died, laying Hatton open to “some kind of manslaughter charge, or murder, or something like that.” If he had it to do over, he would call 911 again, he said: “I didn’t want him to die.”

In Weil’s case, the officer who was reportedly exposed, Jamie Fellows, wrote, “The cloud of fentanyl came down around me and I had breathed in a portion of the powder.” Fellows said he felt something drip down the back of his throat, and later complained of a headache. He declined a request for comment.

An emergency medical technician employed by Alton Fire and Rescue who treated Fellows that night observed that he had an ordinary respiratory rate and blood oxygen saturation. After consulting a doctor, the technician determined that the officer required no treatment and had “no apparent illness or injury.”

The prosecutor, Adam Woods, offered no evidence that Weil had caused injury, but said that was not the point. “What he’s charged with doing is knowing that that substance was dangerous, disregarding that danger, that risk, and recklessly blowing it in the air,” Woods said in an interview. “He’s not charged with calling the police. He’s not charged with possessing the drug.”

Weil was convicted by a jury in September.

His lawyer, Harry N. Starbranch Jr., asked that the verdict be overturned, arguing that there was no evidence that fentanyl was a deadly weapon or that Fellows ingested any. On Nov. 1, the judge granted the motion, setting aside the verdict. The prosecutor has vowed to retry the case.

Weil, who said he spent more than $10,000 on legal fees and another $300 on security cameras trained on his driveway, said the experience had changed him.

“If ever I go into a situation where somebody’s OD-ing, I’m going to stand over them and watch them die,” he said. “If they say, why didn’t I call? Are you out of your mind? The last time I called somebody, I got a Class B felony.”

This article originally appeared in <a href="https://www.nytimes.com/2018/12/17/us/fentanyl-police-emt-overdose.html" id="43d6340b-9717-396d-a796-54bbc24696a8">The New York Times</a>.

What Can Make a 911 Call a Felony? Fentanyl at the Scene.

ALTON, N.H. — Eric Weil, a gregarious 50-year-old painter who lives in a wooded neighborhood hugging the shores of Lake Winnipesaukee, never suspected he would face felony charges when he called 911 last August.

In one Kentucky case, an emergency medical technician named Scottie Wightman radioed for help after he used a towel to dry off a patient who overdosed. He lost consciousness and was treated with naloxone, but his drug test was negative for opiates.

Three people have each been charged with 10 counts of wanton endangerment as a result of the episode. One of them, the patient who overdosed, recently pleaded guilty. The case against his stepson, Scotty Hatton, who had called 911, is still pending.

Hatton said he had lost custody of his son and that local officials had thrown all his possessions over fears of contamination. “I would understand if they found a bunch of dope or had a test that said, ‘Yeah, that’s carfentanil,'” Hatton said. “But they had no test or anything.”

Had he not called 911, he said, his stepfather could have died, laying Hatton open to “some kind of manslaughter charge, or murder, or something like that.” If he had it to do over, he would call 911 again, he said: “I didn’t want him to die.”

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Peter Andrey Smith

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Escape the Anxiety Trap

What Can Make a 911 Call a Felony? Fentanyl at the Scene.

What Can Make a 911 Call a Felony? Fentanyl at the Scene.

What Can Make a 911 Call a Felony? Fentanyl at the Scene.