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Dr. Keane
Dr. Keane, Therapist
Category: Mental Health
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Experience:  Clinical Psychology PhD, Licensed Professional Counselor with experience in marriage/family, teens and child psychology.
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I have a friend who is on xanax prn. She has been many

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So I have a friend who is on xanax prn for anxiety. She has been for many many years. she utilizes the drug 15 to 20 times a month for social anxiety mostly. she has tried other medications without success. She was recently told by her pain management doctor that the cdc had now issued GUIDELINES stating she can not be prescribed opiods for pain and benzos for anxiety and that she must chose which she would like to be treated for. This to me is proposterous. I have googled and found the opiod guideline for prescription of opiods but i cant find this benzo/opiod guideline. Can you help verify this information. is it true?

Submitted: 3 months ago.
Category: Mental Health
Expert:  TherapistMarryAnn replied 3 months ago.

Hello and thank you for requesting my assistance. However, your question is better answered by a psychiatrist. I will opt out to allow one to answer.

Take care,


Expert:  Norman M. replied 3 months ago.

The CDC has issued guideleines, and here is the nut of it:

11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible (recommendation category: A, evidence type: 3).

Benzodiazepines and opioids both cause central nervous system depression and can decrease respiratory drive. Concurrent use is likely to put patients at greater risk for potentially fatal overdose. The clinical evidence review did not address risks of benzodiazepine co-prescription among patients prescribed opioids. However, the contextual evidence review found evidence in epidemiologic series of concurrent benzodiazepine use in large proportions of opioid-related overdose deaths, and a case-cohort study found concurrent benzodiazepine prescription with opioid prescription to be associated with a near quadrupling of risk for overdose death compared with opioid prescription alone (212). Experts agreed that although there are circumstances when it might be appropriate to prescribe opioids to a patient receiving benzodiazepines (e.g., severe acute pain in a patient taking long-term, stable low-dose benzodiazepine therapy), clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. In addition, given that other central nervous system depressants (e.g., muscle relaxants, hypnotics) can potentiate central nervous system depression associated with opioids, clinicians should consider whether benefits outweigh risks of concurrent use of these drugs. Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians (see Recommendation 9) and should consider involving pharmacists and pain specialists as part of the management team when opioids are co-prescribed with other central nervous system depressants. Because of greater risks of benzodiazepine withdrawal relative to opioid withdrawal, and because tapering opioids can be associated with anxiety, when patients receiving both benzodiazepines and opioids require tapering to reduce risk for fatal respiratory depression, it might be safer and more practical to taper opioids first (see Recommendation 7). Clinicians should taper benzodiazepines gradually if discontinued because abrupt withdrawal can be associated with rebound anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death (contextual evidence review). A commonly used tapering schedule that has been used safely and with moderate success is a reduction of the benzodiazepine dose by 25% every 1–2 weeks (213,214). CBT increases tapering success rates and might be particularly helpful for patients struggling with a benzodiazepine taper (213). If benzodiazepines prescribed for anxiety are tapered or discontinued, or if patients receiving opioids require treatment for anxiety, evidence-based psychotherapies (e.g., CBT) and/or specific anti-depressants or other nonbenzodiazepine medications approved for anxiety should be offered. Experts emphasized that clinicians should communicate with mental health professionals managing the patient to discuss the patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care.

Now, the issue really is this. How does the patients need for opiate pain control stand up against the patients need for anxiety issues. This is s decision that should be made with her clinician and a mental health professionsl.

Now, obviously, I do not know the person, but I recommend that she talk to her Doc about continued opiate treatment for her pain and a course ofCognitive Behavioral issues to deal with her anxiety issue.

Here is a brief overview what it is about.



Clients likeyourself often bring to therapy uncomfortable emotions which could be labelled,generally, as 'stress" or "upset". The cognitive therapist (or other practitioner usingcognitive therapy skills) finds such labels too vague. The focus is then onagreeing a clearer description, usually in terms of a so-called "unhealthynegative emotion". The main unhealthy negative emotions are anxiety,depression, anger, guilt and shame.

ANXIETY is an emotional reaction to a perceived, threat, dangeror pressure including (self-generated pressure).

So far, emotions have been presented asthe bot***** *****ne in causing destructive behaviour and psychosomaticdifficulties. The cognitive therapist, however, holds that emotions, behaviourand biology cannot be changed in any lasting way until underlying"cognitive" factors (including thoughts, beliefs, attitudes, valuesand standards) have been addressed. This point probably needs to be emphasised:for example, a predisposition towards anger and its behavioural/biologicalconsequences isn't going to shift until you look at the underlying attitudetowards other people; a guilty reaction isn't going to change until a higherdegree of self-acceptance has been taken on board; and anxiety will remainaround as long as the anxiety symptoms themselves continue to be seen as dangerous.

There's no magic bullet to changeunhealthy negative emotions and their destructive/painful consequences. Theonly way is to have a good look at your attitude towards yourself, otherpeople, the world in general and the future. Particularly unhelpful attitudesinclude dogmatic musts/shoulds, focusing/dwelling on the negative, maximisingthe negative, minimising the positive/realistic, emotional reasoning (arguingsolely on the basis of your feelings), labelling, taking things personally andall-or-none thinking. For lasting beneficial changes to happen at theemotional/behavioural/biological level, these patterns need to be uncovered,challenged and replaced by more helpful attitudes.

Specific guidelines on how to do thisare presented during sessions. Work between sessions to consolidate is alsoimportant


The goals of cognitive therapy could beexpressed as follows. The initial focus is to identify unhelpful attitudesunderpinning emotional, behavioural and psychosomatic difficulties. Then,you're encouraged to think flexibly, logically, realistically (rather than positively and pragmatically. Other keywords here are self-responsibility and acceptance. This will help you to minimise emotional disturbance, self-defeating behaviour and psychosomatic difficulties, generally as well as targeting the presenting problem itself. Inthe longer term, you will then feel better and be more able to fulfill your potential.

The working relationship in cognitive therapy is flexible,depending on your preferences. Dimensionsfor us to consider and agree are formality (formal v informal), support(supportive v challenging) and direction (being guided minimally v being toldwhat to do). Common denominators, however, include equality (client andtherapist being viewed as equals), empathy, respect (no matter how irrationalyour thinking may be, you're guaranteed to be valued as a person) and"psychoeducation" (there are no hidden agendas in cognitive therapy -it's an upfront approach with a clear set of ideas to be taught and learned).The working relationship we develop may itself give vital clues about yourbelief system.

The tasks in cognitive therapy arevaried and involve, for example, discussion, role play, role reversal (where Irole play your unhelpful attitude and you argue back in the same way it's hopedwill happen within yourself thereafter), mental rehearsal and"homework" assignments.


The main idea here is unconditional self-acceptance (USA). USA is based onthe logical notion that you can't rate your whole self - because you toocomplicated. Sure, you can rate your thoughts, feelings and actions as good,bad or indifferent. But to rate your totality in this way is absurd. Even on apurely psychological level, you're made up of a huge variety of memories,thoughts, images, attitudes, values, emotions, actions - conscious andunconscious - past, present and future. How on earth can you pin a singlerating on all that? Of course you can't. So get off your case. Like anybodyelse, you're just a fallible human being prone to thinking, feeling and actingimperfectly, often very imperfectly. Leave it at that.

Refuse to be prejudiced against yourself.Just because you have a disability doesn't make you a mad or a bad person, evenif you're creating it yourself. (You wouldn't want to "ethnicallycleanse" people like you, would you - something based on the exact sameprinciple of prejudice?!) And would you go up to someone else when they're inthe middle of their problem, and feeling panicky or whatever, and bellow intheir earhole, "What a complete failure you are"? Well, isn't thatpretty much what you've been doing to yourself. Stopit. Be more supportive of yourself. (Andapply these same principles to others too - just because they behave badlydoesn't make them a totally bad person. If that were really true, they would beincapable of acting any other way, which is clearly nonsense.)

*"I mustn't have this problem"becomes something like (feel free to use your own words): "I don't likehaving this problem, but there's no reason why it mustn't happen. ! wish Ididn't have the problem, but where is it written that I absolutely shouldn't?!!f I've got a problem, I've got a problem. Welcome to reality". (Thesemore helpful beliefs need to be practised, of course, and then applied withforce and conviction.)

"Having thisproblem means I'm a failure' becomes something like: "This problem meansonly that I'm a fallible human being, prone just like anyone else to havingproblems. I can accept myself with the problem and work at solving it withoutbeating myself over the head for having the problem in the first place. I caneven accept myself for

"I mustn't make a fool of myself'becomes something like: "I really hope I don't make a fool of myself, butthere's no reason why I absolutely mustn't. If I do make a fool of myself,unfortunately all the conditions will be in place for me to make a fool ofmyself especially my belief that I mustn't make a fool of myself. I like beingtogether all the time, but I don't have to be. I like presenting myself as acoherent and credible person, but who says I have to! There's no universal lawto dictate that I mustn't make a fool ofmyself. If I do, I do. Too bad".

"Making a foalof myself means I'm a complete fruitbat" becomes something like:"Making a fool of myself means nothing about my whole self. I'm only afallible human being, just like anyone else, prone to acting stupidly. My wholeself simply isn't on the line here, no matter how stupidly I behave".

Again, this same reassuring approach -flexible, logical and pragmatic - can be applied to thousands of examples. Doso with your own unhelpful thoughts as they crop up during the day. In theprocess, make yourself increasingly immune from disturbing yourself - whileaccepting that you'll never be totally successful in this.

Basically, CBT stems from the theorythat our emotions and feelings(and the actions that flow from them) are theresult of our thoughts

Each ofthese areas can affect the others. How you think about a problem can affect howyou feel physically and emotionally. It can also alter what you do about it.There are helpful and unhelpful ways of reacting to most situations, dependingon how you think about them.

For example:


You've had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you.




He/she ignored me - they don't like me

He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?


Low, sad and rejected

Concerned for the other person


Stomach cramps, low energy, feel sick

None - feel comfortable


Go home and avoid them

Get in touch to make sure they're OK

The same situation has led to two very differentresults, depending on how you thought about the situation. How you thinkhas affected how you felt and what you did. In the example in theleft hand column, you've jumped to a conclusion without very much evidence forit - and this matters, because it's led to:

  • a number of uncomfortable feelings
  • an unhelpful behaviour.

If you go home feeling depressed, you'll probablybrood on what has happened and feel worse. If you get in touch with the otherperson, there's a good chance you'll feel better about yourself. If you don't,you won't have the chance to correct any misunderstandings about what theythink of you - and you will probably feel worse. This is a simplified way oflooking at what happens. The whole sequence, and parts of it, can also feedbacklike this:

This "vicious circle" can make you feelworse. It can even create new situations that make you feel worse. You canstart to believe quite unrealistic (and unpleasant) things about yourself. Thishappens because, when we are distressed, we are more likely to jump to conclusionsand to interpret things in extreme and unhelpful ways.

CBT can help you to break this vicious circle ofaltered thinking, feelings and behaviour. When you see the parts of thesequence clearly, you can change them - and so change the way you feel. CBTaims to get you to a point where you can "do it yourself", and workout your own ways of tackling these problems.

"Five areas" assessment
This is another way of connecting all the 5 areas mentioned above. It builds inour relationships with other people and helps us to see how these can make usfeel better or worse. Other issues such as debt, job and housing difficultiesare also important. If you improve one area, you are likely to improve otherparts of your life as well. "5 areas" diagram.

(Thisexample courtesy of the Royal College of Psychiatrists)

These are summarised on the following situation analysis sheet.

Situation / Activating Event / Adversity (A)

  • Examples: Threat, pressure, loss , failure, frustration, unfairness, rejection, doing the wrong thing, not doing the right thing, showing weakness in public.
  • Can be real inferred, imagined, past, present, future (ie worrying), internal or external
  • Difficulties at Box C below can easily feed back to become a “Level 2” A which compounds the disturbance – reacting to your own reaction, having a problem with a problem

Unhelpful Attitudes/Beliefs (B)

General Attitude – uncompromising, illogical, unrealistic, self-centered, superiority focused.

Must-ing and Mustn´t –ing

  • Examples – things must go my way, I mustn´t be out of control, I must do my best, ***** ***** want something I must have it, I mustn´t create a bad impression
  • Common themes – control, achievement, perfectionism, approval, love, entitlement, freedom
  • Variations – should, got to, have to – and their negatives
  • Escalating, hyping-up human wants, preferences and desires into needs, demands and high rigid standards
  • Visual Analogy – King Canute
  • Puts yourself under pressure, creates a restricted comfort zone (straightjacket) and highlights the “must” not happening and the feared “must not”

Self Esteem Judgements

  • I´m a bad person (for doing a bad thing), I´m an idiot (for behaving stupidly), I´m weak (for having a weakness, I´m a failure (for having failed at some task)
  • Negative person rating – rating your whole self, downing your entire self with a condemning label
  • Defining yourself mainly in terms of one aspect of your life – what you achieve, your difficulties, other’s approval, how your children turn out etc
  • Being prejudiced against yourself
  • Similar over-generalisations being applied to other people (“jerks”), the world – all bad, the future “bleak”

Helpful Attitude/Dispute of B (D)

General Attitude – Flexible, logical, realistic, task centred, demonstrating humility.

Full Flexible preferences

  • Examples – Just because I want things to go my way doesn´t mean they have to. It´s great fulfilling my potential, and I will try to, but there is no earthly reason why I must. It does not logically follow that because I want something, I absolutely must have it. It´s nice to be treated fairly, but there is no universal law that says I must be.
  • Accidents – These things happens – shit happens, whatever exists, exists, this is the way of the world. Must-ing or mustn´t –ing about this just makes things worse for me.
  • Downscaling hyped-up needs into wants.
  • Loosening – rather than lowering your high standards.

Unconditional Self Acceptance

  • Examples - I accept myself as a fallible person who has done a bad thing/behaved stupidly/shown weakness/failed etc. I´ll take the consequences and try to prevent a recurrence, the forget it.
  • Appreciating that your whole self cannot be rated – we are in infinitely complex web of feelings, actions and thoughts impacting on the past, present and future, and this makes any overall rating/judgement impossible
  • Accepting other people, the world and the future as fallible and uncertain, a mixture of good, bad and indifferent
  • Viewing self-esteem as a useless concept, at the root of which is prejudice


General: stress, upset, disturbance, agitation.

Unhealthy Negative Emotions anxiety, depression, anger, guilt shame, hurt, jealousy, envy

Troubled Thinking : unsettled, chaotic, cynical, obsessive, worrying, self –absorbed, over-serious, defensive. Problems with concentration/memory/decision making.

Destructive Behaviour – the useless side of life –avoidance, withdrawal, procrastination, sulking, self punishment, addictions, compulsions, reassurance seeking, aggression, shyness, frantic problem solving attempts etc

Bodily Symptoms headaches, skin complaints, high BP, lethargy, digestive disorders, restlessness, insomnia etc. – These tend to feed back to A above, creating further stress.


General – taking things in your stride.

Healthy Negative Emotions concern, sadness annoyance, regret, disappointment

Balanced Thinking acceptance, settled, clear, task focused, lightening up, enhanced concentration, better memory and decision making etc

Constructive Behaviour - the useful side of life – assertiveness, openness, doing things now, letting go if indicated, problem solving attitude etc.

Bodily Response more comfort and far fewer physical symptoms, those remaining tending to be medical rather than psychosomatic. This tends to feed back to Box A and reduce stress and disturbance.




  • Examples – it´s awful, terrible, dreadful etc

Failing, having problems, being ridiculed etc

  • Catastrophising – usually when “musts” don´t happen or “must nots” do.
  • Exaggerating the negative – being a drama king/queen
  • Having a badness scale from 101% to infinity!

Low Frustration Tolerance

  • I can´t cope with………(fill in the blank)
  • It does my head in, I´m falling apart, I´ll never be happy again

Faulty Emotional Reasoning

· I feel it, so it must be true

· Because I´m this angry, they must be out of order.

· Because I´m this anxious, I really must be in danger

Fanatical Belief in All Mental Processes

· I think it, so it must be true

· I have to believe all my worries

Perceptions of Self as Abnormal

  • It´s abnormal to think as irrationally as me, and to have the problems I do.

All or Nothing, Black and White Thinking

  • Because I haven´t succeeded I´m a total failure
  • I´m right, you´re wrong

Personalisation/Self Reference

  • Seeing yourself as responsible for things outside your control
  • Thinking “It´s all my fault”
  • I make them feel uncomfortable


  • I can´t change my unhelpful attitudes

Lack of Autonomy

  • The way I feel depends entirely on what happens to me

Fortune Telling/Crystal Ball Gazing

  • The future is…………….(fill in the blank)

Mind Reading

  • They´re thinking/feeling/saying ………… about me.




  • What´s so terrible about this
  • Examples – It´s pretty grim/bad/inconvenient/a nuisance…….but not terrible/the end of the world.
  • Keeping things in perspective

High Frustration Tolerance

  • It´s difficult/uncomfortable/painful……but I can put up with it/lump it/muddle through
  • I´m not literally falling apart at the seams. Chances are I will be happy again

Restriction of Credibility on Emotions

  • How does this logically follow? Maybe I´ve got the cart before the horse. My feelings are stirred up by my unhelpful attitudes, not the other way round.

Healthy Scepticism about Mental Processes

  • My mind, just like anyone else´s is capable of generating nonsense. Just because it presents me with a particular thought or image does not mean I have to believe it

Perceptions of Self as Normally Irrational

  • Many respected thinkers in psychology believe irrationality to be built in to the human condition. Irrationality is a the core of human being – normality is not. Some people can harness irrationality quite well, but most of us have problems with it

Spectrum / Continuum thinking

  • Totally? Completely? What would others say about this? Are there no shades of grey? Is there no middle ground at all?

Assuming Appropriate Responsibility

  • How can this be so? Are there no factors not involving me which could account for this? Isn´t this just me trying to regain self esteem through a twisted way of seeing myself as powerful enough to make a (negative) difference?


  • It´s very difficult, and I might not be 100% successful at this, but with dedicated work and practice, I can make a lot of headway.


  • What happens to me certainly contributes to and triggers they way I feel, but it doesn´t cause it. That´s where I come in. If I feel unhealthily negative about anything (see box C above), it´s because I´m choosing to have some unhelpful attitudes which I can choose to change

Realistic Uncertainty

  • The future has not happened yet, and is therefore still uncertain Keep the Jury out. There are no 100% guarantees. Who knows what might happen?

Maintaining Psychological Boundaries

  • How do I know? Things generally feel worse on the inside than they look from the outside. Anyway, it´s doubtful if I´m the centre of their universe. Who cares? It does not really matter.

F:\Data\practice\Forms 2007\CBT\CBT Introduction2007.doc 23/03/2007

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