Spouse taking patient's meds

[F0nzie]

Any recommendations on what to do about a patient who admits they are not taking their medications as prescribed because their spouse steals them?

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[st2205]

What meds?

 

[F0nzie]

Benzos

 

[OldPsychDoc]

Benzos

Of course...

 

[wolfvgang22]

Stop prescribing.

 

[PikminOC]

Solved on SDN!

 

[Doctor Bagel]

Stop prescribing.

Seems like the only option right now. I don't think it would be unreasonable to consider options for restarting them (assuming you think they're still indicated) with certain checks in place -- patient gets a lockbox and doesn't give the code to his partner, no early refills ever, urine screens looking for positives (sometimes tricky because these aren't 100%). I guess the hassle and second chance depends on how strongly you feel like the patient should have benzos.

I don't think you have any obligation to report it to the police. Am I wrong here? That wouldn't be my reflexive response.

 

[notdeadyet]

I don't think you have any obligation to report it to the police. Am I wrong here? That wouldn't be my reflexive response.

Unless it's an Adult Protective Services suitable call.

 

[F0nzie]

Thanks for the replies. I have had several other similar cases where patients did not reveal this fact but it seemed suspicious when the spouse or family member spoke entirely for the patient. They also presented intense and agitated like they were high on something... But by not being the patient they can avoid detection.

 

[F0nzie]

What is this even called? Malingering by proxy?

 

[Doctor Bagel]

What is this even called? Malingering by proxy?

Could be straight up malingering because the secondary gain is appeasing your antisocial spouse. Or your dependency needs, or whatever.

 

[nitemagi]

What is this even called? Malingering by proxy?

How about fraud?

 

[milesed]

Our state requires each patient who is prescribed a controlled substance to sign an agreement that specifically states that the patient is responsible to keeping meds safe and meds may be stopped if the contract is violated. They also get yearly drug screens. Real world though- I usually give someone a second chance if the story sounds okay. Lockboxes are cheap and sold at Walmart. No third chances.

 

[BugsNotDrugs]

Any recommendations on what to do about a patient who admits they are not taking their medications as prescribed because their spouse steals them?

It's a tough spot, but you can't ethically, or even legally, continue to prescribe medicines that are misdirected to another person. I've run into this a few times, and for the most part I explain calmly to the patient that I cannot continue the prescription if I know that the medication is being misdirected. I also explain to the patient that I appreciate their honesty, but because they would be asking me to do something illegal, I must terminate care with the person. If it's in a community clinic, I talk to their social worker about switching care to another provider, and communicate my concerns with that provider. If this is in my private outpatient clinic, I terminate care and give them a list of other providers. I also offer contact information for substance abuse treatment, then I send them a certified letter to this effect with a list of alternative providers. APA has a decent termination letter template that you can follow. Of course, everything is documented clearly in the chart so that I don't get accused of abandonment.

In a hospice setting, I once arranged with the hospice providers to bring a patient their medications in IV form, monitored daily by a nurse, because things got out of hand with regards to misuse and misdirection (the patient wasn't even able to take his medications on a weekly basis because he claimed his dog ate them).

There was one time I gave a second chance to a patient in a similar situation. She used maybe 15 tabs of Xanax/ year PRN and reported to me at one visit that her father (a substance abuser) had visited from out of town and had stolen her rx. She had never before run out ahead of schedule, I knew the PRN benzos had been helpful in the past, her father lived in another state, and she promised to get a lock box and keep her rx in there from that point on. I renewed the script and documented everything, and 6 months later her father visited again without incident. This was a specific case, but if she'd lived with her dad or had a history of misuse, this would have been the spent second chance and I would have terminated our therapeutic relationship and referred her elsewhere. So, it's case by case, but most often the best choice is to not continue to prescribe the medicine.

Regardless, you document everything.

 

[F0nzie]

It's a tough spot, but you can't ethically, or even legally, continue to prescribe medicines that are misdirected to another person. I've run into this a few times, and for the most part I explain calmly to the patient that I cannot continue the prescription if I know that the medication is being misdirected. I also explain to the patient that I appreciate their honesty, but because they would be asking me to do something illegal, I must terminate care with the person. If it's in a community clinic, I talk to their social worker about switching care to another provider, and communicate my concerns with that provider. If this is in my private outpatient clinic, I terminate care and give them a list of other providers. I also offer contact information for substance abuse treatment, then I send them a certified letter to this effect with a list of alternative providers. APA has a decent termination letter template that you can follow. Of course, everything is documented clearly in the chart so that I don't get accused of abandonment.

In a hospice setting, I once arranged with the hospice providers to bring a patient their medications in IV form, monitored daily by a nurse, because things got out of hand with regards to misuse and misdirection (the patient wasn't even able to take his medications on a weekly basis because he claimed his dog ate them).

There was one time I gave a second chance to a patient in a similar situation. She used maybe 15 tabs of Xanax/ year PRN and reported to me at one visit that her father (a substance abuser) had visited from out of town and had stolen her rx. She had never before run out ahead of schedule, I knew the PRN benzos had been helpful in the past, her father lived in another state, and she promised to get a lock box and keep her rx in there from that point on. I renewed the script and documented everything, and 6 months later her father visited again without incident. This was a specific case, but if she'd lived with her dad or had a history of misuse, this would have been the spent second chance and I would have terminated our therapeutic relationship and referred her elsewhere. So, it's case by case, but most often the best choice is to not continue to prescribe the medicine.

Regardless, you document everything.

Wish I would have done this sooner

 

[unidentfied2]

It's a tough spot, but you can't ethically, or even legally, continue to prescribe medicines that are misdirected to another person. I've run into this a few times, and for the most part I explain calmly to the patient that I cannot continue the prescription if I know that the medication is being misdirected. I also explain to the patient that I appreciate their honesty, but because they would be asking me to do something illegal, I must terminate care with the person. If it's in a community clinic, I talk to their social worker about switching care to another provider, and communicate my concerns with that provider. If this is in my private outpatient clinic, I terminate care and give them a list of other providers. I also offer contact information for substance abuse treatment, then I send them a certified letter to this effect with a list of alternative providers. APA has a decent termination letter template that you can follow. Of course, everything is documented clearly in the chart so that I don't get accused of abandonment.

In a hospice setting, I once arranged with the hospice providers to bring a patient their medications in IV form, monitored daily by a nurse, because things got out of hand with regards to misuse and misdirection (the patient wasn't even able to take his medications on a weekly basis because he claimed his dog ate them).

There was one time I gave a second chance to a patient in a similar situation. She used maybe 15 tabs of Xanax/ year PRN and reported to me at one visit that her father (a substance abuser) had visited from out of town and had stolen her rx. She had never before run out ahead of schedule, I knew the PRN benzos had been helpful in the past, her father lived in another state, and she promised to get a lock box and keep her rx in there from that point on. I renewed the script and documented everything, and 6 months later her father visited again without incident. This was a specific case, but if she'd lived with her dad or had a history of misuse, this would have been the spent second chance and I would have terminated our therapeutic relationship and referred her elsewhere. So, it's case by case, but most often the best choice is to not continue to prescribe the medicine.

Regardless, you document everything.

This is an interesting approach which I respect, but Am not convinced that other approaches would violate ethics and law. As a medical review officer I have seen spousal use of narcotics often. It is a daunting dilemma, and there are no easy answers.

 

[vistaril]

Any recommendations on what to do about a patient who admits they are not taking their medications as prescribed because their spouse steals them?

"well unless we can fix this problem, I cant prescribe this medication to you anymore knowing that"......that seems like the common sense approach.

a more interesting question is why in the world did the pt tell you this? I'm sure a bunch of the bzds and stimulants I prescribe don't get taken by the patient but instead wives, husbands, friends, etc.....but the patient almost never tells me.