Benzos and Alcohol

[SpongeBob DoctorPants]

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In reviewing paperwork for a new patient I have coming in, I discovered this patient has been receiving Klonopin for at least the past 5 years (possibly longer, but our state database doesn't go back further), when the patient was only 14 years old. And according to the paperwork she completed, she tried Zoloft in 2014 but since then has only been on Klonopin, and according to the database it appears the dose and quantity have gradually increased over the years.

On top of this, the patient reports drinking alcohol multiple days per week (and she's only 19), and she uses marijuana occasionally. (Perhaps not surprisingly, there is a family history of drug and alcohol abuse in both of her parents, too.)

Obviously, this patient has been mismanaged for quite a while and it's up to me to clean up the mess. I plan to start tapering off the Klonopin, especially due to the risks associated with concurrent alcohol and marijuana use, although I don't want to taper too quickly, either.

In the past I've dealt with a patient who had a history of substance use and was still drinking alcohol regularly, and he was very clearly seeking for Klonopin, though wasn't on it; I tried every alternative I could think of with him, and he eventually stopped coming to see me because I wasn't giving him Klonopin.

I'm just curious, for those who may have more experience treating patients who drink regularly, aside from encouraging them to abstain from alcohol, do you check labs such as CDT or GGT to ensure the patient is no longer drinking? Aside from checking a random urine drug screen as part of the treatment agreement, I'm wondering if I should also get some kind of random alcohol screen.

 

[Sushirolls]

One plan to consider. Set a fixed taper plan off klonopin. State any deviation with taking extra, running short, etc.immediately warrants inpatient 'detox' referral.

You can manage the klonopin, but the patient has to manage the alcohol. I wouldn't go as far as ordering the labs. Patient either wants sobriety or doesn't. Patient isn't in a court ordered program or professional diversion program. Go off of self report.

 

[MBBSMOM]

From the first appointment there needs to be a contract written . Your expectations of the patient and the consquences if pt strays from the expectations . I’m curious if pt is already on klonopin why she made an appointment with you ? I would start tapering the klonopin from the first appointment and start her on buspar . I would educate on dangers of long term benzo use . If pt is not okay with tapering. I would tell her I can’t help her and refer her to someone else .


The alcohol use you have to work with . Why is pt drinking ? Is she self medicating or social drinking? Also educate on dangers of alcohol abuse . Work with pt on cutting back . If it’s truly abuse consider naltrexone .

 

[SpongeBob DoctorPants]

Thank you both for your replies. I appreciate the input. Patient is establishing care with me because she's attending college in our area, and her last provider is in a different part of the state.

 

[birchswing]

I find it vindicating to see another person started on long-term benzo "therapy" at 14 years of age, the same age I was as the ridiculousness of it is sometimes not noticed or recognized—too anomalous to notice almost, or even to believe. I was 18 when the university psychiatrist (who obviously saw things differently than you and than I do now) added on a second benzodiazepine. I hope all the best for your patient. It could be a wonderful turning moment.

One thing I can be grateful for is due to my extreme anxiety I was terrified of taking any medication (I refused to take the Ativan at first and was called non-compliant until I finally agreed to take it), but I also always had a fear of alcohol or any other drug interacting with the meds I was taking. I was never given specific knowledge that alcohol interacted with benzodiazepines, but I had a general sense that alcohol interacted with meds. And so at the very least I can say I've never made things worse by ever having alcohol.

 

[ara96]

From the first appointment there needs to be a contract written . Your expectations of the patient and the consquences if pt strays from the expectations . I’m curious if pt is already on klonopin why she made an appointment with you ? I would start tapering the klonopin from the first appointment and start her on buspar . I would educate on dangers of long term benzo use . If pt is not okay with tapering. I would tell her I can’t help her and refer her to someone else .


The alcohol use you have to work with . Why is pt drinking ? Is she self medicating or social drinking? Also educate on dangers of alcohol abuse . Work with pt on cutting back . If it’s truly abuse consider naltrexone .

Do you have a sample contract you can share? I have a ton of patients on Benzo's and I'm trying to get them off, but I'm having a hard time because PCP's love handing out Benzo's like candy.