I find that continuation of high dose bzd and opiates on a non-intermittent basis is generally inconsistent with recovery, as these patients often tend to get worse and use their dependence on opiates and bzd as evidence of how sick they are.
I've yet to see someone get off disability and get a job because of a remarkable recovery due to Xanax qid. In fact, what I hear more often is, "I'm so sick that I need Xanax qid and now that doesn't even work." They use their dependence as evidence of why they'll never recover. My experience may be different than others.
The debate then becomes, what is our goal as physicians? Keeping people comfortable, or helping them recover? These are often mutually exclusive.
For those few patients that recover and do get jobs because of klonopin and are able to keep them ONLY because of klonopin, then these extended prescriptions certainly do make sense.
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The way things work in South Australia now, specifically in regards to the regulation of Schedule 8 opiate medication, I do actually think is fair, and it does tend to weed out the 'But X drug of addiction is the only thing that works for me, don't tell me I need to try other options' drug seeking crowd.
For example, and I've mentioned this on here before but for those who might not know, I am currently prescribed a limited dosage of MS Contin 30 mgs (10 tablets once per month) for the treatment of severe menstrual pain due to endometriosis. I've actually had two separate rounds of prescription for it over the years. First time was around 2003, I'd always had pretty bad period pain but for several years it had been getting steadily worse until every month I was almost completely bedridden. My GP tried me on some hormonal treatments, I reacted badly to those, so she eventually allowed me a time limited prescription of Morphine, once a month, with the caveat that it was only until I had been thoroughly assessed and treated at a local hospital's Gynaecology unit. Two months later I was booked in as a hospital outpatient, and poked, prodded, ultrasounded, scanned, blood drawn, whatever else needed to be done (seriously I had that many internal examinations done that at one point I was almost tempted just to strip off and lie spreadeagled, in the middle of the ward's thoroughfare, and be like "Hey, anyone else wanna have go while you're at it?"). Anyway I was eventually scheduled for surgery 6 weeks later (laparoscopy, hysteroscopy, and diathermy), they found extensive endometriosis lesions and adhesions between my bowel and pelvic wall, they managed to fix all of it and for 2-3 years afterwards it was like night and day -- the Morphine prescriptions were immediately stopped, I barely even had to take paracetamol during my period, it was great. Until it started to reoccur.
Second time around pain gradually worsened again, until I was back to square one. Again I was allowed a time limited supply of Morphine while we concentrated on trying to fix the underlying cause (again), but the second surgery failed for reasons I'm not quite sure of. So then it became a matter of, "Well okay how are we going to manage this in the long term". It wasn't like anyone went, "right, that's it surgery's a bust, just stick her back on Morphine", my medical team still had to prove to the drugs of dependence unit, who authorise ongoing prescriptions of opiates, that a limited supply of Morphine once per month for pain management was the best thing for me under the circumstances, if that's what they even considered to be the most appropriate option. In order for me to receive an authorisation to prescribe a drug of dependence I had to provide a letter from the initial referring GP, a letter from the Surgeon, and a further appointment and treatment review from a Professor of Gynaecology (the head of the department basically), all stating that they had exhausted all other treatment options/or other options were not suitable. The authorisation is reviewed every 12 months, it is only valid for the clinic where the notification of authorisation is held (in other words I don't have a copy I can just take to another Doctor's surgery and scam some extra pills), and I am required to nominate one chemist to pick the medication up from and if I try and get it from anywhere else then I'm pretty much in breach of the terms of the authorisation. Considering my age as well I also keep a close eye on any changes to my menstrual cycle, because once I hit menopause, and I no longer need the Morphine for pain relief, then obviously the DoD-U needs to know that so they can remove the authorisation.
And yeah it's not an ideal situation or solution, but at least now my life doesn't come to a grinding halt 5-7 days out of every month and I'm actually able to get up and do stuff. I think the difference between the patients who's lives are genuinely changed, or at least improved through medication like opiates, and those that just wanna bang on about how they 'need' their meds and nothing else works and no I'm not going to try any alternatives, is the patients who the medications do truly help are the ones that are fed up enough to do whatever is required to get some semblance of normality back in their life -- whether that's exercise, hydrotherapy, surgery, non addictive potential medications, acupuncture, doing the hokey pokey and turning themselves about, or a prescription of a controlled substance. In other words I think most of us don't just want the 'easy fix' we want a solution that's actually going to work.
Just my humble opinion and experience of course.
