Substance abuse with diabetes, doctors who don’t like the way you’re using your insulin pump — these are just a few of the prickly issues we deal with here at our weekly advice column, Ask D’Mine, hosted by veteran type 1, diabetes author and community educator Wil Dubois.
Send us your queries related to life with diabetes — nothing is off-limits here! (except of course specific medical instructions for your own care; that’s what doctors are for)
{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}
Megan from California, type 1, writes: I am addicted to benzodiazepines, if you know what they are, and I’m wondering if the drug abuse can affect or be the reason I’m a diabetic now? I’m having a really hard time coming off them … I guess my question is, can it affect my blood sugars?
Wil@Ask D’Mine answers: Oh yeah, I know what benzos are. But just in case some of our readers don’t: They’re a highly addictive family of depressant meds—tranquilizers in plain English—intended to counteract seizures, reduce muscle spasms, relieve anxiety, or serve as sleep aids. They act in a dose-dependent manner. Small doses have a mild sedative effect, middle of the road doses chill people waaaaay out, and whopping doses knock your lights out. Ummm… and I’m not even sure if I should mention this, but benzos are one of the media-hyped “date rape” drugs.
Worldwide, more than 2,000 different benzos are in production, but here in the U.S. there are 15 different types that are FDA approved including the trade names Ativan, Librium, Versed, Xanax, and my personal favorite: the 38-year-old blockbuster Valium. More than 108 million prescriptions are written for benzos in the U.S. annually, placing them at the number 11 slot of the top-20 most prescribed types of meds. For perspective, in sixth place, are anti-diabetes meds, with 165 million prescriptions. (Inquiring minds want to know the top three? In first place are cholesterol meds, in second place are antidepressants, and in third place are narcotic pain killers. Welcome to PharmaLand.)
Oh, and just so none of you judgmental-types mistake Megan for a low-life, benzos are handed out like candy by primary care docs, are highly addictive, and benzo addiction is a lot more common than you might suspect. Try this on for size: six percent of the U.S. population has abused benzos at one point or another.
In addition to being highly addictive, benzos have some nasty side effects from long-term use. As the drug’s effect is on the central nervous system, long-term bad shit includes amnesia, hostility, irritability, and funky dreams. Withdrawal is also markedly wicked, not unlike the DT’s suffered by severe alcohol abusers.
I remember my wife’s grandmother, a sweet little old lady of 86 years old, had gotten addicted to very high volumes of Ativan prescribed by her primary care doc. She had been hospitalized for some other issue and the hospitalist (who must have gotten his medical degree in Mogadishu) stopped her Ativan cold-turkey, rather than tapering it down as any first year Resident would know to do. That night she attacked a nurse and pulled out huge clumps of the poor woman’s hair.
She had to be restrained and we were called in.
Grandma had a wild-animal look in her eyes when I arrived on the scene, and she was convinced that I’d been replaced by an imposter. “That can’t be Wil, he’s too skinny!” (I had lost around 70 pounds following my diagnosis.) As we wheeled her out to the car she was screaming at the top of her lungs that she was being kidnapped by strangers. Oh, and she also started screaming that there was a bomb in the hospital and everyone should run for their lives. Interestingly, no one came to her rescue and no one ran for their lives. I don’t know if that says more about our society or how respectable I look.
Moving on… did your addiction cause your diabetes? Well, we don’t really know what causes type 1 diabetes, but I think we can be pretty confident that it isn’t benzos or we’d have a helluva lot more type 1s on our hands. And let’s not forget that benzo-addicted kids, while not unheard of, are a lot less common than benzo-addicted adults ― while most newly diagnosed type 1s are kids.
As to the effect the benzos might have on your blood sugar, not much, or least not much that I can find. (Although apparently scarfing down a lot of carbs can make withdrawal symptoms worse in some people trying to kick the habit.) Of course, coming off of benzos is going to entail some serious withdrawal, which can be pretty grueling, as you know. I wouldn’t be surprised if you had some trouble with blood sugar control during this time as your body will be putting up quite a fight.
For what it’s worth, I did find one source, from the Japanese Journal of Pharmacology, reporting on a study in Brazil, on diabetic rats… and at this point I wonder if I should even go on? Oh well, what the hell: this study showed that if you give diabetic rats benzos it increases their insulin levels and lowers their blood sugar. But I couldn’t even find out how many rats were studied.
So if anything, your addiction should help lower your blood sugar, not make higher.
That said, I think you should continue your efforts to get yourself clean, and to do that you need some folks on your side. You’ll need to come off the benzos slowly. You’ll need expert medical guidance, some counseling, and a ton of support from friends and family. And don’t forget your online family. We’re here for you, Sister.
Kellan from Ireland, type 1, writes: My endo wasn’t impressed when he was going through my pump and discovered I was having up to 12 boluses per day. Even though I’m achieving much better numbers now than I ever was, he feels like I need to change this. If I’m achieving better numbers, then what’s the problem??
Wil@Ask D’Mine answers: For about 12 years, my mom’s VCR flashed “12:00” all the time because no one could figure out how to set the damn clock and it really didn’t matter because she never did any timed recording, anyway. Did that make the VCR useless? Heck no. She could still make Blockbuster runs or hit the record button to tape something she was watching.
Was she using the VCR wrong? Maybe. But who the f— cares? It was working for her.
And speaking of little old ladies, I have a little old lady patient we put on a pump about a year ago (she chose the pink one). Epic medical politics were involved, as her primary care doc was in another city but couldn’t sort out her diabetes so she sent the lady to us. We decided a pump was the best solution, but her particular insurance would only accept a pump prescription from an endo. Then the endo wanted the little old lady to see the CDE in the endo’s office, and this particular CDE was a complete idiot. No really, she was. The patient was a type 2 but the CDE set the bolus limit so low the pump wouldn’t give the patient any insulin at meals (type 2s need more). But I digress.
Anyway, this little old lady had, pre-pump, been doing absolutely terribly. Her A1C was through the roof and her blood sugar was highly variable. Like all over the map. Ambulances were called for lows. She spiked into the 500s. She was what I like to call a CTW: a certified train wreck.
Over a couple of months I got her back on track. Her mornings ran a hair low, 90ish, but stable, and her peak after-meal readings were coming in around 160. It was a frickin’ miracle in my book.
But her endo had a fit.
Why?
Because she wasn’t counting carbs and using the bolus wizard.
Did I mention this lady has had a couple of strokes? Or that her eating patterns are very uniform from day-to-day? I didn’t think she was up to learning carb counting, so I did an end-run and had her use a flat-rate meal bolus from the pump. We got a good basal rate set up, and worked out an effective correction ratio for her rare high blood sugars, all of which were triggered by tangles with her alcoholic low-life daughter. (Not that alcoholics are low-lifes; this woman just happened to be both.)
Was I using her pump “right”? Not really. Did I give a shit? Not really. Look, a pump is just a fancy syringe. It’s “job” is to help PWDs control their blood sugar to the best of their abilities. I was judging our success by our results. Silly me.
The endo blew a gasket ‘cause we weren’t using the pump to the fullest extent possible. She got so mad she yelled at my little old lady and made her cry. My patient came back to me with her tail between her legs, depressed and defeated that her 6.1 A1C and lack of ambulance rides just wasn’t good enough for the endo. “I guess I have to learn to carb count,” she told me.
Or we can use the phone book, I said.
“But how will the phone book help me count carbs?” she nearly wailed.
I won’t, I said, but we can use it to find another endo.
So I’ll confess to being willing to break all the rules. When it comes to health, at least, I do believe the ends justify the means. My mom’s VCR served her just fine with no idea what time it was. My little old lady controlled her diabetes just fine using 10% of her pump’s capabilities.
Kellan, I think if you have to take correction boluses 12 times per day it’s true that your pump is not programed to its fullest capabilities. And I guess that in theory, if you took too many boli too close together you could “stack” your insulin and give yourself a down-stream low. But if you’re not having lows, don’t mind taking the 12 boli, and your diabetes is well-controlled, then the problem is your endo’s, not yours.
Ireland, huh? I think you and your pump should go to the nearest pub, get out the phone book, and find a new endo.
Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.
12 boluses? 3-4 I assume are for meals? Are the other 8-9 food or corrections? Could tweaking the bolus ratio or the basal settings get him off the roller coaster?
My CDE and endo have learned to worry less about protocols. I change my settings more often than advised, often several at a time. That’s why I prefer a pump to Lantus. My insulin needs and my life change constantly and unpredictably. Making one change then waiting a week before making the next would mean the only constant in my life would be misery. I try to fix things and then go on to the more important stuff. Sometimes they help me figure out how to fix things.
If you have good numbers, and relatively stable control, roll with it.
For me, if I want to change, I know it’s going to take time and adjustment period – and I don’t always literally have time to go through that if my current settings are technically working.
For example, I only do boot camp before lunch, because I can maintain a 140 blood sugar start to finish if I haven’t had carbs yet that day. I want to learn how to accomodate the same for an evening workout, but just don’t have the time right now. What I am doing works; fixing it would give me more flexibility on my schedule, but it’s not end of the world.
You have to choose your battles!
Wil, you are a fbreath of fresh air!!!
(ps I bolus a lot, sometimes throughout a meal, as I decide how much more I may want, or if find more of something like a potato in my mouth – I mean, inside a large vegetable stir-fry I’ve made)
Another good explanation for the extra boluses.
Susan, well said. It’s important to learn to use your insulin pump’s features so that you accomplish the most important goal–maintaining target BGs fasting and 1 to 2 hours after meals. Everyone starts from a different place. As you said, you accomplished your goal of maintaining target BG for lunch, and when you’re ready to tackle the next goal which is doing the same incorporating a PM workout, you’ll do that. For others who want basics, if that means using only 10% of the pump’s features, that’s great as long as the goal of target BGs is met.
As for the multiple boluses, I’ve worked with young children using pumps, and that works great for them. If someone is a grazer, the multiple boluses make sense. Now if the reason for the multiple boluses is to correct high BGs, the questions you want to ask yourself are ‘Does my basal have to be adjusted for this time of day?’ ‘Is there a pattern as to when these high BGs occur?’ If it’s after eating, then usually it’s your meal bolus that needs adjusting, or lowering your carb intake if it’s excessive. If the high BGs occur more than 2 hours after eating, closer to your next meal, then it’s more than likely your basal dose. Of course, the only way these questions will be answered is is to check your BGs pre and between 1 to 2 hours post meal.
Benzos. I had bipolar disorder for 20 yrs and was on the benzo Klonopin – generic name clonazepam – for 20 yrs. Believe me, my anxiety was off the charts and I really needed it. When my bipolar d/o went away, my shrink helped me TAPER OFF. It’s super-important not to cold-turkey off, as grandma’s story above illustrates. For me, tapering was easy and I was benzo-free in 5 weeks. No side effects. But, Megan, you must be very careful. Everyone’s body is different. Get a good taper-schedule – it’s officially called ‘titration’ – with the help of a professional. Good luck!