Another polypharmacy tale

[sweetlenovo88]

Scheduled to see patient outpatient for the first time. Look at what his inpatient doc discharged with:



Seroquel 300mg po qhs
prazosin 6mg qhs
neurontin 300mg po QID
lithium ER 600mg po bid
effexor xr 150mg po daily
wellbutrin SR 300mg qam
prozac 80mg qdaily
tegretol xr 300mg po bid
naltrexone 50mg qam
zyprexa 30mg po qhs

---

Members don't see this ad.

 

[WisNeuro]

Looks like that patient needs some opiates and benzos on board.

 

[erg923]

Kind of makes you wonder how we survived 50 years ago without all this junk? Oh wait...

 

[st2205]

Odds they complain about how bad things are but resist any net reduction in medication?

I know, I know. Counter transference and all that. I can look at that med list and know where it's headed. Could probably document enough for 99213 without even laying eyes on the patient.

 

[PistolPete]

I'd add clozapine for good measure.... (kidding). Good luck with that one.

 

[Merovinge]

Scheduled to see patient outpatient for the first time. Look at what his inpatient doc discharged with:
Seroquel 300mg po qhs
prazosin 6mg qhs
neurontin 300mg po QID
lithium ER 600mg po bid
effexor xr 150mg po daily
wellbutrin SR 300mg qam
prozac 80mg qdaily
tegretol xr 300mg po bid
naltrexone 50mg qam
zyprexa 30mg po qhs

Failed to titrate Effexor and Seroquel, for shame!

 

[sweetlenovo88]

The majority of these agents were started inpatient and there is a suicide risk with patient (OD on lithium). Patient abuses meth/heroin and does not see the harm in these agents. Claims to have untreated seizure disorder hence the tegretol. I ended up with

naltrexone 50mg qam
zyprexa 30mg qhs
tegretol xr 200mg po bid
prazosin 4mg po qhs

which he will receive daily.

 

[PistolPete]

You're stopping the others cold turkey or coming up with a certain tapering schedule? If so, what did you chose? Or is they patient non-adherent to most/all of these meds? The odds that he/she is adherent to all of those prescriptions is close to 0%. Studies show it's about 50% per prescription, if I remember correctly.

 

[smalltownpsych]

The majority of these agents were started inpatient and there is a suicide risk with patient (OD on lithium). Patient abuses meth/heroin and does not see the harm in these agents. Claims to have untreated seizure disorder hence the tegretol. I ended up with

naltrexone 50mg qam
zyprexa 30mg qhs
tegretol xr 200mg po bid
prazosin 4mg po qhs

which he will receive daily.

If he is still using meth and heroin, then why prescribe any medications? I mean, is any psychotropic really going to do anything for someone in active addiction with such effective street drugs? I guess the naltrexone will help when he can't get any heroin or is cycling down. I have heard a few addicts say that seroquel can help ease the comedown from a good meth run, too. The seizure might have been back when was drinking more. Probably don't drink much now cause with heroin and meth, you are so high already, alcohol is not even necessary.

 

[sweetlenovo88]

If he is still using meth and heroin, then why prescribe any medications? I mean, is any psychotropic really going to do anything for someone in active addiction with such effective street drugs? I guess the naltrexone will help when he can't get any heroin or is cycling down. I have heard a few addicts say that seroquel can help ease the comedown from a good meth run, too. The seizure might have been back when was drinking more. Probably don't drink much now cause with heroin and meth, you are so high already, alcohol is not even necessary.

This is a constant problem I run into. I am concerned with liability if I just stop everything especially since patient has recurrent inpatient admissions. The majority of the members at the CMHC are actively using and then I could have a large case load with no one taking any medication.

 

[Shikima]

Prescribe low dosage of Zoloft and make sure they're attending psychotherapy. If not, document that they need to go. See them out in 15 mins at CMH. Can't force them and you're certainly liable for polypharmacy side effects.

 

[sweetlenovo88]

You're stopping the others cold turkey or coming up with a certain tapering schedule? If so, what did you chose? Or is they patient non-adherent to most/all of these meds? The odds that he/she is adherent to all of those prescriptions is close to 0%. Studies show it's about 50% per prescription, if I remember correctly.

Yes, cold turkey in this case. Of all the STOPPED medications, the ones NOT introduced in the past couple of weeks were lithium, prozac and neurontin. I am not giving him lithium because of interaction with tegretol and his risk of OD. Prozac has a long halflife and will be in his system until his next appointment and can restarted as needed. Not seeing a need for neurontin for "anxiety" given everything else going on right now. Patient has chosen to see a different provider at the next visit which I have no qualms about. I also continued the high zyprexa dose because of the tegretol.

 

[sweetlenovo88]

Prescribe low dosage of Zoloft and make sure they're attending psychotherapy. If not, document that they need to go. See them out in 15 mins at CMH. Can't force them and you're certainly liable for polypharmacy side effects.

I called case management into the meeting and asked them to find substance abuse treatment and therapy. All documented. Oh, and per patient, "the hospital psychiatrist told me you may have a problem with my medications, they can interact and cause side effects, but I need all of them." And then opposition concerning drug use. Why did the inpatient doc rx these meds if they realize what can happen? Ugh

 

[nexus73]

Luckily with the tegretol on board the effective levels of many of the medications are significantly reduced. But not the lithium

 

[wolfvgang22]

Patient has chosen to see a different provider at the next visit which I have no qualms about.

Well, at least there is some good news. Hopefully you'll never see him again unless he is ready to work with you.

 

[smalltownpsych]

Yes, cold turkey in this case. Of all the STOPPED medications, the ones NOT introduced in the past couple of weeks were lithium, prozac and neurontin. I am not giving him lithium because of interaction with tegretol and his risk of OD. Prozac has a long halflife and will be in his system until his next appointment and can restarted as needed. Not seeing a need for neurontin for "anxiety" given everything else going on right now. Patient has chosen to see a different provider at the next visit which I have no qualms about. I also continued the high zyprexa dose because of the tegretol.

Setting appropriate and healthy boundaries and being honest and upfront with patients leads to a more motivated overall case load which is good for both us and for the patients. When or if that patient decides they want to get better, they know who to trust now.