stimulants

[randomdoc1]

Is it just my jadedness or are a lot of people I see on stimulants really without a clear indication for them? I'd say the majority of the people I come across who are on stimulants or requesting stimulants (often because they had been on them at some point) really don't seem by history to have ADHD, treatment resistant MDD, or a sleep disorder. Does anyone have literature on this? I heard someone in my area did a talk about how the majority of adults on stimulants really don't have a convincing indication for it after you do a thorough eval. However, I haven't been able to find her ppt or sources. Kind of asking because I inherited a number of people on them. So far one patient actually does seem to have ADHD, but the other cases seem to be more an anxiety spectrum disorder (which stimulants can worsen their symptoms) or borderline traits...

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[WisNeuro]

Wait!? You mean all of my patients with symptoms that started well into adulthood and are better accounted for my anxiety/PTSD/malingering/etc, may not have ADHD and are just being mis-managed?

Biggest problem is, this diagnosis is given out without any real evaluation done. Not talking about a neuro eval, unnecessary. But, just a good, thorough, clinical history that asks about academic history and rules out pill seeking or more likely mental health diagnoses. I still see providers who use patient report of "doing better" on a stimulant as conformation of their ****ty diagnostic skills.

 

[MacDonaldTriad]

Patients push us to do all kinds of crazy things that we normally wouldn’t have thought of on our own. We are asked to write letters demanding a landlords allow pets, we write letters limiting work hours to day shifts for people who say they have sleep disorders, and we even give medical students extra time to complete licensing examinations. Never underestimate the capacity for psychiatrists to collude in patient’s rationalizations for why we should do things that go against our rational judgment. Giving out stimulants to people who have those diseases that are not in the DSM, but are well defined in grocery store tabloids is far from rare. I often wonder if doctors who do this are consciously influenced by their need to make a living, or just clueless enough to not realize they are being manipulated.

If anyone is inflamed enough by my point of view to burn up their keyboard with a long list of citations about the justifications for treating adult ADHD, please introspect on the nature of rationalization before posting any vitriolic counterpoint. Yes, ADHS doesn’t magically evaporate when you turn 18, but it also doesn’t exist in everyone who wants stimulants.

 

[splik]

Yes, ADHS doesn’t magically evaporate when you turn 18, but it also doesn’t exist in everyone who wants stimulants.

that's not quite true the epidemiological data suggests only half as many adults have symptoms of ADHD as do children, and often not the same people! so at least of people do grow out of it, or likely we force children to pay attention and sit still to an abnormal extent that many people don't have to face in adult life (particularly if they are not going to college or engaged in more high skilled labor)

 

[northernpsy]

No, it's not just you. I think the only way I'll ever go back to outpatient is if I work in a setting where I can make it a policy that I don't give out benzos or stimulants on the first visit. I think it would save so much trouble if the drug seekers would know not to bother trying to argue with me.

Addicts do talk with each other and they find out which docs are easy to get controlled substances from. If you take a firm stance I think it helps to keep them away.

 

[VA Hopeful Dr]

My bigger problem as a PCP is new patients who have been on these meds for some time and want to continue - now there is no way all of these people have ADHD but they, naturally, feel better being on them and no amount of testing/diagnosing on my part will change that.

 

[Shikima]

My bigger problem as a PCP is new patients who have been on these meds for some time and want to continue - now there is no way all of these people have ADHD but they, naturally, feel better being on them and no amount of testing/diagnosing on my part will change that.

Easy, say no. Take a careful history and do not rely on piss poor diagnostic skills of a lazy doctor and question everything. Include Bipolar Diagnosis ("It's my bipolar acting up")...

 

[WisNeuro]

Easy, say no. Take a careful history and do not rely on piss poor diagnostic skills of a lazy doctor and question everything. Include Bipolar Diagnosis ("It's my bipolar acting up")...

It's just like a trick knee. "Yup, whenever it gets cold, my knees start to ache and my bipolar acts up. Damn weather changes."

 

[cookymonster]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

 

[randomdoc1]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

Dooo it. Dooo it. Deeeeeewwww eeeiiiit. Speaking of which...what's with seeing so many patients with borderline personality disorder on stimulants? I see that a lot too. If a psychiatrist knew in their right mind that a patient's predominant diagnosis is borderline personality disorder, they wouldn't be giving stimulants...I would hope. I wonder how that happens? Is it all that affective dysregulation looking like inattention? The comorbid AODA histories many patients have and drug seeking? Some combination of both? blech....

 

[Jules A]

Dooo it. Dooo it. Deeeeeewwww eeeiiiit. Speaking of which...what's with seeing so many patients with borderline personality disorder on stimulants? I see that a lot too. If a psychiatrist knew in their right mind that a patient's predominant diagnosis is borderline personality disorder, they wouldn't be giving stimulants...I would hope. I wonder how that happens? Is it all that affective dysregulation looking like inattention? The comorbid AODA histories many patients have and drug seeking? Some combination of both? blech....

And anecdotally most I come across on my inpatient unit with the well known triad of BPD, benzo and speed also happen to be female, young and kinda cute in a stripper sort of way, lol. Then there is the major league baseball ADHD epidemic. Seriously though I'd guess the reason so many give whatever the patients request is a combination of those who are clueless that stimulants improve most everyone's focus and the others are either gullible or don't have the balls to say no.

 

[Jules A]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

I can't speak to this specific case but I don't continue an unsafe or ridiculous regimen. I cut the dose, order CIWA with prn coverage and at some point place a call to OP doc for collateral and to discuss my concerns especially because their tox screen is usually positive for other things as well.

 

[artorious22]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

How are you going to taper her off the Klonopin?

 

[Fan_of_Meehl]

Easy, say no. Take a careful history and do not rely on piss poor diagnostic skills of a lazy doctor and question everything. Include Bipolar Diagnosis ("It's my bipolar acting up")...

Right. This may be an example of the you can 'pay me now' or you can 'pay me later' axiom.

Often just spending the time/effort to do a more in depth evaluation and/or a delay in responding (maybe it takes a few more visits for you to effectively rule in/out other contributing factors) can dissuade the casual drug-seeker by increasing their response effort--they're likely to ditch you if you don't give them what they want and seek it elsewhere. You're likely to get some push back by many but this 'pay me now' is far better than the 'pay me later' several months or years down the road when you're trying to backpeddle or wean someone off a med they shouldn't have been receiving in the first place?

 

[birchswing]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

What the . . . flumazenil? You would give her the drug and the antidote at the same time? She'll align herself with an attorney. And no one goes from 6 to 2 who wants to maintain a lower dose. That's like the drug equivalent of going on a crash diet.

 

[northernpsy]

I can't speak to this specific case but I don't continue an unsafe or ridiculous regimen. I cut the dose, order CIWA with prn coverage and at some point place a call to OP doc for collateral and to discuss my concerns especially because their tox screen is usually positive for other things as well.

Agreed. No better time to detox a benzo addict than while they're on inpatient. As for the RN calling, can't you just tell the RN pre-emotively that you will not be changing the benzo overnight and that if the patient has concerns about it that you'll discuss it in the AM?

 

[cookymonster]

There's no point in detoxing a benzo addict when as soon as they get out their outpatient psychiatrist is going to put them right back on it. Well, I take that back. The only point is to get them out of the hospital.

And obviously I was being facetious about the flumazenil.

 

[randomdoc1]

There's no point in detoxing a benzo addict when as soon as they get out their outpatient psychiatrist is going to put them right back on it. Well, I take that back. The only point is to get them out of the hospital.

And obviously I was being facetious about the flumazenil.

We may be starting to steer a little off topic here, but the conversation is fun though. I've learned some of the most effective ways to get complicated/challenging patients off the unit/your service is to do them a big service. This often entails doing the right thing and it is often something many patients don't want. My colleague is doing his fellowship at a place that does etoh detox with Tegretol instead of Ativan. Even when I was on the medicine unit in residency, a lot of the cases involved admissions that were preventable if the patient was only adherent to their regimen and stuck to recommended lifestyle changes like an ADA diet. Me, being an intern at that time with all these ideals about modeling good lifestyle inpatient for my patients, I would put people on diets like ADA, low sodium, and low cholesterol. Often all for one patient. Of course that leaves the food tasting like cardboard. I've had a number of patients decide to leave a little earlier (they were medically stable of course) because they complained about the food I ordered for them. lol.

 

[cookymonster]

What I didn't mention is that this patient is on over 500 mg of Geodon in divided doses and takes 800 mg of Lamictal. And it can't be the generic.

This is the part of the outpatient world I don't understand. I know saying no to patients isn't easy. But when they're obviously personality-disordered and miserable to deal with, why are THESE the patients you want to like you??? and if you can't say no to these people, who walk our of your office after 30 minutes, how do you deal with your wife and kids?

 

[birchswing]

There's no point in detoxing a benzo addict when as soon as they get out their outpatient psychiatrist is going to put them right back on it. Well, I take that back. The only point is to get them out of the hospital.

And obviously I was being facetious about the flumazenil.

Sorry. There's a very controversial clinic near me that uses flumazenil after taking patients off benzos cold-turkey. They claim that by immediately resensitizing the sensors they can prevent seizures. It has a very bad reputation among local doctors and people who have been there. There is actually evidence, though, for very low-dose flumazenil after completely tapering benzos (not the cold-turkey approach). I missed the joke and thought you might have been in this very small group that does do rapid detox with flumazenil. I agree with you on the setting not being ideal, assuming it's a 2-3 day stay.

 

[st2205]

What I didn't mention is that this patient is on over 500 mg of Geodon in divided doses and takes 800 mg of Lamictal. And it can't be the generic.

Wow!

 

[Jules A]

What I didn't mention is that this patient is on over 500 mg of Geodon in divided doses and takes 800 mg of Lamictal. And it can't be the generic.

Yowza, might want to add a ekg if you don't routinely do them on admission?

 

[clausewitz2]

that's not quite true the epidemiological data suggests only half as many adults have symptoms of ADHD as do children, and often not the same people! so at least of people do grow out of it, or likely we force children to pay attention and sit still to an abnormal extent that many people don't have to face in adult life (particularly if they are not going to college or engaged in more high skilled labor)

The socialization/acculturation piece is often underappreciated. In my old career I did some fieldwork in the Republic of Georgia and by my informal, unscientific reckoning, 80% of adult Georgian males met criteria for ADHD. Georgian culture simply did not traditionally reward many men for sitting still and paying attention to boring things for a long time. Much more culturally supported was drinking wine by the jerrycan, close harmony singing, and carrying knives.

 

[VA Hopeful Dr]

Easy, say no. Take a careful history and do not rely on piss poor diagnostic skills of a lazy doctor and question everything. Include Bipolar Diagnosis ("It's my bipolar acting up")...

Heh, I don't think I've seen true bipolar since residency. "Sorry ma'am, going from happy to sad/angry four times a day isn't bipolar" as I was taught that rapid cyclers were 3-4 times per year.

I have gotten to the point that unless some psych person diagnosed you then you aren't getting stimulants from me.

 

[Ceke2002]

What the . . . flumazenil? You would give her the drug and the antidote at the same time? She'll align herself with an attorney. And no one goes from 6 to 2 who wants to maintain a lower dose. That's like the drug equivalent of going on a crash diet.

I can't comment as to flumanzenil as I'm not familiar with its use, but if this patient has been observed in hospital, and she's pilled out on 6 mgs, then dropping her down to 2 mgs is the right move. The difference between the benzo dose you need to get off your face, once you're physically dependent, and the actual dose you need to not go into major withdrawals can often be pretty significant. Example: The maximum dosage of Xanax I was ever prescribed was around 16 mgs, at the time I actually only needed to take between 6 and 8 mgs to stave off withdrawals - anything above that, especially anything between 12 and 16 mgs was just my allowance to get off my face if I wanted, because my prescribing Doctor at the time was also treating me for heroin addiction and figured it was preferable if I was allowed to just pill myself into oblivion rather than having me go and use.

 

[cookymonster]

Yowza, might want to add a ekg if you don't routinely do them on admission?

I did, along with metabolic labs that hadn't been checked in years.

 

[Liquid8]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

Heh. Before I formally started psychiatry training, I remember taking an inpatient off 6mg of Xanax fairly quickly over a couple of weeks switching to valium towards the end. It ended up being pointless in the long term, as their treating outpatient psychiatrist didn’t believe Xanax was addictive and put him back on it immediately.

Normally when high dose benzos are being prescribed for "sleep" I'd probably look reducing dose every few days and adding a sedating antipsychotic. With your case also being on stupidly high doses of multiple other medications, the issue of medication rationalisation needs to be breached. While one can justify high doses if there is a clinical benefit and side effects are being closely monitored, if a patient is still in distress (i.e. requiring admission) AND on high doses of medications, then clearly the medication isn't having the desired effect so there is a case for change. In your patient the most obvious culprit impairing sleep is the ritalin - tackle that first and the requirement for sleepers should dimish. Good luck!

No, it's not just you. I think the only way I'll ever go back to outpatient is if I work in a setting where I can make it a policy that I don't give out benzos or stimulants on the first visit. I think it would save so much trouble if the drug seekers would know not to bother trying to argue with me.

Addicts do talk with each other and they find out which docs are easy to get controlled substances from. If you take a firm stance I think it helps to keep them away.

Definitely agree with this. Some of my colleagues who do a lot of Addiction/ADHD work will make a point about no guarantees on prescribing on first visit clear at the start of a consult, or even when making the appointment. One of the plus sides of working in the Australian system that requires referrals for specialists is that the GPs tend not to refer patients who they think are drug seeking to psychiatrists, and there's also the added disincentive of high upfront fees (around the $400 mark for an hour intake, $200+ for reviews) - drug seekers will find it more economical to go to their local dealer. I have the opportunity to review referrals, and if there's any inkling of a forensic or substance dependence history accompanying an ADHD request I will usually decline. Sometimes there are other clues eg. hepatitis C in the medical history, or a patient address that is very far away from the GP, which usually points to IV drug use or doctor shopping.

Prescribing stimulants in our system also requires additional paperwork in the form of state department of health permit application. The permit is to prevent doctor shopping, but it also helps to give another out as I can say that based on the history that has been provided it is likely that the permit will be rejected.

 

[AcronymAllergy]

It's definitely problematic. Unfortunately, in the surrounding area here, the response typically seems to be prescribe stimulants first, ask questions later. And the prescription then often validates the "diagnosis" in the patient's mind. When I then tell them they likely don't have ADHD, they still have the option of going outside our system and fairly easily getting a stimulant in the community.

 

[Ceke2002]

Heh. Before I formally started psychiatry training, I remember taking an inpatient off 6mg of Xanax fairly quickly over a couple of weeks switching to valium towards the end. It ended up being pointless in the long term, as their treating outpatient psychiatrist didn’t believe Xanax was addictive and put him back on it immediately.

Normally when high dose benzos are being prescribed for "sleep" I'd probably look reducing dose every few days and adding a sedating antipsychotic. With your case also being on stupidly high doses of multiple other medications, the issue of medication rationalisation needs to be breached. While one can justify high doses if there is a clinical benefit and side effects are being closely monitored, if a patient is still in distress (i.e. requiring admission) AND on high doses of medications, then clearly the medication isn't having the desired effect so there is a case for change. In your patient the most obvious culprit impairing sleep is the ritalin - tackle that first and the requirement for sleepers should dimish. Good luck!



Definitely agree with this. Some of my colleagues who do a lot of Addiction/ADHD work will make a point about no guarantees on prescribing on first visit clear at the start of a consult, or even when making the appointment. One of the plus sides of working in the Australian system that requires referrals for specialists is that the GPs tend not to refer patients who they think are drug seeking to psychiatrists, and there's also the added disincentive of high upfront fees (around the $400 mark for an hour intake, $200+ for reviews) - drug seekers will find it more economical to go to their local dealer. I have the opportunity to review referrals, and if there's any inkling of a forensic or substance dependence history accompanying an ADHD request I will usually decline. Sometimes there are other clues eg. hepatitis C in the medical history, or a patient address that is very far away from the GP, which usually points to IV drug use or doctor shopping.

Prescribing stimulants in our system also requires additional paperwork in the form of state department of health permit application. The permit is to prevent doctor shopping, but it also helps to give another out as I can say that based on the history that has been provided it is likely that the permit will be rejected.

Doing a couple of week swap over from Xanax to Valium, at a starting dosage of 6 mgs, sounds reasonable actually. That's pretty much what I did when I was weaned off Xanax - swapped over to Valium from 4 mgs of Xanax and then weaned from there (obviously the entire process took a bit longer than a couple of weeks, but the switch over to Valium didn't take an inordinate amount of time). I can't believe their treating outpatient Psychiatrist put them back on Xanax, because it 'wasn't addictive', seriously, what the bloody hell? No, actually I can believe that, sadly enough; there are some seriously dumb f**k Physicians out there, you know the sort where you just want to ask them if they slept through the entire ethics portion of training or just didn't bother to rock up at all.

And yeah trying to get a prescription for Dexamphetamine here is like 'Okay, please jump through these umpteen dozen hoops, perform a three ring circus, do the hokey pokey, and then we might consider your application'. It's seriously not worth the time, cost and effort when a) It's Dexamphetamine FFS, in the scheme of 'fun drugs to party on' it's not really up there, and b) It's way easier, and cheaper just to find a dealer and score meth. Even someone who legitimately has ADHD/ADD (raises hand) gets put through the ringer in order to be prescribed meds, and from what I've heard they've tightened things up even further from when I was first prescribed dexies back in the late 90s (didn't stay on them that long though, personal choice to stop taking them, after enough time had passed the side effects of daily use outweighed the benefits I was getting).

Although, having said the above, bright spark here did have the following paraphrased conversation with her Psychiatrist about 4 years ago...

Me: Okay, I've had a really great idea. You know how reluctant I am to even consider antidepressants, well I think I might just have a solution. I'm already diagnosed with ADD, so just prescribe me some Dexamphetamine and I can take that when I need an energy boost.

Psych: You're also experiencing some psychotic symptoms at the moment (explain why an amphetamine based medication under these circumstances is actually a really stupid idea).

Me: Oh, I just figured you could throw an antipsychotic on top and it would like cancel everything out.

Psych: *looking like he's about to face plant his desk at any moment* It doesn't actually work like that.

And no, I didn't push the issue after my somewhat not very brilliant brainwave of random what the eff-ness.

 

[carlosc1dbz]

Heh, I don't think I've seen true bipolar since residency. "Sorry ma'am, going from happy to sad/angry four times a day isn't bipolar" as I was taught that rapid cyclers were 3-4 times per year.

I have gotten to the point that unless some psych person diagnosed you then you aren't getting stimulants from me.

I get very annoyed at the Bipolar I diagnosis I see in clinic, especially when there is a 10-15 year history of methamphetamine use with only a few 1 month periods of sobriety. Same thing with schizophrenia and a clear history of polysubstance abuse history(not that they don't occur together). Inpatient units around the city seem to always be giving these diagnosis despite the facts. Then in the outpatient clinics around town, it just ends up sticking with them, and pt's get put on all psychotics and mood stabilizers over the years. :/

 

[PistolPete]

I get very annoyed at the Bipolar I diagnosis I see in clinic, especially when there is a 10-15 year history of methamphetamine use with only a few 1 month periods of sobriety. Same thing with schizophrenia and a clear history of polysubstance abuse history(not that they don't occur together). Inpatient units around the city seem to always be giving these diagnosis despite the facts. Then in the outpatient clinics around town, it just ends up sticking with them, and pt's get put on all psychotics and mood stabilizers over the years. :/

Ugh. It's sloppy work, and I hate it too. Then you gotta explain to them when they ask why you're stopping their Seroquel. "but it's for my bipolar!"

Just like the click of a mouse in prescribing a benzo can cause months of problems, so can a quick second "you have bipolar" verbalization.

 

[cookymonster]

For those who are curious how things turned out, I kept the patient on all her meds, except I only gave her 3 mg of klonopin at a time 2 hours apart the first night and required vitals collection before the second dose was administered. EKG and labs looked good.

The next morning she was furious at me for "changing my meds" ranted at me for hating her and being the worst psychiatrist she had seen in 20 years... But her SI had resolved and she completed a safety plan with the social worker.

Her geodon dose had actually been reduced in the past year.

There's still some internal conflict about whether letting her go was taking the easy way out vs. whether hospitalization was futile. She was a voluntary patient and I didn't have a whole lot of choice anyway. But there's a good chance she'll be back in a few months when her disability is denied, and I'll have to decide if I want to keep kicking the can down the road.

 

[smalltownpsych]

For those who are curious how things turned out, I kept the patient on all her meds, except I only gave her 3 mg of klonopin at a time 2 hours apart the first night and required vitals collection before the second dose was administered. EKG and labs looked good.

The next morning she was furious at me for "changing my meds" ranted at me for hating her and being the worst psychiatrist she had seen in 20 years... But her SI had resolved and she completed a safety plan with the social worker.

Her geodon dose had actually been reduced in the past year.

There's still some internal conflict about whether letting her go was taking the easy way out vs. whether hospitalization was futile. She was a voluntary patient and I didn't have a whole lot of choice anyway. But there's a good chance she'll be back in a few months when her disability is denied, and I'll have to decide if I want to keep kicking the can down the road.

When a patient has no understanding of the need to change anything, then we have to kick the can down the road. The positive spin is that each interaction with them is a chance to work on their motivation to change. I look at it as laying the groundwork for the next time we see them.

 

[Merovinge]

For those who are curious how things turned out, I kept the patient on all her meds, except I only gave her 3 mg of klonopin at a time 2 hours apart the first night and required vitals collection before the second dose was administered. EKG and labs looked good.

The next morning she was furious at me for "changing my meds" ranted at me for hating her and being the worst psychiatrist she had seen in 20 years... But her SI had resolved and she completed a safety plan with the social worker.

Her geodon dose had actually been reduced in the past year.

There's still some internal conflict about whether letting her go was taking the easy way out vs. whether hospitalization was futile. She was a voluntary patient and I didn't have a whole lot of choice anyway. But there's a good chance she'll be back in a few months when her disability is denied, and I'll have to decide if I want to keep kicking the can down the road.

You are making me remember why I love child/adolescent inpatient so much more than my adult inpatient time, thanks

 

[666357]

I just admitted a patient with borderline PD who takes Ritalin 20 mg six times a day and Klonopin 6 mg QHS, all confirmed by drug monitoring database. I know I can't give her 6 mg of Klonopin tonight. But I just do not know how I am going to deal with the unholy ****show of phone calls tonight that will ensue when I limit it to 2 mg and she throws temper tantrums all night long, and also when she potentially aligns her outpatient psychiatrist on the other side of the split.

Should I just give her 6 mg with flumazenil?

I took the flumazenil remark as hyperbole.
The problem is you accepted her as a patient.
I've had these patients before and I typically say, "I don't think I'm the right doctor for you. I don't prescribe such and such at those doses, etc..."
They'll ask what they should do. I say they need to go back to the doctor who put them on Adderall 30mg TID and Xanax 2mg TID (or Klonopin 6mg qhs in your case) and tell their prescribing physician he/she has a legal/ethical responsibility to taper/wean them off. If they're unable, then I advise them to go to the nearest ED for inpt detox.
Bill accordingly. Just because you evaluate a patient doesn't mean a therapeutic relationship has been established.
I've saved myself countless headaches by not accepting such patients.
And believe it or not, one patient really didn't know Xanax 2mg TID could cause seizures if he abruptly quit and wanted me to taper it. I did accept him as a patient, tapered him on an outpt basis with Ativan over a couple of months, and have been managing him on Lexapro 10mg qd and Propranolol 10-20mg q8hr prn (the latter which is underutilized for panic disorder imo). Still has some intense anxiety but panic attacks are controlled, he has his wits about him, and both he and his wife have been profoundly thankful.

 

[cookymonster]

Thats not really how inpatient treatment works.

 

[666357]

Thats not really how inpatient treatment works.

my bad, didn't catch that "admitted" part...funny how inpt work seems light-years ago

rapid taper and d/c them, cc a copy of the d/c summary to their PMDs and psychiatrists- you can find out who's Rx'ing them the meds from your state's controlled Rx database
and be sure to document sed/hyp dependence- with or w/o withdrawal, delirium, etc.


inpatient work....gives me the shudders just thinking about it

 

[Shikima]

Thats not really how inpatient treatment works.

That's not how any of this works?