prominence

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I am currently working as an outpatient psychiatrist. I am inheriting the majority of my patients from a psychiatrist who left the practice. He gave benzos out like candy, especially to patients with histories of drug and alcohol dependence.

I am very clear in the expectations I have for patients when I am the provider initiating benzos.

I have inherited these patients, who are on their conventional Klonopin 1mg tid prn anxiety, which they have been maintained on for the past 1-2 years by this previous psychiatrist.

However, I am coming across a recurring problem. I see these patients for one or two 15 minute med checks visits, and everything is status quo, meds are working, no specific problems voiced, so I do not alter their med regimen on such visits. Eventually, these patients take the benzo more frequently than prescribed, and begin running out of their presciption a week or two earlier than anticipated. They call our clinic and demand refills of the benzo from me, and specifically make it clear that they do not want to experience withdrawal seizures if I do not handle the refill in a timely fashion.

How is the scenario best handled? I do not want to abandon these patients and have the suffer any adverse consequences of benzo withdrawal. On the other hand, I do not want to ignore their manipulation and benzo misuse or abuse. I have no idea if they simply lying about running out of the medication too early in order to hoard or selling their benzos.

I would greatly appreciate any suggestions or recommendations on how others safely and reasonably handle this type of problem. Thanks in advance!
 
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Doc Samson

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I am currently working as an outpatient psychiatrist. I am inheriting the majority of my patients from a psychiatrist who left the practice. He gave benzos out like candy, especially to patients with histories of drug and alcohol dependence.

I am very clear in the expectations I have for patients when I am the provider initiating benzos.

I have inherited these patients, who are on their conventional Klonopin 1mg tid prn anxiety, which they have been maintained on for the past 1-2 years by this previous psychiatrist.

However, I am coming across a recurring problem. I see these patients for one or two 15 minute med checks visits, and everything is status quo, meds are working, no specific problems voiced, so I do not alter their med regimen on such visits. Eventually, these patients take the benzo more frequently than prescribed, and begin running out of their presciption a week or two earlier than anticipated. They call our clinic and demand refills of the benzo from me, and specifically make it clear that they do not want to experience withdrawal seizures if I do not handle the refill in a timely fashion.

How is the scenario best handled? I do not want to abandon these patients and have the suffer any adverse consequences of benzo withdrawal. On the other hand, I do not want to ignore their manipulation and benzo misuse or abuse. I have no idea if they simply lying about running out of the medication too early in order to hoard or selling their benzos.

I would greatly appreciate any suggestions or recommendations on how others safely and reasonably handle this type of problem. Thanks in advance!
I specifically state that I give one "get out of jail free card" just in case their dog really did knock the klonopin into the toilet, but if there's any further indication of misuse/abuse then I'm happy to taper their meds or refer them for inpt detox. Once they've used up their one free chance, sometimes it's even worth officially documenting the strategy with their signature indicating receipt and understanding (including the idea that I might even ask for the occasional random UTox). For outpatient tapers, I'd probably convert them to Librium and taper over the course of 7-10 days. If they choose to seek care elsewhere, that's up to them.
 

kugel

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I specifically state that I give one "get out of jail free card" just in case their dog really did knock the klonopin into the toilet, but if there's any further indication of misuse/abuse then I'm happy to taper their meds or refer them for inpt detox. Once they've used up their one free chance, sometimes it's even worth officially documenting the strategy with their signature indicating receipt and understanding (including the idea that I might even ask for the occasional random UTox). For outpatient tapers, I'd probably convert them to Librium and taper over the course of 7-10 days. If they choose to seek care elsewhere, that's up to them.
Many feel BZD's are not the Devil's Brew that most of us on SDN think they are. If pt's are stable, not abusing, not using drugs/alcohol, and not escalating use - then what's the problem? At least that's the argument. And many private outpt psych's have pt's stable on them for years and years. Personally, I avoid them like the plague except in emergency use in Inpt setting.

Many advocate a much slower taper than our local Super Hero does, on the level of 10-25% every 2-4 weeks. It may take many months to successfully taper off, but you run much less risk of seizures - or at least the report of withdrawal seizures. If there is a history of seizures, you may want to prescribe an antiepileptic like carbamazepine, during the BZD taper and then taper the antiepileptic over the next 2-4 weeks.

During any BZD taper more than a week, it can be very helpful to contact the pharmacy and talk with an individual pharmacist, and verify that he/she carries the drug/doses you want to use, and can dispense the BZD 3-7 days at a time. Then you can write "Dispense only 3 days at a time" at the end of each Rx, FAX (or call) it to the pharmacy (don't give the pt the chance to think of altering the Rx).

If you have to taper quickly b/c of pt demand/misuse/etc, seriously consider using a non-BZD antiepileptic that is unlikely to be abused (carbemazepine, oxcarbazepine, valproate).

DOCUMENT, DOCUMENT, DOCUMENT
your conversations, including exact quotes from your pt AND from you.
Signed contracts can help, but the combo of contracts and printed policies with clear and detailed Progress Notes is nearly unbeatable for protecting yourself. But when it comes to protecting yourself, talk with your Risk Management Attorney at your agency or Malpractice Insur. Company.
When it comes to Risk Management, don't take advice only from other docs, talk with the Medico-legal expert that you already pay for this advice.
 

toby jones

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If they are concerned about having seizures if they don't get their supply then I guess they appreciate that they are physically dependent on them. Similarly, if they are requesting more before they are due then they must know that they are taking them in excess of their prescribed dose. I really like the idea of making your expectations (or line) clear then giving them some time to decide whether they want treatment for their dependency or whether they would rather attempt to locate an alternative provider.
 

purpledoc

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Many advocate a much slower taper than our local Super Hero does, on the level of 10-25% every 2-4 weeks. It may take many months to successfully taper off, but you run much less risk of seizures - or at least the report of withdrawal seizures. If there is a history of seizures, you may want to prescribe an antiepileptic like carbamazepine, during the BZD taper and then taper the antiepileptic over the next 2-4 weeks.
Sorry, I'm with Doc Samson. A safe rate to prevent withdrawal seizures is a drop of 10%-20% per day, not per week. The person will feel anxious, but the risk of withdrawal seizures or delirium tremens is very low. This is the reason that medical detox unit admissions are 3-7 days. My goal is to get the person off the BZD as rapidly and safely as possible so that addiction treatment can begin in earnest, if the person is willing. I am not an addiction psychiatrist and would not follow the person long-term -- certainly not if they're antisocial and just using me to get their BZD supply. Therefore, my goal is safe detox and referral for specialty treatment.

If you have to taper quickly b/c of pt demand/misuse/etc, seriously consider using a non-BZD antiepileptic that is unlikely to be abused (carbemazepine, oxcarbazepine, valproate).
Unfortunately, an antiepileptic opens up a can of worms regarding the potential of causing drug-induced Stevens-Johnson syndrome, hepatitis, hyponatremia, etc. Studies have also shown no real benefit to using antiepileptics routinely for standard ETOH or BZD detox. So I would only do this if I were following a patient long-term, not for someone I'm detoxing rapidly.

I'll clarify that I'm talking about patients whom I believe are deliberately lying and misusing prescriptions I have given them, not patients who have not been misusing medications but would like to stop taking them. Those patients I will taper off more gradually, because I am treating them for anxiety, not for a substance-abuse problem. For antisocial patients, my goal is to provide the basic standard-of-care and no more, in order to discharge them from my practice without getting sued. Patients should always be given information about signs/sx of severe BZD withdrawal and when to go to the ED or call 911.
 

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Particularly the long-acting benzos like clonazepam and diazepam has very limited withdrawal risk. The bad player is alprazolam, which is such a strong seizure suppressant that withdrawal can rebound into seizures, even with no history (It also has an immediate withdrawal feeling, even at first dose). In fact, in my training, we were taught to treat alprazolam withdrawal or overdoses with qid clonazepam.

I have used clonazepam scheduled and with lorazepam backup for breakthroughs plenty of times with severe PTSD. Works like charm, and over time, and with specific therapy, I get them transitioned nicely to vistaril and maybe one or two lorazepam per week which frankly doesn't bother me.

But If they have been stable for a long time, but with no therapy to build up their resilience, then they need their butt into therapy yesterday. Because cooling down their adrenaline response only works as long as nothing else goes wrong in their lives (And, BTW, if they go to therapy, they don't take any benzos till AFTER the therapy session).
 

kugel

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Studies have also shown no real benefit to using antiepileptics routinely for standard ETOH or BZD detox.
I'm very interested. I don't use them in "standard ETOH or BZD detox," but For those with increased Sz risk (like a known hx of sz'z, underlying sz hx, or reported hx of w/d sz's), why wouldn't they be used?
 

nancysinatra

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I'm very interested. I don't use them in "standard ETOH or BZD detox," but For those with increased Sz risk (like a known hx of sz'z, underlying sz hx, or reported hx of w/d sz's), why wouldn't they be used?
Isn't it really DT's that is the big fear of either benzo or Etoh withdrawal? (or barbiturates?) How would antiepileptics prevent DTs? (And pt's can have DTs without going through seizures first, correct? That happens to hospitalized patients quite often who don't mention how much they drink, doesn't it?) I thought I'd heard that pt's with preexisting seizure disorders should be maintained on their antiepileptics, but that they can't be used for preventing withdrawal seizures. I have no idea why, though, or if it's really true...

Do AED's have some role in DT prevention? Purpledoc mentions studies comparing them to benzos in withdrawal, so possibly? (Including for EtOH detox.) Otherwise how would it be safe to use them?
 

whopper

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I really hate saying this because I'm not putting in links to the studies (again, I'm really choked up for time--this week I have to do a state-wide presentation), but there was, I believe, an article in Current Psychiatry mentioning that some AEDs were useful in preventing seizures in alcoholics. If I remember correctly, Depakote was the one with the most data.

That said, however, the idea of giving an alcohol dependent patient another medication that taxes the liver, when there are other medications available such as Serax, well, I'd rather go with the Serax. It won't require lab draws that are bothersome to the patient, and will add another few hundred dollars to our national healthcare expenses.
 

kugel

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Do AED's have some role in DT prevention? Purpledoc mentions studies comparing them to benzos in withdrawal, so possibly? (Including for EtOH detox.) Otherwise how would it be safe to use them?
Seizures are my big worry, and the problem most likely to kill pts, in BZD w/d. And the issue driving the OP to feel unsure about cutting off BZDs to potentially abusing pts. In ETOH w/d, you have DT's and Sz's to worry about.

Few ETOH pts and fewer BZD-dependent pt's have overtly failing livers and there just isn't any clear evidence that temporary use of AED's will cause/exacerbate liver problems in those without overt damage. And there is significant risk of seizures in both conditions. IF (IF!) a pt has hx of seizures in w/d, I add an AED for 1-2 weeks.

But there are LOTS of opinions about these issues. Just make sure you can defend your practice.

I used to think Serax was the most liver-sparing BZD (and that's what I was taught) until I looked it up. (last time I looked was 2003, but I haven't come across anything new since then) Couldn't find any evidence that it's significantly more safe for the livers of such pts.

Outside of overt liver failure (I'm not treating ICU pts), I no longer worry as much about temporary use of drugs metabolized by the liver. (Not that I don't think about it, just not as much.) I worry about getting them off the addicting agent(s) and keeping them alive through the detox/taper.
 

whopper

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I used to think Serax was the most liver-sparing BZD (and that's what I was taught) until I looked it up. (last time I looked was 2003, but I haven't come across anything new since then) Couldn't find any evidence that it's significantly more safe for the livers of such pts
Well, it's not metabolized by the liver.

I don't think your post was counter to mine, but a point I want to emphasize was that I don't see the point in giving someone Depakote for example to prevent an alcohol or benzodiazepine withdrawal induced seizure when it's just going to require more labwork that costs the system (or the patient) a lot of money and 2 blood draws that are annoying for the patient.

The odds of Depakote causing damage to a patient with an already taxed liver is unlikely, even to the point where I wouldn't lose sleep on the risk that it could do it, but even aside from this point, the above points make the use of benzos to treat withdrawal a much better option.

IMHO, I do think there is an argument that patients who were dependent on a benzodiazapine, and tapered off of it should be considered for an AED for at least a few weeks. A seizure can still happen a few weeks after the patient has been taken off of a benzodiazapine. It's not the standard of care, but I figure why not?
 

birchswing

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For outpatient tapers, I'd probably convert them to Librium and taper over the course of 7-10 days. If they choose to seek care elsewhere, that's up to them.
The scientific evidence I've seen shows that the risk of protracted withdrawal syndrome is drastically reduced with a slow, gradual taper (months to years). There is no harm in side-stepping. More research on benzodiazepine withdrawal has been done using than Valium.

Sorry, I'm with Doc Samson. A safe rate to prevent withdrawal seizures is a drop of 10%-20% per day, not per week. The person will feel anxious, but the risk of withdrawal seizures or delirium tremens is very low. This is the reason that medical detox unit admissions are 3-7 days. My goal is to get the person off the BZD as rapidly and safely as possible so that addiction treatment can begin in earnest, if the person is willing. I am not an addiction psychiatrist and would not follow the person long-term -- certainly not if they're antisocial and just using me to get their BZD supply. Therefore, my goal is safe detox and referral for specialty treatment.
That is not a safe withdrawal rate and would likely lead to a person becoming hospitalized. It's not about how fast you can get the person off a drug, it's how long the brain takes to adjust to a lower dose. The person would still be having withdrawal from the first day's taper by the seventh day and would obviously be exacerbated by an even steeper drop and cessation of the medication.

Very fast tapers increase the amount of kindling that takes place, and fast withdrawals are much less successful than long-tapers. The kindling that takes place during rapid withdrawals leads to less successful future attempts at withdrawal and to long-term or even life-time protracted withdrawal syndrome and even seizure disorders.

Read the British National Formulary's recommendations if you don't trust me.

Going slow is not only less painful it is more successful (in terms of actually getting patients off) and leads to fewer cognitive and physical effects down the line.
 
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