What! Another pt on klonopin AND adderall!

[PikminOC]

Read the article. Error made in transcribing by a PA. Doc got in trouble and reported.

Keep on collaborating and supervising!

---

Members don't see this ad.

 

[vistaril]

Read the article. Error made in transcribing by a PA. Doc got in trouble and reported.
!

I did read the article. The article doesn't really tell us anything about what happened. As I said before....we know there was a death involved and that's it. The med reconciliation issue almost certainly came about because a review was initiated after a adverse event. the med rec error may or may not have even been related to the event that got the ball rolling in the first place.

Again, we have no clue what the real issue here is. Let's say that a med reconciliation error was made(heck med lists are ften 15+ long I know they are made to some degree frequently). That has nothing to do with clinical acumen and doctor vs PA/NP differences....it may just have meant seeing an 8 on the computer when it was really 6.

 

[hamstergang]

I think I can help fix this.

@Grover: what point were you making in posting that article?
@vistaril: what point do you think he was making in posting that article?

 

[PikminOC]

I think I can help fix this.

@Grover: what point were you making in posting that article?
@vistaril: what point do you think he was making in posting that article?

Docs are responsible for the mistakes their NP/PA's make. Don't forget that, ever.

 

[vistaril]

Docs are responsible for the mistakes their NP/PA's make. Don't forget that, ever.

how many med rec's have you done wrong in your life? *Any* error....not neccessarily big ones.....do you honestly believe that having an MD/DO makes one better at med reconciliations and doing discharge paperwork vs an NP/PA?

 

[PikminOC]

how many med rec's have you done wrong in your life? *Any* error....not neccessarily big ones.....do you honestly believe that having an MD/DO makes one better at med reconciliations and doing discharge paperwork vs an NP/PA?

But at least it's MY error and MY fault.

Wait until you are an attending at whatever field it is you purport to do.

 

[vistaril]

But at least it's MY error and MY fault.

Wait until you are an attending at whatever field it is you purport to do.

umm, I work in multiple different settings now without supervision. If you don't want to delegate anything to nurses and support staff, that's fine. Personally I'm not all that excited to do discharge summaries and med recs....but if that's your thing not yourself out.

 

[Krushed0nyxx]

Is this a new trend--patients being on klonopin and adderall? In the past month I have seen two new patients who report to me they are on both klonopin and adderall as well as other meds but why two controlled substancese at the same time! Now both of these patients were in 8 week partial hospitalization programs which is where the adderall was started. So now they expect me to continue it for them. I find this annoying and even when I tell them I am not prescribing them adderall they continue to ask for it repeatedly.

It's clear I am not comfortable prescribing both but I am wondering from more experienced psychiatrists if there would ever be a valid reason/dx for a patient to be on both a benzo and a stimulant. I guess if a patient has ADD and panic attacks but I am not comfortable with this as a stimulant can cause anxiety and klonopin can cause poor focus. Please someone give me a good reason to keep a patient on both of these.

Wow,
I am glad you are only a student because apparently you know nothing about modern psychology at all. You have have read the physcians drug reference or the dsv 4 or maybe googleed drug interations, however my doctor has saved my life using this combo plus several other rx psych meds. Modern psychology is way different from the traditional where a stimulant and a depresant may cause a rubber band effect. But, some more progressive psychistricts have patientd who trancent textbook percentiles and ratios.

My doctor has outweighed the risks and found the benefits of prescribing a patient with debilitating GAD, PTSD, and bipolar spectrum patient these medications realizing that adderally actually provides an antidepresive effect in those who have taken anti depressants and only have came up with sucidial side effects. Hopefully by this point you have steered away from this field years later because if youre still working under a judgement and scrutinized thumb with the mentally ill - then in my professional opinion you made need some psychiatric assistance for your biogotted narcissism and delusions of grandeur.

Haha!

Also, everytime a student doctor has interferred with my.psychistricts relationship and I, my medications have changed and I nose dive for the worst. So, to all those out there who are judging people like this person due to a lack of experience in the field. I suggest you sit back and listen to people, learn from the doctor, and if you make it to DR in this field one day - then PER your practice you can make judgements on your own patients and see how many people come to you for help or end up seeking out help somewhere else due to unorthodox and bogus, uncomfortable (inside the box) ideals.

 

[Shikima]

Yawn.

:troll:

 

[MacDonaldTriad]

........,

 

[sunlioness]

Not enough opiates. He can't be that good ....


Sent from my iPad using Tapatalk

 

[Shikima]

Look at the timing of the post. Too much of a good thing, those helpful amphetamines....

 

[sunlioness]

Look at the timing of the post. Too much of a good thing, those helpful amphetamines....

Hmmm. Need more klonopin.


Sent from my iPad using Tapatalk

 

[Ceke2002]

Aw come on you guys, show some empathy. This isn't your regular, garden variety kind of GAD, PTSD and Bipolar Spectrum Disorder we're talking about here, it's defribillating!...sorry I mean delibitating...no, wait, it's Debilitating GAD, PTSD and Bipolar Spectrum Disorder!!! That's like waaaaay more serious, and as soon as any patient quantifies their symptoms as debilitating' you should immediately proceed to throw as many drugs at them as humanly possible -- it's not like you're fuelling a potential substance abuse problem if the person really enjoys getting ****faced ...er, sorry I mean 'needs' to be 'properly medicated'.

 

[Ceke2002]

Yawn.

:troll:

Can we at least mock them?

 

[MacDonaldTriad]

 

[anon12894]

My God, what disrespectful posts by the physicians here to the person expressing how they felt the RX's worked for them. Did it ever occur to you that some people are up at 4AM because of school? Because of a job where they work the evening shift at a hospital and can't fall asleep until ~3 or 4:30AM due to their altered sleep schedule from work? Have you ever experienced such a thing, or are you just jumping to the conclusion that this person is prescribed amphetamines, therefore, they're abusing them and/or are up at an ungodly hour to you because they are, in your eyes, simply a mechanism and effect of their medications?

I get home from my work at the hospital at 1 AM. I can't sleep until about 3-4am, depending on how stressful the day was and whether I have work the next afternoon. I also currently work the evening shift at an inpatient psychiatric hospital. I do not choose the evening shift. It was the only position open, and I chose it because it was incredibly relevant to my career interests.

It is incredibly bizarre and disconcerting that these comments in this thread, responding to a patient, were made by attending physicians.

I am not facing the issues that krushedonyxx is, but, let me tell you my story. I too am on these two medications. I went to a great college, was a Psych major, but struggled academically and went undiagnosed with ADHD and horrible anxiety for years. A couple of my family members also have ADHD. I did not truly understand why one of my (untreated but very successful) parents acted the way they did (e.g., their ADHD symptoms I thought was just....quirky or inattentive behavior) until I sat down and started to talk through it with my psychiatrist. I was not so lucky - my ADHD wasn't a benefit for me like it was for one of my parents.

But I graduated albeit with a mediocre GPA and some grades that were totally all over the place. I took the step to see a psychiatrist to talk about my anxiety after college...but we didn't click. Then a psychologist that specialized in anxiety. Then another psychiatrist...finally someone who was able to take the damn time to sit down and talk to me and work through each and every issue step by step....and, we clicked. It was extremely challenging to make that first step to see someone. I'm glad I did. Over time, I came to work on my anxiety, and discovered that I had ADHD that had probably gone undiagnosed my entire life.

These were NOT the first two medications I was prescribed. It was not my goal, nor my doctor's, to be on these medications. The goal was to find what worked.

Fast forward several years.

I was accepted into medical school 2 weeks ago, and have a strong desire to go into psychiatry. I am grateful I took that first step to see a Psychiatrist.

Please do not lose sight of your patients as people. Please do not lose your empathy. Making condescending remarks like the ones above does nothing to further the field of Psychiatry. We all agree the field is not perfect. Help be the positive change in that regard, not the condescending, arrogant physician who sits in their ivory tower judging without thinking.

Wow,
I am glad you are only a student because apparently you know nothing about modern psychology at all. You have have read the physcians drug reference or the dsv 4 or maybe googleed drug interations, however my doctor has saved my life using this combo plus several other rx psych meds. Modern psychology is way different from the traditional where a stimulant and a depresant may cause a rubber band effect. But, some more progressive psychistricts have patientd who trancent textbook percentiles and ratios.

My doctor has outweighed the risks and found the benefits of prescribing a patient with debilitating GAD, PTSD, and bipolar spectrum patient these medications realizing that adderally actually provides an antidepresive effect in those who have taken anti depressants and only have came up with sucidial side effects. Hopefully by this point you have steered away from this field years later because if youre still working under a judgement and scrutinized thumb with the mentally ill - then in my professional opinion you made need some psychiatric assistance for your biogotted narcissism and delusions of grandeur.

Haha!

Also, everytime a student doctor has interferred with my.psychistricts relationship and I, my medications have changed and I nose dive for the worst. So, to all those out there who are judging people like this person due to a lack of experience in the field. I suggest you sit back and listen to people, learn from the doctor, and if you make it to DR in this field one day - then PER your practice you can make judgements on your own patients and see how many people come to you for help or end up seeking out help somewhere else due to unorthodox and bogus, uncomfortable (inside the box) ideals.

Look at the timing of the post. Too much of a good thing, those helpful amphetamines....

Hmmm. Need more klonopin.

Edit: grammar and typos and such...shouldn't have tried typing all of this without a proper keyboard

 

[Shikima]

Can anyone check the IP addresses?

 

[anon12894]

Why?

Edit: Also, very sad to see the immaturity level in here is so high. Unproductive responses that contribute nothing to the topic.

I hope you don't act this way around your coworkers or patients.

 

[Shikima]

 

[sunlioness]

It's true that my response wasn't the most mature. I apologize for that. Having said that, when you think about it . . . Neither is creating a new account to necro bump a three year old thread for the purposes of insulting the regular posters here with such phrases as "biogotted [sic] narcissism and delusions of grandeur."

I don't mind it when patients post here even though this isn't intended to be a forum for patients. But I do mind when said patient comes with an axe to grind.

Best wishes.

 

[anon12894]

Someone else's immaturity is no excuse for your own.

This is a public online forum. If you care about yourself, your profession, and your patients, act as if the world is listening. Because technically, on here, it is.

As a psychiatrist you do the rest of the profession, and physicians in general, a disfavor when you act in such an unprofessional manner. I read those posts as if they were written by 12 year olds. Because that's how they sounded.

I don't care who you are.

I don't care if a patient comes in here with an axe to grind.

You don't have to respond.

The attendings who responded were simply mean and completely unprofessional. If you fail to see that then I seriously worry.

 

[cookymonster]

I only hope that you teach professionalism to your psychiatry attendings in medical school as proficiently as you have with us.

 

[Shikima]

Why would you misrepresent yourself as being apart of this profession? Why would you make 2 accounts in violation of the TOS?

 

[anon12894]

If you actually read my post, you would see that I did not misrepresent myself at all. I was very clear about who I was.

You're simply dodging the fact that what was said above was ridiculously unprofessional, and instead you're attacking me, perhaps because it appears that you now look rather bad for having said such statements.

Enjoy the thread, I'm done.

 

[Shikima]

Define unprofessional on a public forum.

 

[MacDonaldTriad]

My obligation to act in a strictly professional manner is almost universal, but this is lightened considerably when a patient’s behavior is obviously outrageous. You simply cannot coerce, cajole, or deceive us into taking a clearly out of the standard of practice approach with you and then accuse us of being unprofessional. None of us are feeling guilt so you might as well quit while you are behind on this high moral ground pissing match. Besides, you are not in a therapeutic relationship here so since when did you start to feel like your sensibilities should sensor our feelings about dealing with drug seekers? The non-physicians on this thread seem to be split 50/50 and others can recognize rationalization when they see it. This is when we invoke the truism about the heat in kitchens and staying out. I think I just fed the Troll.

 

[nancysinatra]

This is the most ridiculous thread I have ever seen. Goodbye, troll!

 

[birchswing]

Do people really not get what happened?

There's no troll.

This thread started with someone expressing surprise/dismay that physicians prescribe multiple scheduled substances to one patient. Discussion was had about the prevalence of this.

Obviously someone searching the Internet who is prescribed multiple scheduled substances found the thread and felt threatened at the idea that doctors would be against his/her treatment. Why? Fear. Loss of control. Being powerless against the fact that your psychiatrist can move across the country, quit, lose their license, whatever, and your next doctor might cut you off.

Fear leads to anger.

This was, from what I can tell, a fear/anger response.

The big argie-bargie didn't really make sense from the patient because there *are* people who will give him/her what he/she wants. And the blowback doesn't make sense because there's already agreement in the thread and, generally in the forum, that this is not uncommon. It doesn't make sense to suddenly claim there's a super high standard of care when a patient gets upset, and as I said the patient getting upset doesn't make sense.

Although I rarely say it, I believe I am the only one who makes sense. JK . . .

RE: Trolls, A troll, IMO, is akin to a Candid Camera type situation, which can also be influenced by pain/fear, but it's a completely different type of rhetoric than someone who is obviously pained and powerless. In trolling the audience may not even be its target (e.g., the real callers to the Phil Hendrie show were collateral damage to attacks on absurd parts of society).

 

[nancysinatra]

Do people really not get what happened?

There's no troll.

This thread started with someone expressing surprise/dismay that physicians prescribe multiple scheduled substances to one patient. Discussion was had about the prevalence of this.

Obviously someone searching the Internet who is prescribed multiple scheduled substances found the thread and felt threatened at the idea that doctors would be against his/her treatment. Why? Fear. Loss of control. Being powerless against the fact that your psychiatrist can move across the country, quit, lose their license, whatever, and your next doctor might cut you off.

Fear leads to anger.

This was, from what I can tell, a fear/anger response.

The big argie-bargie didn't really make sense from the patient because there *are* people who will give him/her what he/she wants. And the blowback doesn't make sense because there's already agreement in the thread and, generally in the forum, that this is not uncommon. It doesn't make sense to suddenly claim there's a super high standard of care when a patient gets upset, and as I said the patient getting upset doesn't make sense.

Although I rarely say it, I believe I am the only one who makes sense. JK . . .

RE: Trolls, A troll, IMO, is akin to a Candid Camera type situation, which can also be influenced by pain/fear, but it's a completely different type of rhetoric than someone who is obviously pained and powerless. In trolling the audience may not even be its target (e.g., the real callers to the Phil Hendrie show were collateral damage to attacks on absurd parts of society).

When I am reading this forum, the last thing I want to do is evaluate some poster's emotional or psychological state.

EDIT: I am probably feeding the troll now too... Should stay away from this discussion.

 

[Shikima]

I shoulda had a V8!

 

[clausewitz2]

Do people really not get what happened?

There's no troll.

This thread started with someone expressing surprise/dismay that physicians prescribe multiple scheduled substances to one patient. Discussion was had about the prevalence of this.

Obviously someone searching the Internet who is prescribed multiple scheduled substances found the thread and felt threatened at the idea that doctors would be against his/her treatment. Why? Fear. Loss of control. Being powerless against the fact that your psychiatrist can move across the country, quit, lose their license, whatever, and your next doctor might cut you off.

Fear leads to anger.

This was, from what I can tell, a fear/anger response.

The big argie-bargie didn't really make sense from the patient because there *are* people who will give him/her what he/she wants. And the blowback doesn't make sense because there's already agreement in the thread and, generally in the forum, that this is not uncommon. It doesn't make sense to suddenly claim there's a super high standard of care when a patient gets upset, and as I said the patient getting upset doesn't make sense.

Although I rarely say it, I believe I am the only one who makes sense. JK . . .

RE: Trolls, A troll, IMO, is akin to a Candid Camera type situation, which can also be influenced by pain/fear, but it's a completely different type of rhetoric than someone who is obviously pained and powerless. In trolling the audience may not even be its target (e.g., the real callers to the Phil Hendrie show were collateral damage to attacks on absurd parts of society).

This is SDN, where "troll" just means "poster I find annoying".

 

[smalltownpsych]

If you actually read my post, you would see that I did not misrepresent myself at all. I was very clear about who I was.

You're simply dodging the fact that what was said above was ridiculously unprofessional, and instead you're attacking me, perhaps because it appears that you now look rather bad for having said such statements.

Enjoy the thread, I'm done.

If you go to any 12 step meeting you will see recovering addicts laughing at the lies they told themselves and others to feed their habits. I don't think anyone on here said that all patients who take adderall and/or benzos are addicts, but a lot of then are and the truth is underlying the defense of humor, most of us feel a great deal of sadness and anger as we watch people destroy themselves and their families. You have no idea how hard we fight to maintain compassion and provide good treatment to these patients. So why not cut us a little slack, huh?

 

[MLT2MT2DO]

Fear leads to anger.

And we are now quoting Yoda...can't wait to see where this thread heads to next.

 

[MacDonaldTriad]

I found a strange one: Happens to every guy sometimes this does – Yoda

 

[birchswing]

And we are now quoting Yoda...can't wait to see where this thread heads to next.

I haven't seen Star Wars. The only thing I've heard from Yoda was "There is no try."

 

[Ceke2002]

If you go to any 12 step meeting you will see recovering addicts laughing at the lies they told themselves and others to feed their habits. I don't think anyone on here said that all patients who take adderall and/or benzos are addicts, but a lot of then are and the truth is underlying the defense of humor, most of us feel a great deal of sadness and anger as we watch people destroy themselves and their families. You have no idea how hard we fight to maintain compassion and provide good treatment to these patients. So why not cut us a little slack, huh?

This!

Oh, and Anon12894, I'm not a Doctor, I'm not even in the healthcare field. I'm a recovered drug addict and a current psych patient, and all I'm hearing when I read that other post is "BAAAAWWWLLLLL!!!" Ya see, us addicts (former or otherwise) are kinda like Daffy Duck in that classic Ali Baba cartoon...you know the one, where he's so focused on getting what he wants that he does this...

 

[MacDonaldTriad]

Careful Ceke, you will be called unprofessional if you tell the truth.

 

[schmoob]

BUMP BUMP BUMP.

Without all of the metaphors and jargon to outwit one another, I truly want to know WHY it's so "wrong" to have both of these meds prescribed.

If there is a legit GAD dx as well as a legit ADHD dx, which is currently amplified by an acute situation that is preventing the pt from performing at full...or even partial cognitive potential, then why the stigma?
Just because the pt would significantly benefit in their life from these 2 schedule prescriptions, does not automatically make them a lowlife drugseeker. ESPECIALLY if this is not a permanent treatment.

I understand there are many BC/BE psychs who can school the hell out of me on a lot of the details, but I would just like to point out that they can try and take a look from the other side. Hopefully they would gauge their pts enough to know if their requests were legitimate, or if they were just trying to manipulate you to write them an rx to get them high.

There ARE situations where both of these meds prescribed simultaneously are scientifically ethical. To brush ALL of the pts off requesting this would be (in my, untrained, and possibly ignorant world) as irresponsible.

I try to look at things from multiple angles. Perspective is key. I do not doubt for a second that there are those that come in with some sob story as to why they NEED both meds simultaneously. As physicians, you have worked too hard to lose everything over some drug addict. But to label EVERYONE who wants this, or a similar combo as an addict or lowlife would (again, in my untrained opinion) be irresponsible and may not be in the best interest of the pt. That is where the major challenge for you lies. I do not envy you.

 

[Shikima]

BUMP BUMP BUMP.

Without all of the metaphors and jargon to outwit one another, I truly want to know WHY it's so "wrong" to have both of these meds prescribed.

If there is a legit GAD dx as well as a legit ADHD dx, which is currently amplified by an acute situation that is preventing the pt from performing at full...or even partial cognitive potential, then why the stigma?
Just because the pt would significantly benefit in their life from these 2 schedule prescriptions, does not automatically make them a lowlife drugseeker. ESPECIALLY if this is not a permanent treatment.

I understand there are many BC/BE psychs who can school the hell out of me on a lot of the details, but I would just like to point out that they can try and take a look from the other side. Hopefully they would gauge their pts enough to know if their requests were legitimate, or if they were just trying to manipulate you to write them an rx to get them high.

There ARE situations where both of these meds prescribed simultaneously are scientifically ethical. To brush ALL of the pts off requesting this would be (in my, untrained, and possibly ignorant world) as irresponsible.

I try to look at things from multiple angles. Perspective is key. I do not doubt for a second that there are those that come in with some sob story as to why they NEED both meds simultaneously. As physicians, you have worked too hard to lose everything over some drug addict. But to label EVERYONE who wants this, or a similar combo as an addict or lowlife would (again, in my untrained opinion) be irresponsible and may not be in the best interest of the pt. That is where the major challenge for you lies. I do not envy you.

Why do you need uppers and downers which are controlled substances?

 

[turtle8787]

BUMP BUMP BUMP.

Without all of the metaphors and jargon to outwit one another, I truly want to know WHY it's so "wrong" to have both of these meds prescribed.

If there is a legit GAD dx as well as a legit ADHD dx, which is currently amplified by an acute situation that is preventing the pt from performing at full...or even partial cognitive potential, then why the stigma?
Just because the pt would significantly benefit in their life from these 2 schedule prescriptions, does not automatically make them a lowlife drugseeker. ESPECIALLY if this is not a permanent treatment.

I understand there are many BC/BE psychs who can school the hell out of me on a lot of the details, but I would just like to point out that they can try and take a look from the other side. Hopefully they would gauge their pts enough to know if their requests were legitimate, or if they were just trying to manipulate you to write them an rx to get them high.

There ARE situations where both of these meds prescribed simultaneously are scientifically ethical. To brush ALL of the pts off requesting this would be (in my, untrained, and possibly ignorant world) as irresponsible.

I try to look at things from multiple angles. Perspective is key. I do not doubt for a second that there are those that come in with some sob story as to why they NEED both meds simultaneously. As physicians, you have worked too hard to lose everything over some drug addict. But to label EVERYONE who wants this, or a similar combo as an addict or lowlife would (again, in my untrained opinion) be irresponsible and may not be in the best interest of the pt. That is where the major challenge for you lies. I do not envy you.

For one, adderal and benzo aren't indicated for gad and adhd because adderal + benzo hasn't been studied in population with both gad and adhd. In our clinical trials we usually exclude patients with comorbidities which makes the results lacking in external and real life validity. Therefore this question falls to expert opinion. The medical analogy is the patient admitted to the ICU for heart failure who has concurrent cardiogenic shock. Giving lasix will make the volume status worse and giving fluids can cause flash pulmonary edema from the heart failure. What do you do? You turn to expert opinion, which is an ICU doctor who won't practice cookie cutter medicine but applies current medical knowledge to this unique patient's circumstances.

The issue with our psychiatric diagnoses is that they constitute symptom clusters and DSM generally lacks biologic validity. By that I mean just because someone has a DSM diagnosis doesn't mean they need a certain medication. SSRI, TCA, MAOIs can help someone with depression, but giving these to a case of mild MDD is likely no better than therapy or even placebo. What I'm saying is it's a misunderstanding to say just because a medication is indicated for a certain DSM diagnosis means this medication should be given to everyone who "meets criteria" for that diagnosis, especially when they check off so many symptoms that they are given multiple diagnoses.

So in the case of "legit" ADHD and GAD, I am going to wonder what are the primary drivers of illness/disability. Anxiety in general can manifest with distractibility, trouble concentrating, and "not getting stuff done." ADHD and more developmental attention/frontal deficits can manifest with difficulty applying oneself in life with a resultant adjustment anxiety. I see treatment going one of three directions. 1) clarify the diagnostic picture with something like neuropsych testing. 2) patient seems to have a clear ADHD hx with collateral with resultant anxiety; treatment could include psychostimulant with psychotherapy. 3) patient has severe anxiety with ruminations that affect executive function; treatment can include psychotherapy +/- ssri.

Notice that initial treatment of both of these is likely strongly emphasizing psychotherapy. The problem is that often the patient who asks for both stimulant and benzo has underlying issues with externalizing their problems (adhd causes me to yell at wife and medication will fix it) and doesn't want any part of psychotherapy. This then causes the medical provider to feel helpless and frustrated because they aren't able to control their environment as they wish, which is not coincidentally the experience of the patient. The psychiatrist may then sabotage the relationship and the patient will start over again by scheduling a new intake with the next psychiatrist. Obviously this transference would be better dealt with in an underlying therapy.

 

[smalltownpsych]

BUMP BUMP BUMP.

Without all of the metaphors and jargon to outwit one another, I truly want to know WHY it's so "wrong" to have both of these meds prescribed.

If there is a legit GAD dx as well as a legit ADHD dx, which is currently amplified by an acute situation that is preventing the pt from performing at full...or even partial cognitive potential, then why the stigma?
Just because the pt would significantly benefit in their life from these 2 schedule prescriptions, does not automatically make them a lowlife drugseeker. ESPECIALLY if this is not a permanent treatment.

I understand there are many BC/BE psychs who can school the hell out of me on a lot of the details, but I would just like to point out that they can try and take a look from the other side. Hopefully they would gauge their pts enough to know if their requests were legitimate, or if they were just trying to manipulate you to write them an rx to get them high.

There ARE situations where both of these meds prescribed simultaneously are scientifically ethical. To brush ALL of the pts off requesting this would be (in my, untrained, and possibly ignorant world) as irresponsible.

I try to look at things from multiple angles. Perspective is key. I do not doubt for a second that there are those that come in with some sob story as to why they NEED both meds simultaneously. As physicians, you have worked too hard to lose everything over some drug addict. But to label EVERYONE who wants this, or a similar combo as an addict or lowlife would (again, in my untrained opinion) be irresponsible and may not be in the best interest of the pt. That is where the major challenge for you lies. I do not envy you.

It is all about risk and these drugs have significant risks for patient and us. The accusation of referring to everyone as a lowlife drug seeker is a straw man. A significant percentage of our patients have addiction problems and we treat them as best we can. It tends to be everyone else that stigmatizes them and then pressures us to "fix" them. Have you ever been in an ED when one of our patients is there and head how people talk about them?