Controlled Substances

[Shikima]

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So, I have an interesting question and cannot cite/find any specific policy in this regard.

I'll use the following brief example to outline what I'm confused about and could use clarification on;

A psychiatrist had someone on a low dosage benzo along with Ambien for a short while and one day received a letter from the PCP asking the psychiatrist when the psychiatrist would be weaning the patient off of these medications.

I know there is a slow federal investigation into physicians and pharmacies in dispensing controlled substances. I'm seeing more and more PCPs telling Pt's, which they've diagnosed and treated with controlled substances that they now must see psychiatry for said controlled substances.

Can anyone clarify the position on the micromanagement and the sudden abandonment with turfing to psych for prescribing controlled substances saying "Not it!"? Is there a new policy that has or will be coming down? Are Insurance companies now holding payment from PCPs because certain metrics aren't being met?

 

[nexus73]

Not sure about insurance but sounds like CYA for the primary doctor. In case anything goes wrong there is a record the pcp suggested the medication be stopped and the psychiatrist continued it anyways.

 

[st2205]

I wish the referring PCPs here would be making statements like that...

 

[F0nzie]

The PCP is protected from liability by referring out to a psychiatrist. For example, if a patient is on a benzo for anxiety and the patient dies from an overdose there are so many ways the PCP can get nailed in a lawsuit: 1) Was the patient referred to a psychiatrist? Why not?2) Were first line medications tried? Were the trials adequate? 3) Was psychotherapy recommended? Why not? 4) And if anxiety symptoms were so severe requiring a benzodiazepine why was the patient not referred to a psychiatrist?

The PCP is right to fear the forensic psychiatrist on the other side....

 

[nexus73]

Hi Dr. Psych, I've got this anxious patient on 6 mg of xanax bid. I'd like you to fix the anxiety and taper them off the xanax.

Luckily I don't see this too much from young doctors. Old doctors who's hearts are in the right place and pill mills seem to be the main problem; though they never refer out...I only see them once admitted inpatient. It would be nice to have a way to report inappropriate prescribing practices for monitoring that would be supportive and not punitive to the candyman MDs out there.

 

[DD214_DOC]

Response: "Taper them off yourself first, then refer to address the underlying anxiety"

Good luck treating anxiety on someone you're tapering off BZD's.

 

[sunlioness]

I wish the referring PCPs here would be making statements like that...

No it's no fun.

"I'm going to start you on 2mg lorazepam TID, but you have to get it filled through psych from now on."


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[birchswing]

Response: "Taper them off yourself first, then refer to address the underlying anxiety"

Good luck treating anxiety on someone you're tapering off BZD's.

No it's no fun.

"I'm going to start you on 2mg lorazepam TID, but you have to get it filled through psych from now on."


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Reading comprehension.

The OP is talking about psychiatrists who prescribe scheduled substances being questioned by those patients' PCPs.

 

[sunlioness]

Reading comprehension.

The OP is talking about psychiatrists who prescribe scheduled substances being questioned by those patients' PCPs.

Reading comprehension? Did you mean this to come off as condescendingly as it did?

I'm seeing more and more PCPs telling Pt's, which they've diagnosed and treated with controlled substances that they now must see psychiatry for said controlled substances.

Reading comprehension . . .

 

[DD214_DOC]

Reading comprehension.

The OP is talking about psychiatrists who prescribe scheduled substances being questioned by those patients' PCPs.

oh no, I overlooked something in the short amount of time between everything else I actually get to myself. You got me!

Although there's also the entire last part of the post you happened to completely ignore...

 

[sunlioness]

I don't know if this is the time or place to make this plea . . . It's probably just the long day taking because I don't always feel this way. But I would really really like a patient free space.

Nothing personal against any of the patients who post here. But I'd really like a patient free space to just be a shrink with other professionals.


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[birchswing]

Reading comprehension . . .

You were responding to someone who said they wish there were as many concerned PCPs as the one in the OP's post. You weren't responding to the other statement you quoted.

In another thread recently I tried to write about the inherent biases in psychiatrists studying the problems that psychiatrists face.

The mind sees what the mind knows.

 

[DD214_DOC]

I don't know if this is the time or place to make this plea . . . It's probably just the long day taking because I don't always feel this way. But I would really really like a patient free space.

Nothing personal against any of the patients who post here. But I'd really like a patient free space to just be a shrink with other professionals.


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Yes, I strongly agree.

 

[Ceke2002]

...

 

[st2205]

Good luck treating anxiety on someone you're tapering off BZD's.

I think there should just be an unofficial recommendation that everyone just let this out to pasture. There's no usefulness in treating people exposed to benzos. It just pisses everyone off. Except maybe the PCP who is just relieved that they don't have to deal with it anymore. I know we argue that we can help make some change with these folks and there will be the select few who are motivated to actually treat the anxiety (rather than expect to extinguish it in rapid fashion), but I feel like this is like continuing to play the slot machines because every now and again it spits out a few nickels.

 

[psych md jd]

I once had a PCP start one of my patients on valium for anxiety.

I called him and said since he was now prescribing the patient's psych meds I was going to let him prescribe the Clozaril and Depakote as well.

No problems ever since.


This may have something to do with the referral:

http://www.nydailynews.com/news/cri...rs-life-patient-drug-deaths-article-1.2522071

 

[Armadillos]

I don't know if this is the time or place to make this plea . . . It's probably just the long day taking because I don't always feel this way. But I would really really like a patient free space.

Nothing personal against any of the patients who post here. But I'd really like a patient free space to just be a shrink with other professionals.


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Yeah I agree, I think at one point there was a sub forum in peds where you needed to be at least in medschool to join, don't remember how they did the vetting

 

[nitemagi]

Hi Dr. Psych, I've got this anxious patient on 6 mg of xanax bid. I'd like you to fix the anxiety and taper them off the xanax.

Luckily I don't see this too much from young doctors. Old doctors who's hearts are in the right place and pill mills seem to be the main problem; though they never refer out...I only see them once admitted inpatient. It would be nice to have a way to report inappropriate prescribing practices for monitoring that would be supportive and not punitive to the candyman MDs out there.

I get these every so often. They're definitely challenging. Had some successes actually resolving it all. It's the long taper that's the difficulty. Lots of phone calls and emails seeking reassurance.

 

[sunlioness]

Yeah I agree, I think at one point there was a sub forum in peds where you needed to be at least in medschool to join, don't remember how they did the vetting

That would work. Like I said, I don't feel that way all the time. A sub forum would be a perfect solution. I wouldn't restrict it to just physicians and med students. Psychologists and psychology students should be in too. And anyone who works as a licensed mental health professional or is a student to become one. That should be easy to verify the same way they did the "verified physician" thing.

I'll stop detailing the thread now.


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[Shikima]

So, what I gathered from this from last night to this morning is.... you guys "need muscle" for a "safe place" and that there is no collective set policy from any organization where PCPs are turfing to psych.

 

[MLT2MT2DO]

No it's no fun.

"I'm going to start you on 2mg lorazepam TID, but you have to get it filled through psych from now on."


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I'd refuse any consult from that pcp from here until eternity

 

[Psychotic]

I don't know if this is the time or place to make this plea . . . It's probably just the long day taking because I don't always feel this way. But I would really really like a patient free space.

Nothing personal against any of the patients who post here. But I'd really like a patient free space to just be a shrink with other professionals.


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Not sure why I had not done this before now, but I have put them on "ignore." I don't think I have ever replied to any of their posts, certainly have not had any contact with them. I don't think psych patients belong on this forum - surely there are other places where they can post thoughts and questions.

 

[DD214_DOC]

Not sure why I had not done this before now, but I have put them on "ignore." I don't think I have ever replied to any of their posts, certainly have not had any contact with them. I don't think psych patients belong on this forum - surely there are other places where they can post thoughts and questions.

I did the same.

One important thing to keep in mind -- and this does depend somewhat on the system in which you practice -- is that you do have the option to refuse a referral. Don't be the dumping ground PCP's try to make you.

 

[Shikima]

It would be hard for me to "refuse" while in PP. One, I'd spend an inordinate amount of time micromanaging the practice thus taking away from me generating revenue, and two, I wouldn't be generating revenue.

But what I'm wondering, is there something else happening with similar regards to the opiate policies that specifically mention stimulants and benzos?

 

[nexus73]

It would be hard for me to "refuse" while in PP. One, I'd spend an inordinate amount of time micromanaging the practice thus taking away from me generating revenue, and two, I wouldn't be generating revenue.

But what I'm wondering, is there something else happening with similar regards to the opiate policies that specifically mention stimulants and benzos?

Have you had PCPs refer patients to you already on benzodiazepines or stimulants stating they refuse to continue prescribing the medication themselves?

 

[sunlioness]

I have. I'll see the patient, but if I don't think the Rx is warranted I won't continue it. I tell them to go back and talk about it with their PCP.

Or PCPs who will write for benzos, but when the patient requests a higher dose they say that has to come from psychiatry. "Dr So and so says I need a higher dose of Xanax, but you have to write for it." People don't seem to get it when I try to explain that Dr So and so isn't the boss of me. Or the variation of, "He said he'd write for it, but you have to say it's okay." "It's not okay." "No, you don't understand. You don't have to write anything. You just have to say it's okay." "No, you don't understand. It's NOT OKAY."

I feel like I'm being set up some times. PCPs don't want to have the conversation, so they make me have it. Though sometimes I suspect patients are lying about it. Especially the ones that say, "My PCP thinks you're ridiculous. He, my pharmacist and I all laugh at you. Why won't you prescribe this medication? They don't get it."


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[FlowRate]

PCPs don't want to have the conversation, so they make me have it.

After having rotated on CL, this is unfortunately unsurprising. Do you think the PCP's would be receptive to some teaching?

 

[PikminOC]

I feel like I'm being set up some times. PCPs don't want to have the conversation, so they make me have it. Though sometimes I suspect patients are lying about it. Especially the ones that say, "My PCP thinks you're ridiculous. He, my pharmacist and I all laugh at you. Why won't you prescribe this medication? They don't get it."


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Oooh peer pressure.

 

[DD214_DOC]

Have you had PCPs refer patients to you already on benzodiazepines or stimulants stating they refuse to continue prescribing the medication themselves?

Yes, all the time. I document they're stable and doing well without side effects and send them back.

 

[keifernny2]

If a PCP isn't comfortable prescribing the stimulant or benzo, then I usually will take over care for the patient.

That doesn't mean I'll continue to prescribe those dosages or specific drugs, however.

Psychiatrists are more acquainted with addiction and mgt of benzos than primary care physicians and kicking patients back to the PCP who is asking you for help is somewhat disrespectful and guarantees that they won't ask you for help in the future.

If I received a letter from a PCP like op described I would call PCPs office and ask what their concern is. It doesn't sound like an auto generated letter and it may stem from something the PCP is aware of that you are not.


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[Shikima]

Have you had PCPs refer patients to you already on benzodiazepines or stimulants stating they refuse to continue prescribing the medication themselves?

Yes. Thus the crux of my question for this thread. Is there a policy I'm unaware of? I know there is a bruhaha regarding opiates, but that's not really a concern of ours unless it's frank addictions.

I'm trying to understand better without having to throw someone under the bus.

 

[keifernny2]

In one state that I practice, the state prescription monitoring program generates a list of my annual prescriptions and tells me who my highest dosage controlled Rx patients are. If I were a PCP, I may go through that list and try to shorten it by making referrals. In addition, I have received letters multiple times from insurance companies asking if I am aware that PT X is on zolpidem and clonazepam, or that they are on multiple antipsychotics. If I had insecurity about my prescribing, these things it may lead to a psychiatric referral.


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[AcronymAllergy]

Yes. Thus the crux of my question for this thread. Is there a policy I'm unaware of? I know there is a bruhaha regarding opiates, but that's not really a concern of ours unless it's frank addictions.

I'm trying to understand better without having to throw someone under the bus.

There might be policies in place, or perhaps misunderstandings of somewhat-related policies. Our PCPs have begun sending all folks on benzos (many of whom were started by prior PCPs) to psychiatry, as none of the primary care folks (that I know of) want to start or manage the meds themselves. There's been a BIG push to reduce both benzo and opiate prescriptions here (as I'm sure there has been elsewhere), and particularly to significantly reduce concurrent prescription. Hence one reason the PCPs no longer want to hand out benzos.

My clinic actually has worked on a benzo policy that involves implementing a contract (similar to an opioid pain med agreement), considering alternative/concurrent treatments (e.g., psychotherapy), and possibly participating in a one-time benzo-oriented psychoeducation class. Not sure where we are in the process of having it approved, though.

I generally support the paradigm shift of "benzos for everyone!" to the more conservative "benzos for no one unless through psychiatry!" However, it's resulting in a number of pts who've gotten Xanax for 20+ years now being told that they need to be tapered off. While also being told (by primary care) that they may need to taper off their opiates for chronic pain.

I do not envy our psychiatrists for having to be the ones handling those conversations. I'd imagine it'll calm down over the next few years, but it may be stormy seas until then.