Benzos in Radiation Oncology

[MidwestRadOnc]

What do you do for pain management for your patients for SpaceOAR? I was using Ativan and Percocet but was thinking to switching something like Pro-Nox to increase patient comfort.

During the procedure or post-procedure?

Mixing benzos and opiates is definitely not ideal. Our specialty in general ridiculously overuses benzos IMO. These are extremely dangerous drugs that should never be started on 99% of the people who have them on their med list. There's nothing I hate more than being goaded into a prescription for 35 ativan for daily mask tolerance. I see colleagues do this without a second thought and I am SMH. Of course half the consults I see have PRN norco, xanax, and adderall on their med list prescribed by their PC(N)P, and of course "medical" marijuana too. Life would be easier if I just stopped caring.

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[medgator]

Mixing benzos and opiates is definitely not ideal. Our specialty in general ridiculously overuses benzos IMO. These are extremely dangerous drugs that should never be started on 99% of the people who have them on their med list. There's nothing I hate more than being goaded into a prescription for 35 ativan for daily mask tolerance. I see colleagues do this without a second thought and I am SMH. Of course half the consults I see have PRN norco, xanax, and adderall on their med list prescribed by their PC(N)P, and of course "medical" marijuana too. Life would be easier if I just stopped caring.

What else would you have these patients do? Bzds work... There's a need for them ("safe, legal, rare")

 

[MidwestRadOnc]

What else would you have these patients do? Bzds work... There's a need for them ("safe, legal, rare")

They are a last resort med for me and prescribed as a single pill. Take the anxiety edge off for treatment is not a valid use. A 24 oz beer in the parking lot will do the same thing. If you want to do that, that's on you but I'm not going to sanction it. I didn't go to med school to make people high, and I have literally had patients come in expecting this because they received radiation before and were given morphine and ativan for every treatment for a bone met or something ridiculous. Xanax should be pulled from the market IMO. Yes, I have opinions on this lol. I would never take benzos under basically any circumstance. Doling out these meds causes real harm that I think is under-appreciated by specialists. Don't get me started on Adderall.

Great recent documentary:

 

[OTN]

They are a last resort med for me and prescribed as a single pill. Take the anxiety edge off for treatment is not a valid use. A 24 oz beer in the parking lot will do the same thing. If you want to do that, that's on you but I'm not going to sanction it. I didn't go to med school to make people high, and I have literally had patients come in expecting this because they received radiation before and were given morphine and ativan for every treatment for a bone met or something ridiculous. Xanax should be pulled from the market IMO. Yes, I have opinions on this lol. I would never take benzos under basically any circumstance. Doling out these meds causes real harm that I think is under-appreciated by specialists. Don't get me started on Adderall.

Great recent documentary:

Using Ativan to help claustrophobic patients tolerate a mask for CNS or H+N RT is a perfectly reasonable use of the medication. I never Rx Xanax, though, and share your concerns about it. Far too habit-forming.

 

[MidwestRadOnc]

Using Ativan to help claustrophobic patients tolerate a mask for CNS or H+N RT is a perfectly reasonable use of the medication. I never Rx Xanax, though, and share your concerns about it. Far too habit-forming.

>90% of the time they are able to tolerate it if they say it's going to be a problem. Yes, it requires talking to the patient and some coaxing and bedside manner, holding their hand at sim and before first treatment, etc. Writing for a pill is easier. You have to dramatically fail a mask trial for me to write that all the way through treatment. You are seriously increasing the risk for addiction at that point. I think I can count on one hand the number of times I've had no other option but to do that in my career. This is a "first do no harm" thing for me and it's weird I kinda feel in the minority sometimes on this.

 

[medgator]

>90% of the time they are able to tolerate it if they say it's going to be a problem. Yes, it requires talking to the patient and some coaxing and bedside manner, holding their hand at sim and before first treatment, etc. Writing for a pill is easier. You have to dramatically fail a mask trial for me to write that all the way through treatment. You are seriously increasing the risk for addiction at that point. I think I can count on one hand the number of times I've had no other option but to do that in my career. This is a "first do no harm" thing for me and it's weird I kinda feel in the minority sometimes on this.

I generally do 1-2 mg Ativan 15-20 mins prior and haven't had a problem in over a decade, mainly for h-n pts. They know it's a finite Rx and they use it as it is intended. And obviously they have a driver. It's a non issue when they are driving themselves because I won't write it

 

[OTN]

I generally do 1-2 mg Ativan 15-20 mins prior and haven't had a problem in over a decade, mainly for h-n pts. They know it's a finite Rx and they use it as it is intended. And obviously they have a driver. It's a non issue when they are driving themselves because I won't write it

That's my practice as well. The vast majority (>90%) of the time they stop taking it within a week or two of tx start as they get used to everything.

 

[MidwestRadOnc]

I generally do 1-2 mg Ativan 15-20 mins prior and haven't had a problem in over a decade, mainly for h-n pts.

Of course red journal has published on this:

https://www.redjournal.org/article/S0360-3016(20)33866-9/fulltext

They know it's a finite Rx and they use it as it is intended.

The problem is that's how literally every addiction starts.

"It's a prescription from a doctor so it's ok"
"I'm responsible with it and only take it as needed"

Everyone who gets a PRN script for an opiate, benzo, or stimulant starts off saying the above. I won't beat a dead horse, but the documentary is worth a watch. 2 mg is a hell of a dose of Ativan. I almost always stick to 0.5 mg and have rarely given 1 mg. These meds are especially bad in the elderly and when combined with opiates, both of which I see commonly done in RO.

 

[Gfunk6]

Of course red journal has published on this:

https://www.redjournal.org/article/S0360-3016(20)33866-9/fulltext

"Conclusion
Benzodiazepine prescriptions among radiation oncologists are significantly associated with many RO characteristics. Years since medical school graduation, Southern location, and practice rurality were predictive for higher benzodiazepine prescription rates. Additional studies are required to understand these differences in prescription patterns."

We know you Southerners love your benzos . . .

 

[medgator]

"Conclusion
Benzodiazepine prescriptions among radiation oncologists are significantly associated with many RO characteristics. Years since medical school graduation, Southern location, and practice rurality were predictive for higher benzodiazepine prescription rates. Additional studies are required to understand these differences in prescription patterns."

We know you Southerners love your benzos . . .

Benzos and bourbon, likes peas and potatoes.

I've literally never prescribed more benzo tablets than fractions in my practice. Ever @MidwestRadOnc part of the addiction cycle will require them to go to another practitioner or the street to keep it going, but at least I got them through curative head and neck tx? 🤷🏽

 

[MidwestRadOnc]

Benzos and bourbon, likes peas and potatoes.

I've literally never prescribed more benzo tablets than fractions in my practice. Ever @MidwestRadOnc part of the addiction cycle will require them to go to another practitioner or the street to keep it going, but at least I got them through curative head and neck tx? 🤷🏽

It’s not personal, just hoping I can convince others to be mindful of the dangers of these “meds” and help us realize that all of us have created addicts whether we realize it or not, it’s inevitable when prescribing controlled substances. The goal is to minimize harm and I frequently see rad oncs dishing out meds that consciousness internists would never. Addiction ruins lives and families and I realize that it’s a trade off with cancer especially at the end of life. Also, diversion is real and if you think none of your patients have diverted your RXes you’re delusional (not saying this is you).

Also, not uncommon to see docs themselves abusing all of the above. I’m a doctor, I can control myself…. Very common. A little adderall here and there to push through a hangover turns bad very quickly.

 

[Gfunk6]

My Valium rep tells me that anxiety is the sixth vital sign

 

[medgator]

My Valium rep tells me that anxiety is the sixth vital sign

Ever since pain got demoted I guess

 

[evilbooyaa]

@MidwestRadOnc with strong opinions.

You are entitled to your opinion.

You are also in what I presume a strong minority.

35Tx H&N requiring daily benzos seems like it should be a rare scenario. But I have no qualms prescribing it for SRS patients who have a driver. The SRS mask is uncomfortable (more so than H&N mask). Anyone who needs meds prior to going for MRI I offer it at CT sim if they're not tolerating mask creation.