another whacked out med list....

[vistaril]

so my fiance reads off a guys med list that his psychiatrist at a private practice has him on(she is seeing him for some unrelated GI issue):

Lamictal 100mg daily
Seroquel 200mg qhs
Klonopin 1mg BID
Adderall 20mg BID(well second dose at 2-3pm)
Ambien 10mg qhs prn
Trileptal dose unknown
Cymbalta 30mg BID
Wellbutrin SR 100mg BID

I asked her how the pt comes across, and she said "needy and annoying".

She states she isnt planning on scoping him and I said "well, you're already practicing better psychiatry as a GI than this person's psychiatrist is"

She then asks me if I would see the pt and I said "heck no"

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[C O M 2014]

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[BushDoc20]

i came across this list the other day:
Acetazolimide 750mg BD
Sodium Valproate 600mg BD
Fluoxetine 40mg Mane
Propranolol 40mg BD
Keppra 250mg BD

 

[Iwillheal]

She then asks me if I would see the pt and I said "heck no"

Why wouldn't you?

 

[zenman]

Why wouldn't you?

Cause he's a weaner...

 

[vistaril]

Why wouldn't you?

the patient has obviously bought into the concept that with just a few more bs tweaks maybe it can finally made right this time and he can be happy and stable.....those patients are the most unpleasant to treat.

 

[OldPsychDoc]

the patient has obviously bought into the concept that with just a few more bs tweaks maybe it can finally made right this time and he can be happy and stable.....those patients are the most unpleasant to treat.

"Obviously".
So you did interview the patient after all?
I would have assumed that once they met you, s/he would be so taken by your superior understanding of psychiatric problems that they would have felt healed simply by being in your presence...

 

[Doctor Bagel]

the patient has obviously bought into the concept that with just a few more bs tweaks maybe it can finally made right this time and he can be happy and stable.....those patients are the most unpleasant to treat.

I agree that this is an annoying and problematic world view, but we create these patients by playing along with the polypharmacy stuff. So I wouldn't blame the patient as much as her previous providers.

 

[vistaril]

I agree that this is an annoying and problematic world view, but we create these patients by playing along with the polypharmacy stuff. So I wouldn't blame the patient as much as her previous providers.

oh no doubt....I do blame her previous providers. And unfortunately this is all too common. when my fiance was a medicine resident and had these types of pts in her clinic, she (rightfully) just refused to refer them to psychiatry, kept them on a simple and straightforward med regimen, and tried to refer them to therapy. She did this because she couldnt be sure the psychiatrist wouldnt just start adding meds from every class aimlessly, which she wanted to prevent.

 

[cbrons]

so my fiance reads off a guys med list that his psychiatrist at a private practice has him on(she is seeing him for some unrelated GI issue):

Lamictal 100mg daily
Seroquel 200mg qhs
Klonopin 1mg BID
Adderall 20mg BID(well second dose at 2-3pm)
Ambien 10mg qhs prn
Trileptal dose unknown
Cymbalta 30mg BID
Wellbutrin SR 100mg BID

I asked her how the pt comes across, and she said "needy and annoying".

She states she isnt planning on scoping him and I said "well, you're already practicing better psychiatry as a GI than this person's psychiatrist is"

She then asks me if I would see the pt and I said "heck no"

Why aren't state medical boards cracking down on this rubbish where psycho GPs and some aberrant psychiatrists are handing out high doses of QD benzodiazepines and z-drugs for highly questionable diagnoses?

 

[vistaril]

Why aren't state medical boards cracking down on this rubbish where psycho GPs and some aberrant psychiatrists are handing out high doses of QD benzodiazepines and z-drugs for highly questionable diagnoses?

well first off, klonopin 1 BID is not "high dose".

second, benzos and z-drugs are some of the most popular drugs prescribed in the outpt world by both pcps and psychs alike. state boards "cracking down" on this is thus not possible. Hell state boards can't even crack down on the docs for the most part who have pts on xanax 2 QID, Soma, and high dose oxy chronically.....if they can only even investigate 1% of those(and opiates are what they are really after, not benzos) you think they have any role in going after some ambien and 1mg of klonopin?

third, if you look at that list and believe the klonopin and the ambien is the main problem I'd say you need to think about it again. these sorts of list are mostly prescribed, unfortunately, by psychiatrists......these patients would do much better if their pcp would have never referred them.

 

[whopper]

Why aren't state medical boards cracking down on this rubbish where psycho GPs and some aberrant psychiatrists are handing out high doses of QD benzodiazepines and z-drugs for highly questionable diagnoses?

The only time I've seen a state board or the law take action against this type of whacked out practice is when the person is so egregiously crossing the line. E.g. a guy about 1 hour north of me was the #1 biggest prescriber of opioids in the entire country. He even had a pharmacy in his office just for opioids. A significant number of my Suboxone patients were addicts directly because of this bum.

And guess what? HE did his thing for years before they took him down.

Not the same thing but an attending I knew of (he worked at the hospital I was at but was fired just as I started, worked in several hospitals where I knew people that knew him) was actively having sex with several patients while I was a resident. Everyone knew he was doing it. The state didn't do anything. Finally, one of his patients sued him, he lost, but appealed it. The case spent about 15 years in appeal, and finally he lost the case in the highest court it could possibly go and then lost his license, and it was the court- not the state board that did all the work. I figure he and his lawyer were expecting the plaintiff to just drop the case, but that lady wouldn't even though she had to pay out of pocket. Well all's well that ends well, and this one didn't end well. The bum just got a license in a different state.

Even during the 15 years legal process he was still having sex with patients and nurses. He even took involuntarily committed patients out to lunch and made passes at them. That's what got him removed from the hospital I was at. I talked about it with the PD and he told me everyone knew what was going on for years but no one ever fired him and he thought it was ridiculous.

 

[zenman]

so my fiance reads off a guys med list that his psychiatrist at a private practice has him on(she is seeing him for some unrelated GI issue):

Lamictal 100mg daily
Seroquel 200mg qhs
Klonopin 1mg BID
Adderall 20mg BID(well second dose at 2-3pm)
Ambien 10mg qhs prn
Trileptal dose unknown
Cymbalta 30mg BID
Wellbutrin SR 100mg BID

I asked her how the pt comes across, and she said "needy and annoying".

She states she isnt planning on scoping him and I said "well, you're already practicing better psychiatry as a GI than this person's psychiatrist is"

She then asks me if I would see the pt and I said "heck no"

Be nice to know a little history and how others would start reducing this list...considering the patient agreed.

 

[whopper]

The first step would be to figure out just WTF the real diagnosis is, and that could require just getting the patient off of meds completely, then starting over.

 

[Sophie]

There's a frequent flyer borderline pt at my hospital who always comes in on the most heinous med lists. Last time I saw her she was on something like Seroquel 800mg QHS, Invega, Wellbutrin, Celexa, Trazodone, PRN Ativan, and Lamictal for "bipolar II". Every time I see her her med list is different. We always try to D/C at least one or two of her meds while she's inpatient, but she AND her psychiatrist freak out about the changes. Unfortunately, he's somehow on my hospital's staff, so no one's been willing to block his admissions or radically change her meds. And, obviously, the pt has gained a ton of weight and always looks like a zombie.

 

[splik]

i have a pt who came in on 20mg bid tamoxifen, 500mg qhs chlorpromazine, 30mg QHS aripiprazole, 300mg QAM + 200mg QHS lamotrigine, 300mg gabapentin, 100mg BID topiramate - all apparently for 'bipolar' (have seen no evidence of mania so far...)

 

[Iwillheal]

We always try to D/C at least one or two of her meds while she's inpatient, but she AND her psychiatrist freak out about the changes...

Seems to me her psychiatrist is the source of the problem. I wonder how many other patients this guy is overmedicating like this. It's just sad.

 

[whopper]

Every time I see her her med list is different. We always try to D/C at least one or two of her meds while she's inpatient, but she AND her psychiatrist freak out about the changes. Unfortunately, he's somehow on my hospital's staff, so no one's been willing to block his admissions or radically change her meds. And, obviously, the pt has gained a ton of weight and always looks like a zombie.

Same thing happened when I was a resident, and as a resident you really can't override the attending even if they're wrong. I've had cases where other attendings that knew what was going on would whine about how they knew this was wrong but they couldn't do much about it.

 

[F0nzie]

I am currently working in an inpatient setting and quite disturbed with other providers' prescribing practices. I am seeing a lot of patients coming in on stimulants, benzo's and opiates (prescribed by psychiatrists and psych NPs) without any clear indication. Drug seeking behaviors are very apparent and reinforced: ie. pt's exhibiting labile and demanding behaviors, bargaining for specific controlled substances, perseverating in an intrusive manner at the nurses station, splitting staff for meds, lacking any interest in treatment or diagnosis, and lying about which pharmacy they use to fill their prescriptions. It's like fighting an uphill battle because not only do I have to clean their meds when I admit them and have a lengthy discussion with them during the intake, the overnight inpatient doctors will simply order Vicodin for pain and mess up all my hard work.

 

[vistaril]

I am currently working in an inpatient setting and quite disturbed with other providers' prescribing practices. I am seeing a lot of patients coming in on stimulants, benzo's and opiates (prescribed by psychiatrists and psych NPs) without any clear indication. Drug seeking behaviors are very apparent and reinforced: ie. pt's exhibiting labile and demanding behaviors, bargaining for specific controlled substances, perseverating in an intrusive manner at the nurses station, splitting staff for meds, lacking any interest in treatment or diagnosis, and lying about which pharmacy they use to fill their prescriptions. It's like fighting an uphill battle because not only do I have to clean their meds when I admit them and have a lengthy discussion with them during the intake, the overnight inpatient doctors will simply order Vicodin for pain and mess up all my hard work.

I have little interest in "cleaning up the meds" of acute inpatients who have longstanding outpt psychs who they plan to go back to immediately after they are released for followup..........

yes, the med list is usually jacked up and it's bs. But I dont know that my role is to reinvent the wheel.

The real problem is that a *large*(it's not a few isolated people) percentage of psychs simply do not practice good psychiatry. I think the reasons for this are multiple. And I don't know that it's going to get any better.

 

[F0nzie]

I have little interest in "cleaning up the meds" of acute inpatients who have longstanding outpt psychs who they plan to go back to immediately after they are released for followup..........

yes, the med list is usually jacked up and it's bs. But I dont know that my role is to reinvent the wheel.

The real problem is that a *large*(it's not a few isolated people) percentage of psychs simply do not practice good psychiatry. I think the reasons for this are multiple. And I don't know that it's going to get any better.

Well to give you an example of what I am referring to, I had an SI pt who's Utox was + for benzo's, opiates, cocaine, amphetamines, and marijuana. Pt's outpatient psychiatrist was prescribing him Oxycodone 30mg q4hr. Only #6 out of #330 pills left in the bottle and it had just been filled several days ago. First do no harm right? I felt there was a duty to minimize medications that could be potentially harmful or diverted, despite the poor practices of his outpatient psychiatrist.

 

[whopper]

On occasion, when I see another attending doing some whacked out practice, I've encouraged the patient to report the doctor to the state medical board.

I only do this if the evidence is overwhelming First off, we see several cluster B patients. The patient may not be reporting accurately what the other doctor did, may be splitting, and could turn on you even though you did nothing wrong. Telling that person to report another doctor to the state board will be inviting them to complain against you too when this borderline patient starts hating you and most will hate you--especially if you're doing your job right.

Second, I've had a lot of instances where if I actually talked to the doctor, I could understand why they did what they did but I wouldn't get that from the patient. Again, I only do this if the evidence is overwhelming.

But I've never seen the state board do anything unless the doctor did something highly egregiously wrong or if the patient tripped the right complaint. Ohio, for example, I'm told the state will investigate if the patient is being held against their will in a hospital and there's an allegation of sexual abuse. The problem being that in the long-term psychiatric hospital I worked at, some patients complained sexual abuse all the time when none was going on-so the state had to intrude often to make sure it wasn't going on.

 

[zenman]

I am currently working in an inpatient setting and quite disturbed with other providers' prescribing practices. I am seeing a lot of patients coming in on stimulants, benzo's and opiates (prescribed by psychiatrists and psych NPs) without any clear indication. Drug seeking behaviors are very apparent and reinforced: ie. pt's exhibiting labile and demanding behaviors, bargaining for specific controlled substances, perseverating in an intrusive manner at the nurses station, splitting staff for meds, lacking any interest in treatment or diagnosis, and lying about which pharmacy they use to fill their prescriptions. It's like fighting an uphill battle because not only do I have to clean their meds when I admit them and have a lengthy discussion with them during the intake, the overnight inpatient doctors will simply order Vicodin for pain and mess up all my hard work.

And a pox on those who send me (because they are tired of dealing with them) a patient with:

Seizure disorder
COPD
CAD
HTN
FMS
Chronic Pain Syndrome
Mild TBI
Osteoarthritis
Hep C
Bipolar Disorder
PTSD
Prescription Drug Dependency

Patient is now weaned down to
Cymbalta 60 mg
Buspar 30 mg Bid
Seroquel 400 bid
Xanax 1 mg Tid

I added Buspar and cut Xanax from 2 mg tid. Her ED visits increased after that, but as of last visit she only had one ED visit and that was for a witnessed seizure. I really doubt this picture is going to change much more.

 

[F0nzie]

And a pox on those who send me (because they are tired of dealing with them) a patient with:

Seizure disorder
COPD
CAD
HTN
FMS
Chronic Pain Syndrome
Mild TBI
Osteoarthritis
Hep C
Bipolar Disorder
PTSD
Prescription Drug Dependency

Patient is now weaned down to
Cymbalta 60 mg
Buspar 30 mg Bid
Seroquel 400 bid
Xanax 1 mg Tid

I added Buspar and cut Xanax from 2 mg tid. Her ED visits increased after that, but as of last visit she only had one ED visit and that was for a witnessed seizure. I really doubt this picture is going to change much more.

There are so many comorbidities that can affect this person's mood. This is where we get into the problem pulling the pill out of the magic hat.

 

[BobA]

Recently got a new pt on:

Bupropion XL 300mg
Effexor XR 300mg
Aripiprazole 2mg
Amytriptyline 10mg HS
Clonazepam 1mg BID
Modafinil 600mg QD ("for energy")
Topiramate 200mg QD
Oxycontin 30mg daily



They've been on this for "years", but I'm concerned they may actually be delirious!

Although I'd love to just go out and stop the abilify, wellbutrin, and modafinil, I don't think I'd get too far with this patient that way. Instead, I take a long-term approach attempt to build trust at the first visit or two. When someone is so attached to their meds (like this person is), I think it's important to build trust first before recommending med changes. Without that trust, they're likely to just walk away to someone willing to continue what they are on. I don't like doing that, but I view tapering meds as a long-term process.

One of the things that I think keeps patients from changing their meds is a fear that they'll become unstable off them or that they'll have withdrawal effects. For that reason, I would really like to be able to admit people for "med detox." In a more controlled environment I think some patients might be more willing to reduce their meds more quickly.

 

[BobA]

There are so many comorbidities that can affect this person's mood. This is where we get into the problem pulling the pill out of the magic hat.

Agree. I recently went to a lecture by Tom Insel (director of NIMH) where he courageously said "depression is not a disease - it's a symptom!" We need to do a better job of understanding the underlying cause of that symptom.

 

[zenman]

Agree. I recently went to a lecture by Tom Insel (director of NIMH) where he courageously said "depression is not a disease - it's a symptom!" We need to do a better job of understanding the underlying cause of that symptom.

Also agree. My patient reports anxiety as her primary concern and that is what I'm trying to address...slowly

Anyone read Psychiatric Drug Withdrawal by Peter Breggin?

 

[whopper]

Anyone read Psychiatric Drug Withdrawal by Peter Breggin?

The problem with Breggin is that while he does bring up valid criticisms of the field, he makes it out, like Scientology, that everything being done is bad.

Someone arguing for reducing polypharmacy, encouraging patients to use psychotherapy to hopefully get off of successful SSRI for an anxiety disorder, arguing that psychiatry has shifted too much to med-only treatment certainly has valid arguments. He also has told patients he barely knew they didn't have anything wrong with them and the only reason why they feel worse when off of an SSRI is because they're addicted to it, and violated the Goldwater Rule to a terrible degree, using psychoanalysis to criticize people who disagree with his political viewpoints, calling liberals fascists, presenting himself as using scientific principles in this determination.

Whether or not you are a conservative or liberal, you're not supposed to start pointing fingers at people you don't like and use psycho-babble distortion to condemn them, then dress it up like it's valid medicine.

 

[ResCon]

So, when med lists like these posted, how can we come to an a priori conclusion about what is and is not appropriate for the patient without having reviewed the relevant medical history and conducting a face to face evaluation? IOW, what valid conclusions can one draw from a medication list isolated from the context of treatment?

 

[zenman]

The problem with Breggin is that while he does bring up valid criticisms of the field, he makes it out, like Scientology, that everything being done is bad.

Someone arguing for reducing polypharmacy, encouraging patients to use psychotherapy to hopefully get off of successful SSRI for an anxiety disorder, arguing that psychiatry has shifted too much to med-only treatment certainly has valid arguments. He also has told patients he barely knew they didn't have anything wrong with them and the only reason why they feel worse when off of an SSRI is because they're addicted to it, and violated the Goldwater Rule to a terrible degree, using psychoanalysis to criticize people who disagree with his political viewpoints, calling liberals fascists, presenting himself as using scientific principles in this determination.

Whether or not you are a conservative or liberal, you're not supposed to start pointing fingers at people you don't like and use psycho-babble distortion to condemn them, then dress it up like it's valid medicine.

That's why I wanted some other opinions, since I was aware of his previous work...which I've never read.

 

[WhoisJohnGalt]

the patient has obviously bought into the concept that with just a few more bs tweaks maybe it can finally made right this time and he can be happy and stable.....those patients are the most unpleasant to treat.

This is exactly why I volunteer to take these patients in intake clinic. Someone needs to get them on a more sensible regimen, and I'm willing to set the limits and do it. If the doctors that think these regimens are ridiculous aren't seeing them, that leaves them only to the doctors that add more meds...

 

[whopper]

So, when med lists like these posted, how can we come to an a priori conclusion about what is and is not appropriate for the patient without having reviewed the relevant medical history and conducting a face to face evaluation?

True, but a phenomenon that happens in psychiatry, unfortunately all too often, is some psychiatrist decides to medicate someone with an Axis II trait or disorder (without a real Axis I, or the Axis I is under control and they try to then control the Axis II with meds), where meds don't really help that problem. Classically, I've seen this usually happen with a borderline PD patient who has a doctor that incorrectly diagnosed the person with bipolar DO and medicates them into zombie-land.

On occasion, I have seen an Axis II trait improve with a med but if this is the case-fine, but if the med doesn't work, it should be stopped. Unfortunately I've seen several doctors put a patient on a polypharm regimen where nothing, I mean nothing worked and they continued this expensive and actually medically harmful regimen on the patient.

I have actually had a few patients on tremendous polypharmacy that I felt was justified. E.g. I had one patient on a high dose of lithium, Depakote, Zyprexa, Haldol, and a low dose of Klonopin and she was still manic, just that on those meds she wasn't quite as bad (e.g. attacking someone every few days vs. several times a day)/ The only times I've encountered patients on tremendous polypharmacy where I thought it was justified was on a long-term unit, or having a patient in the community that was discharged from a long-term unit.

Such patients, unfortunately, often times only get stabilized with heavy duty treatment such as, ECT, Clozaril, or heavy duty polypharm with the biggest guns (e.g. Zyprexa, Lithium, Depakote, and a typical antipsychotic all at high dosages). They are, however, still the extreme minority, and if polypharmacy is the only thing that works well, the treating doctor needs to document and justify this so the next doctor won't think the previous one was just needlessly over-medicating the patient.

But getting back to the point, the ratio of over-medicating vs. justifiably using a lot of meds is tipped way over to the over-medicating side IMHO. It's to the point where I will highly suspect over-medicating if I ever see a patient on more than 3 meds, especially if that person has an Axis II disorder, and one of those meds is a benzo.