That’s why this drug can be dangerous if you take too much or – and this is very important – take it with other medications that cause central nervous system sedation, such as alcohol, opiates, barbiturates, sleeping pills and even some old-style antihistamines.
CNN: What is the potential for abuse with lorazepam? What are the risks?
Saltz: If you’re taking this for anxiety, for example, as we see in the show – and I would say that Victoria appears to be taking it for social anxiety, when she’s going to go have to be with other people – which is different than Timothy, who is just flooded and in a state of utter traumatic panic and is just popping them indiscriminately.
When you have a positive response, that is what makes a drug psychologically addictive, which is not physiologically addictive. It’s not dangerous, but what it does do is make you want to take more, right? Because anxiety feels bad – really bad – and when you can take a medication that makes you relax and not experience the anxiety, it’s positively reinforcing. Of course you’d want to take that medication again. It made you feel better.
CNN: Is there anyone who would not be a good candidate for a lorazepam prescription?
Saltz: Yes, people who need one of these cross-reactive medications that you’re genuinely concerned about the sedative effects. Somebody who is abusing alcohol. Somebody who is abusing other drugs or has really struggled with sobriety, with serious addiction. We try to find ways around prescribing other addictive medication, too.
CNN: Victoria is keenly aware of how many pills she has – or is supposed to have. Is this a more complicated prescription to get or fill than, say, antibiotics?
Saltz: Absolutely. It’s considered a controlled substance.
Generally, physicians can prescribe lorazepam, but it is a different level of prescription where the doctor can’t just call it in on the phone. They are going to look at how many they’re prescribing you, as well as if – and how many – refills they would offer you.
Kind of like we do with opioids, if a patient is blowing through them faster than anticipated via the prescription, there needs to be discussion with the patient of, “Why? Where did that go? What is happening? Do you legitimately need more? OK, maybe this is an underdosing. Let’s discuss that. What symptoms are you having? Or are you heading toward tolerance?” And we have to think about what to do here.
CNN: During another scene in the show, we see Timothy taking these pills while drinking heavily. That can lead to very serious interactions, right?
Saltz: Oh, yes. Alcohol specifically interacts with benzodiazepines. They both affect the GABA system. They both can cause, on their own, respiratory depression and death – meaning you stop breathing and die. But together, they are what’s called synergistic, meaning it makes each of them have more of that effect than the two of them on their own. So it’s dangerous. That’s why they tell you not to drink when you’re taking lorazepam.
So yeah, he’s pounding them. And you know, it would not be a plot twist that Timothy doesn’t wake up in the morning.
By the way, you see Victoria – after her lorazepam disappears, because Timothy has swiped it altogether – now drinking a lot more. And that is probably because, in addition to being stressed about [spoiler redacted], she doesn’t have the medication to cover her, so she’s drinking.
CNN: In the same episode, Timothy steals a security guard’s gun that he forgot to lock up – and later we see him seriously contemplate suicide. While we aren’t inside (show creator, writer and director) Mike White’s head, is suicidal ideation a known potential side effect of this drug, or do you think this is more likely the result of everything else Timothy is going through?
Saltz: Lorazepam by itself does not cause suicidal ideation, but it is disinhibiting – meaning thoughts that might come into your mind, that you might go, “Oh, no, no, no. I don’t want that thought. Can’t have that thought,” and I push it away. Your ability to suppress it is really not there. So whatever thoughts you’re having would be disinhibited.
Timothy’s situation, all by itself, would cause depression. Depression drives suicidal ideation.
Another feature of lorazepam that is adding to that is basically poor cognitive functioning. Lorazepam literally slows your thoughts. It’s called thought deceleration. And in slowing your thoughts, your ability to problem-solve – which he clearly needs right now – is impaired. And so he is probably feeling like he cannot think his way out of anything right now, and this is a very dire situation.
CNN: Now that Timothy has stolen Victoria’s entire prescription bottle, is she going to experience any withdrawal symptoms? What does that look like?
Saltz: The question will be, how frequently was Victoria taking this lorazepam? Was this a prescription that was basically like, “Here are 30 lorazepam for the month”?
If she knows, “I’m going to dinner and I have to be at a resort and socialize with other people, and this makes me feel panicky, I can take a lorazepam for the dinner, and I’ll be OK,” but she’s not taking it during the day or any other time, she’s probably not addicted. She’s probably OK from a physiologic standpoint.
If someone who is taking lorazepam more regularly abruptly stops this medication after they are tolerant to it or addicted – which can be a matter of just a couple weeks – you can have a spike in blood pressure. You can have a whole host of very miserable flu-like feelings, confusion, and actually, these things can rise to the level of causing death.
It’s a very serious medication to be aware of its easy abuse potential, even in a person who has no intention of abusing it. We have yet to see in the plot whether that will come to pass, but it is something I as a psychiatrist have been concerned about as I watch.
CNN: Some people, in consultation with their doctor, will absolutely benefit from a lorazepam prescription. But not everyone with anxiety needs this medication. What are some other tried-and-true ways to manage anxiety?
Saltz: If you struggle with anxiety, there are a lot of coping tools that you can build into your day that will help you manage it and not get to the level of an anxiety disorder. Those run the gamut from things like a regular practice of paced deep breathing, progressive muscle relaxation, 30 minutes of aerobic exercise a day with your heart rate up, talking to somebody about whatever you’re anxious about. That could be someone supportive in your world. That could be a therapist. I always say that should be your first stop.
CNN: A main character dies at the end of every season of “The White Lotus.” Do you want to go on the record with who you think is going to die this season? Just two episodes left!
Saltz: I don’t know why I’m even saying this exactly. It’s just some general gestalt feeling. But I feel this sad feeling like, what’s the name of Rick’s girlfriend again? Chelsea! She’s the one character that maybe I can feel some compassion for on the show.
Chelsea is sort of a lost soul, decent person – seemingly, so far, right? Bad things keep happening to Chelsea, and she’s heralding that this really has meaning to her. She’s anticipating bad things. And so, I don’t know if they’re foreshadowing her in that way, but for me, it’s resonating as, you know – they never take out the truly horrendous people.
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