benzos and amphetamines

[powermd]

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As a pain specialist occasionally I see truly 'difficult' patients with some combination of depression, anxiety, maybe a PD, and, of course, chronic pain. Usually they are on ridiculous doses of opioids that barely "take the edge off", and among their meds you find both benzos and amphetamines. When I see this I have two reactions: 1) this is an incredibly manipulative patient, and 2) the psychiatrist is a weak fool, or just doesn't care.

Can any of you justify putting a patient on both benzos and amphetamines?

To me it would seem the patient has either anxiety as a primary disorder, or has it secondary to ADHD. And if it's truly an anxiety disorder, WTF is the psychiatrist doing treating it with tid Xanax or Valium instead of an SSRI? It just looks like bad medicine to me, pun intended. These guys are always fairly unstable people, and thus the worst possible candidates for potent, tolerance inducing meds fraught with undesirable side effects.

 

[psychotrope]

As a pain specialist occasionally I see truly 'difficult' patients with some combination of depression, anxiety, maybe a PD, and, of course, chronic pain. Usually they are on ridiculous doses of opioids that barely "take the edge off", and among their meds you find both benzos and amphetamines. When I see this I have two reactions: 1) this is an incredibly manipulative patient, and 2) the psychiatrist is a weak fool, or just doesn't care.

Can any of you justify putting a patient on both benzos and amphetamines?

ummmm....you're describing a (fairly common problem unfortunately) polywriter issue......

I wouldn't *ever*(as a soon to be psych resident) write for all 3 of those meds on an inpt unit....

but it's more a problem of fms and internists doing it than psych

 

[billypilgrim37]

Can any of you justify putting a patient on both benzos and amphetamines?

The two really don't have anything to do with each other, as they treat very different symptoms, so I could certainly imagine situations in which using the two could be appropriate. In a different patient population, this regimen might not raise an eyebrow (or at least not very far) in capable hands. With the opiates involved as well, that's a bit of a different issue.

That said, I wouldn't anticipate benzos+amphetamines would be a commonly prescribed appropriate regimen, for all the same reasons that are causing you to seriously question it. And your concern about the lack of an SSRI is spot on (heck, why haven't the Cymbalta reps descended upon your locale?). It doesn't sound like these patients are getting much benefit from their opioids or benzos, and they're now dependent on them with limited insight. Sounds like you need to have a few phone calls with the psychiatrist.

 

[OldPsychDoc]

You mean you don't drive with one foot on the brake and the other on the accelerator?

 

[powermd]

The two really don't have anything to do with each other, as they treat very different symptoms, so I could certainly imagine situations in which using the two could be appropriate. In a different patient population, this regimen might not raise an eyebrow (or at least not very far) in capable hands. With the opiates involved as well, that's a bit of a different issue.

That said, I wouldn't anticipate benzos+amphetamines would be a commonly prescribed appropriate regimen, for all the same reasons that are causing you to seriously question it. And your concern about the lack of an SSRI is spot on (heck, why haven't the Cymbalta reps descended upon your locale?). It doesn't sound like these patients are getting much benefit from their opioids or benzos, and they're now dependent on them with limited insight. Sounds like you need to have a few phone calls with the psychiatrist.

I can understand the rare use of opiates/neuropathic meds + amphetamines in well functioning people who get effective pain relief from the opioid, but need something to wake them up during the day. I do not understand benzos + amphetamines, two drugs that basically cancel each other out. One relaxes the brain and decreases focus, the other does the opposite. A doctor prescribing both seems akin to the guy who can't decide if a patient is volume overloaded, or volume depleted, so he gives both fluid and Lasix. Doh!

 

[powermd]

You mean you don't drive with one foot on the brake and the other on the accelerator?

No, I don't own a Toyota.

 

[billypilgrim37]

I do not understand benzos + amphetamines, two drugs that basically cancel each other out.

Well, if the two are being used to treat vague symptoms of "up" and "down," sure. (And in many clinical scenarios, "cancelling each other out" would probably be an apt description).

But I could imagine this combo in ADHD + panic disorder, bipolar disorder, MR or autism w/ severe agitation, etc. And I have a semi-catatonic inpatient who has failed ECT and is doing moderately better on a combination of Ativan and Provigil (he already failed MPH).

But again, I'm guessing that in the pt's your are seeing, your suspicions are probably the same suspicions the rest of us would have. 😉

 

[whopper]

I've only put perhaps 2-3 patients on an amphetamine. I've only put 1-3 patients on Xanax, my entire career including residency.

In almost all the cases, someone put them on it before me, and I've had great difficulty getting them off.

I picked up a moonlighting job where I've taken over 90% of my patients off of benzos that were on them before. I just took off someone off of Concerta a few days ago.

The few I've kept on are weird cases. On one, the person went through a series of psychological tests all indicating he truly has ADHD. I tried wellbutrin, Effexor, clonidine and strattera with no success.

I have another patient with borderline intelligence in a group home, who if she doesn't get her ativan, she threatens to drink bleach. I've gotten her to half her dose of ativan (2mg a day vs 4mg) but I'm going to have to slowly taper her down--very slowly. Doing it too quickly has ended up with her being hospitalized twice. Some idiot psychiatrist before me put her on it, and she's been on ativan 4mg a day for over 5 years.

I've got someone I put on Xanax for sleep who could not sleep on almost anything after he received chemotherapy. I've prescribed him xanax, but I've informed him that every month I will switch him off of Xanax to prevent tolerance of that medication. If he can't sleep for a month, too bad. I'm not going to continually give xanax. In his case, I've tried several other meds including thorazine, haldol, ambien, lunesta, sonata, seroquel, etc. If you're wondering why I prescribed thorazine just for sleep, well that just shows how weird his case is.

Anyway, getting to the point, IMHO a doctor who liberally puts someone on an amphetamine or benzo is not practicing safe medicine. A benzo IMHO should only be given on an outpatient basis out if it's used as a temporary bridge to relieve a person's anxiety, while an SSRI is supposed to get their anxiety under control, and eventually the benzo should be stopped (hopefully in less than 3 months). I also don't think it's a bad idea for agitation, once in awhile. Certainly not for a patient who demands it at every available opportunity.

In short, I dont' think a doctor who actually knows what he or she is doing would commonly give out benzos or amphetamines. If you see someone on one or both of them, there could be a strange reason for it that is justifiable after you read the history, but these are very rare things.

Unfortunately, I've seen just too many cases where the person becomes dependent on a medication thanks to their PCP, who is all too willing to throw a medication at the person just to get them out of their office.

 

[Regnvejr]

As a pain specialist occasionally I see truly 'difficult' patients with some combination of depression, anxiety, maybe a PD, and, of course, chronic pain. Usually they are on ridiculous doses of opioids that barely "take the edge off", and among their meds you find both benzos and amphetamines. When I see this I have two reactions: 1) this is an incredibly manipulative patient, and 2) the psychiatrist is a weak fool, or just doesn't care.

Or 3) There are circumstances you didn't know about.

Can any of you justify putting a patient on both benzos and amphetamines?

Frequently. Patients with TBI (rarely). Patients with PTSD and ADHD. People who are already on their 5th SSRI with insufficient effect, or who have intolerable side effects to any serotonin-enhancing compound.. People with severe ADHD and mood control problems, and who failed the traditional mood stabilizers. Some of the autism patients who respond poorly to atypical anti-psychotics (rarely).

It just looks like bad medicine to me, pun intended. These guys are always fairly unstable people, and thus the worst possible candidates for potent, tolerance inducing meds fraught with undesirable side effects.

So we could not treat them, and let them stew in their misery?


So yeah, I can imagine lots of situations where that combo is being used, and I have certainly done so myself numerous times. Your outrage seems specific to a subset of patients that are not the typical stimulant/benzo patient, though, so perhaps you could reword and specify your concern?

 

[Regnvejr]

...I do not understand benzos + amphetamines, two drugs that basically cancel each other out.

Ah, but they don't. Unless used in some idiotic fashion. Frankly, your claim, while maybe supporting a perfectly good mood of outrage, shows lack of experience with how these two types of meds can be used effectively together in appropriate patients.

But go tell my TBI patient who now got a part-time job and whose wife didn't leave him after all, that he should get off his medications.

One relaxes the brain and decreases focus, the other does the opposite.

Grossly over-simplified to the point of being ignorant.

A doctor prescribing both seems akin to the guy who can't decide if a patient is volume overloaded, or volume depleted, so he gives both fluid and Lasix. Doh!

Well thanks for that insult. You want my opinion of your kind of addiction treatment as well? 😡

 

[Regnvejr]

..I've got someone I put on Xanax for sleep who could not sleep on almost anything after he received chemotherapy.

Clonazepam is much more sedating. much better for sleep than the short-acting benzos.

Anyway, getting to the point, IMHO a doctor who liberally puts someone on an amphetamine or benzo is not practicing safe medicine.

And what does "liberally" mean? When do you see stimulants as appropriate, then?

A benzo IMHO should only be given on an outpatient basis out if it's used as a temporary bridge to relieve a person's anxiety, while an SSRI is supposed to get their anxiety under control, and eventually the benzo should be stopped (hopefully in less than 3 months). I also don't think it's a bad idea for agitation, once in awhile.

Very nice advice....... For Family Practice. Around here, nobody ever diagnosed PTSD, so I end up with a load of patients coming through the door with chronic symptoms because nobody bothered to treat them. I can tell you that UNDER TREATMENT with benzos is a sore subject with me around here because physicians are so afraid of the meds that they never use them and cause problems for my patients. It is exactly the same mentality as the physicians who never give pain meds because ever patient on opiates must be an addict. If we are uncomfortable with a medication, we need to learn as much as possible about that med to be sure that we use it when appropriate, instead of being afraid of it.

Certainly not for a patient who demands it at every available opportunity.

Sure. Patients who show up in your office or unit demanding them will rarely need them.

 

[whopper]

And what does "liberally" mean?

In the context of my previous post, a doctor who gives out benzos without warning the patient of it's possible addictive potential, and gives out the benzo without an official diagnosis that justifies it's use, or gives it out without a strategy to end it's use.

When do you see stimulants as appropriate, then?

Usually if the person meets a DSM criteria where it's use is justified, in addition to psychological testing verifying there is a disorder. Even then I'd rather give a non-amphetamine based medication such as wellbutrin.

Clonazepam is much more sedating. much better for sleep than the short-acting benzos.

In this individual, clonazepam worked, though it kept him sedated all day long, and that was at a low dosage of Clonazepam. Xanax kept the guy asleep, but when he woke up the next day, he was not sedated. Trust me, I tried. I'd rather have someone on clonazepam than xanax.

I can tell you that UNDER TREATMENT with benzos is a sore subject with me around here because physicians are so afraid of the meds that they never use them and cause problems for my patients. It is exactly the same mentality as the physicians who never give pain meds because ever patient on opiates must be an addict.

True, in your area (based on what you're saying), but in other areas, the problem is the other way around. For example, where I did residency, one of the ER doctors gave everyone any opioid or benzo they wanted. In fact it got to the point where the DEA investigated him. That very week, over a dozen people ended up in the inpatient psychiatry unit, all of them meeting the criteria for benzo dependence because while the DEA investigate the ER doc (who also had an outpt practice), he abruptly stopped benzos on all his patients without a taper down during the DEA investigation. These people did not have an anxiety disorder. They were just substance dependent, enabled by that doctor. I'm talking Ativan or Xanax over 6mg a day--for years. It was to the point where the homeless at the homeless shelter memorized the exact times and days that doctor was on duty just so they could get their benzo or opioid from him.

When I asked them why they were put on a benzo, they gave answers such as "My husband died, so he put me on it, then a few months later it wasn't working, I told him, so he increased the dose." That same person did meet a criteria of depression or an anxiety disorder during the death of her husband.

Another patient told me that the doctor had a local rep for being the doctor to go to get anything you wanted.

(Not to mention the guy would medically clear everybody to psychiatry--even if the person wasn't truly medically stable. E.g. the person had a bad MRSA infection, that's visible to the naked eye and he cleared her).

 

[powermd]

Or 3) There are circumstances you didn't know about.

That possibility always exists, but in the cases I've seen- it looks much more like enabling of chemical coping than anything else.

Frequently. Patients with TBI (rarely). Patients with PTSD and ADHD. People who are already on their 5th SSRI with insufficient effect, or who have intolerable side effects to any serotonin-enhancing compound.. People with severe ADHD and mood control problems, and who failed the traditional mood stabilizers. Some of the autism patients who respond poorly to atypical anti-psychotics (rarely).

I'm not going to question your reasoning, I'll leave that to your colleagues. Clearly these are not run of the mill cases (perhaps to you they are).

So we could not treat them, and let them stew in their misery?

Not every anxious patient needs more benzos, just like not every pain patient needs more opioids. My point is that doctors should strive not to enable chemical coping.

If benzos and stimulants are not truly opposites, and there are legitimate cases for using both, then I can accept that. It just looks real fishy to me.

The last patient I saw on this combination (and a whopping load of opioids) tested positive for cocaine, and was admitted to the hospital for a blood infection of unclear etiology that happened to culture out as skin Staph. Hmm... I wonder what happened.

 

[psychfun]

A doctor prescribing both seems akin to the guy who can't decide if a patient is volume overloaded, or volume depleted, so he gives both fluid and Lasix. Doh!

Again, there ARE indications for some patients to be on FLUIDS and LASIX....for disorders of ADH, lasix will help lose WATER and SODIUM and fluids will replenish the WATER part only!

So, again, important to ensure all the facts!

 

[michaelrack]

Clonazepam is much more sedating. much better for sleep than the short-acting benzos.
.

Clonazepam is good for parasomnias, including sleepwalking and Rem sleep behavior disorder. I don't like to use it for regular insomnia due to morning sedation.

Many of my narcoleptic patients are on a stimulant or provigil/nuvigil during the day and a hypnotic at night. I usually use ambien or lunesta, but occasionally a benzo such as restoril (temazepam) is required. Patients with narcolepsy have an unstable sleep/wake switch and need something to bring them UP during the day and DOWN at night.

 

[powermd]

Again, there ARE indications for some patients to be on FLUIDS and LASIX....for disorders of ADH, lasix will help lose WATER and SODIUM and fluids will replenish the WATER part only!

So, again, important to ensure all the facts!

The point of the example is a common scenario where an analogous mistake is made. I know there are more unusual situations where you may want to give both, hyponatremia would be one example. Just as there may be unusual situations in which benzos and stimulants might be given. My suspicion is that the patient's I've seen do NOT fall into those unusual categories (none have had narcolepsy, or any of the other examples cited previously), and it likely represented inappropriate prescribing.

 

[OldPsychDoc]

I think it's always easy to sit around and Monday-morning-quarterback other doctors' decisions. Polypharmacy is everywhere, and griping about how "that doctor" does this or that thing that we NEVER do is not the most constructive of responses to it.

As one of my mentors once said, "It takes 30 seconds to say yes, and 30 minutes to say no." These can be very difficult patients to figure out in the best of circumstances. In the real world they have fragmented care, dubious histories, idiosyncratic side effects, and a LOT of distress. It is very tempting to throw something at the problem "temporarily" to ease the distress (theirs AND yours!) so you can get on to the next problem. The patient is no better served by a rigid refusal to prescribe anything "addictive", either.

Just make sure you document the hell out of the rationale for your decisions, so the next doc facing this patient has SOME idea of what might be going on.

 

[Regnvejr]

...Just as there may be unusual situations in which benzos and stimulants might be given.....

You keep claiming these are "unusual situations." Before we end up in a drag-down, all-out fight, would you care to clarify what you mean with that?

 

[Regnvejr]

Clonazepam is good for parasomnias, including sleepwalking and Rem sleep behavior disorder. I don't like to use it for regular insomnia due to morning sedation.

Agreed. That is my experience as well. I also have noted that in my more severe PTSD patients, the hypnotics tend to lead to sleep walking. Adding a long-acting Benzodiazepine at low dose will keep them from wandering out into traffic (Or get out of bed with night terrors).

And for the ruminative anxiety these patients experience once they settle down to sleep, there simply isn't anything better to settle down the adrenaline response the PTSD patients all experience at bedtime.

 

[Regnvejr]

...I'm not going to question your reasoning, I'll leave that to your colleagues.

Are you deliberately trying to be a jerk here?

Clearly these are not run of the mill cases (perhaps to you they are).

That list is more than 1/2 of my patient population.

 

[powermd]

Are you deliberately trying to be a jerk here?

By giving you the benefit of the doubt as an expert in the field?

I think someone needs to lay off the stimulants!

If I wanted to be a jerk I'd suggest you were projecting.

That list is more than 1/2 of my patient population.

I assumed as much.

 

[powermd]

You keep claiming these are "unusual situations." Before we end up in a drag-down, all-out fight, would you care to clarify what you mean with that?

The situations you mention are not common to my clinic, or any group of patients I've seen in training. Makes sense that these patients would tend to collect at your office, rather than at mine, right?

 

[whopper]

I think it's always easy to sit around and Monday-morning-quarterback other doctors' decisions. Polypharmacy is everywhere, and griping about how "that doctor" does this or that thing that we NEVER do is not the most constructive of responses to it.

Agree.

But I believe this problem exists on a spectrum.

Most patients IMHO (at least where I've been at), in general there's more attendings than not that give out too many benzos and opioids. I do though believe there are places where maybe they're not given out enough.

There will always be patients who are outside the norm. I listed a few from my experience. I have one patient who has panic disorder that's actually controlled well on gabapentin. I wasn't the one that put her on it, but she's already on it, it stopped her panic attacks, and attempts to put her on an SSRI have not worked.

But from my own experience, there's not enough good documentation in many of the weird cases. If for example, in the case above, the doctor wrote down that 3 SSRIs and 2 SNRIs were tried and failed, and that the use of gabapentin used only after several attempts on the more conventional algorithm were tried and failed, then I'd be more comfortable with these weird cases. Unfortunately I usually don't get that documentation with my new patients, nor do the patients remember what the doctor's decision making process was.

I have about 10 patients in my moonlighting gig where I really don't know if their current polypharmacy is justified, but since the previous doctor didn't document well why he chose those meds, I'm caught in an uncomfortable position of holding the angry wolf by the ears. I don't want to hold on, but I don't want to let go either.

E.g. I have a few patients on Clozaril, but the previous doctor did not document which other antipsychotics were tried and failed. I don't know if another antipsychotic was tried that would not have as many side effects. They are currently to the point where their ANCs only have to be checked once a month. If I screw around with that, and if they indeed needed the Clozaril, well then I'd be consigning them back to the uncomfortable weekly monitoring.

I also have a patient on over 7 psychotropics--3 of which are at megadoses. I'm trying to wean her off of some of them.

I also got a sex offender put on weekly doses of depot-provera. That medication is only supposed to be given once every 3 months, so, the previous doctor put him on 12x the manufacturer's recommended dosage for this medication whuch was being used for unconventional and non-FDA approved uses anyway. I've tapered down his dosage down now to one shot every 2 months, and still no changes in his behavior, so what the previous doctor was thinking, I don't know. He didn't document why he did what he did.

Bottom line, opioids and benzos, while on occasion justified, if given out should have good documentation as to why they are being given, and IMHO should not be used as a long-term solution to a problem. Even better, IMHO these meds should not be given without an exit strategy, or without an occasional weaning off period to prevent tolerance and possible dependence on these meds.

 

[gray27]

I'd like to share my personal experience here. When I was about 18 I started having panic attacks. By the time I was 21 they had become nearly debilitating, it became a major task for me just to work up the courage to go to work and school. This of course caused me to become quite depressed which in turn worsened the panic attacks which worsened the depression etc etc. I had been tried on several SSRIs and none of them helped a bit. At that point I was actually contemplating suicide because I couldn't imagine spending the rest of my life in that sort of misery.

Eventually I saw a psychiatrist (up to that point I had only dealt with my FP) and started CBT and Xanax 0.5 BID. For the first time in years I finally started to get control over the panic attacks and brought the downward spiral to an end. A couple times I've tried to switch to other benzo's but they were either too sedating, interfering with work and school, or just didn't work. So, almost 15 years later I'm still taking the Xanax. Without it I doubt I could have managed my anxiety enough to graduate from undergrad let alone med school. And even as I type this I feel like somehow that's something I should be ashamed of because so many of my colleagues categorize people who take benzos right alongside alcoholics and heroin addicts.

A few weeks ago I was admitting a new patient who had been prescribed Xanax 1mg PO BID and asked if I was going to continue this for him as an inpatient. I agreed, but was later asked by a medical student why I agreed because "It's not like a panic attack is going to kill him. It only lasts a few minutes. Is it really that big a deal?" I then explained that anxiety is a huge risk factor for suicide and considering this guy was inpatient following a pretty serious suicide attempt he was miserable enough already and we should probably try to make him comfortable.

I agree that benzos, stimulants and narcotic pain killers are potentially dangerous drugs that need to be prescribed with caution. I'd urge people however to avoid the mentality that every patient who takes them is simply drug seeking.

 

[Doc Samson]

My point is that doctors should strive not to enable chemical coping.

I'm not entirely sure what "chemical coping" is, but it sure sounds like psychopharmacology.

Just as the complex PTSD or TBI patient is more likely to show up at Reg's office, the malingering substance abuser is more likely to show up at yours (in my experience these folks avoid psychiatrists because we have a little more time to ask pesky questions). Thus, in answer to your original question, yes there are reasons to prescribe both a stimulant and a benzo, but the folks that you're seeing on that combo are probably just looking to add an opiate for the trifecta of abusable substances.

 

[Regnvejr]

By giving you the benefit of the doubt as an expert in the field?

I think someone needs to lay off the stimulants!

If I wanted to be a jerk I'd suggest you were projecting.



I assumed as much.

And.. We're done.

 

[powermd]

I'm not entirely sure what "chemical coping" is, but it sure sounds like psychopharmacology.

Cut from an article by Steve Passik and Ken Kirsch-

"Simply put, chemical copers occasionally use their medications in nonprescribed ways to deal with stress. For these patients, medication use becomes central to life, while other interests become less important. As a result, chemical copers in treatment often fail to move forward toward stated psychosocial goals. They are typically uninterested in treating pain or coping with pain nonpharmacologically and do not take advantage of other treatment options provided (eg, fail to follow up on recommendations to see psychologists or physical therapists). As a manifestation of chemical coping, these patients remain on the fringe of appropriate use of their medication. They occasionally self-escalate their medication dosage in times of stress and sometimes need to have prescriptions refilled early.

Chemical coping can complicate opioid therapy, but many chemical copers are able to comply with their physician's opioid agreement enough to avoid being removed from treatment."

The doctors who enable chemical coping make my life as a pain specialist difficult because by providing a means to put off needed psychotherapy, psychopharmacology, counseling, lifestyle changes, and PT, these patients never move forward in their care. They just continue to wallow in misery and whine about why their pain isn't getting better, and, oh... "could I get a refill on my Norco?"

 

[sunlioness]

Patients with PTSD and ADHD.

I have one patient who is on both and this is his specific situation. I don't do it frequently and not without a lot of thought beforehand and re-evaluating frequently, but I do have one patient on both.

 

[whopper]

Interesting when you get a patient with 2 disorders where the meds that treat one can exacerbate the other disorder.

Anxiety and ADHD--I'd consider Effexor, not as a first choice, but at least for consideration. (The first choice must be based on a myriad of factors too long to list here for my purposes). Effexor can reduce anxiety and has studies backing it's benefits in ADHD, though it is not FDA approved for it.

Giving a stimulant can make the person's anxiety worse.

 

[billypilgrim37]

Giving a stimulant can make the person's anxiety worse.

Unless their anxiety is because of their inattentiveness, or because mean old Whopper won't give them their Concerta 😉

 

[whopper]

Unless their anxiety is because of their inattentiveness,

Of course true, though I was responding to the above post where someone had PTSD and ADHD.

Though I believe we need to be sharp on these situations. People's symptoms in other disorder spectrums may or may not be from another disorder. We have to try to understand these to treat the patient in the best manner possible.

 

[Regnvejr]

Interesting when you get a patient with 2 disorders where the meds that treat one can exacerbate the other disorder.

Anxiety and ADHD--I'd consider Effexor, not as a first choice, but at least for consideration. (The first choice must be based on a myriad of factors too long to list here for my purposes). Effexor can reduce anxiety and has studies backing it's benefits in ADHD, though it is not FDA approved for it.

Unfortunately, in reality, it does diddelysquat. If Effexor can cover ADHD, it is almost not severe enough to treat. And it is problematic in anxiety.

Giving a stimulant can make the person's anxiety worse.

Which is why the anxiety needs to be controlled first. My regimen generally includes Clorazepam, esp. at night, and Lorazepam prn for breakthrough, and an SSRI (and possibly a mood stabilizer with PTSD). After about 1-2 mths, I hit the ADHD with a short-acting stimulant unless they have insurance to cover anything better. And once the PTSD-specific therapy gets toward completion, we can generally cancel the benzo and hit the ADHD even better.

 

[whopper]

I've actually had some good results with treating anxiety with an SNRI. The data backs up SNRIs have benefits in anxiety disorders.

I don't generally try to treat ADHD with an SNRI. The reason being no FDA approval, though there is some data backing it up in studies. The theory is it may work on the norepinephrine that may be involved in that disorder.

 

[OldPsychDoc]

What do you think about atomoxetine, particularly with anxiety and ADHD?

 

[whopper]

I've seen people on atomoxetine for ADHD and it worked. though out of the few times I've seen it, in almost all of them, the side effects warranted I stop it's use.

IMHO my experiences were a fluke. The data does not support that troublesome side effects are the norm. Two of them were paranoia, a disturbing increase in the HR (e.g. 70-160).

I've never used it to treat anxiety, though I speculate it could work for it. After all, its an NRI.

 

[OldPsychDoc]

I've seen people on atomoxetine for ADHD and it worked. though out of the few times I've seen it, in almost all of them, the side effects warranted I stop it's use.

IMHO my experiences were a fluke. The data does not support that troublesome side effects are the norm. Two of them were paranoia, a disturbing increase in the HR (e.g. 70-160).

I've never used it to treat anxiety, though I speculate it could work for it. After all, its an NRI.

I've started using it more as my first-line for adult ADHDers who have a substantial anxiety component. Seems to help--at least they keep coming back for refills, and usually aren't asking for Adderall like many of my <ahem> other clients.

 

[whopper]

I try to avoid stimulant-based medications in the treatment of ADHD. The reasons we already discussed several times. I am open to giving out treatment for ADHD without psychological testing and purely on DSM criteria if I'm not treating the condition with a stimulant-based med (unless you consider Wellbutrin a stimulant, which in a strict sense it is.)

If they want a stimulant-based med, I give them the speech that the medications are potentially addictive, could cause several health problems, and I ask them to get an EKG, if they have any heart conditions: discussions with their PCP on their opinion of that patient being on a stimulant, and psychological testing verifying they truly have ADHD.

Mentioned this before in another thread, but I only got a very small number of patients on stimulants.

 

[JohnTheAtheistGod]

No, I don't own a Toyota.

Not funny, at all. But you have to have the last word.

 

[Shikima]

Uppers and downers keep the world going around...

 

[randomdoc1]

There's plenty of bad medicine from all specialties I have to say 🙁. I was in a surgical specialty before psychiatry and I had a colleague that would prescribe boat loads of opiates (regardless of whether or not they had pain complaints or even a major procedure to begin with!) to whoever she discharged as a default because it was just more convenient for her (fewer patients calling back with complaints of pain). That's the only explanation I have. For me personally, it does blare red flags when I see someone who's been established on pain killers, stimulants, and benzos. Time is a huge limiting factor but I try my best to get a good thorough history, preferably with collateral because it can be very revealing. People who truly have disorders like panic disorder and ADHD are often able to give you a good, genuine, convincing, and unique story. Not just vague complaints of not being able to concentrate or being anxious. I try to give as many open ended questions as I can and try not to lead to get to the most accurate history. For example, it is tempting to ask down the list of the DSM V criteria but I always ask for things like descriptors, contexts of when symptoms occur, other comments people have made, etc. I also check the prescription drug monitoring program in my state to see if there is any history of multiple prescribers and other suspicious activity, which I'm surprised that not more providers do before going ahead and giving more controlled substances.

 

[Crayola227]

holy necrobump from 2010 to 2016

save this moment for posterity

 

[Ceke2002]

holy necrobump from 2010 to 2016

save this moment for posterity

Oh you missed the other 2 or 3 posts of frothing rage and petty insults that were being thrown at previous posters in thread (because apparently making sense deserves the full weight of scorn and ridicule). 🙄