How to handle a Xanax addict who won't take no for an answer?

[Trismegistus4]

I have, on my schedule on Friday, one of my least favorite patients. When I first saw this guy a little over 2 years ago, he was a 50-something man with a history of depression and anxiety. He was already on Xanax 1 mg TID, as well as the ridiculous regimen of Wellbutrin 100 mg BID, nefazodone 400 mg at bedtime, trazodone 50 mg at bedtime, and Seroquel 200 mg at bedtime. It wasn't clear why his PCP was referring him at that particular time. He endorsed having been on the above regimen for years, and I would have thought PCP was punting to psych to get the Xanax off his hands, but he had been filling it for a couple of years. Before that, the patient was seeing a local psychiatrist who retired. The patient also has COPD, still smokes, and the month before I first saw him, had been to the ER with chest pain (MI was ruled out.) He endorsed periods of major depression with suicidal thoughts in the past, He had been on disability for depression and anxiety for almost two decades.

He was still complaining of anxiety and, of course, requesting an increase in the Xanax at that initial appointment, which I turned down. Other than that, he was strongly resistant to making any changes to his regimen (including simplifying the aforementioned polypharmacy.) Predictably, he also didn't want to switch to a longer-acting benzo as he had supposedly tried clonazepam and diazepam in the past and they allegedly "didn't work." He in fact wasn't even taking the full dose of Seroquel since he found it too sedating, so I changed that to 25 mg in the morning and 50 mg QHS, in the thought that a small AM dose would help with the daytime anxiety for which he was requesting a Xanax increase.

Over the next few visits, it became clear he didn't really understand his medication regimen, meaning, what doses he was to be taking and when. He kept playing with the Seroquel dosing on his own, and it also emerged that he was not taking the nefazodone as prescribed. I first suspected this when he said he was taking 200 mg instead of 400 mg, but then at the next visit it turned out he was taking 200 mg BID. I repeatedly went over with him what all these meds are and what they are supposed to do, but he seemed like he just wasn't getting it. I kept trying to get rid of either the nefazodone or trazdodone, but he was strongly resistant to this, being adamant he needed them both. It turned out he was taking the Wellbutrin only for smoking cessation and it was ineffective, so I eventually discontinued that. However, he believed that without all the other meds, he wouldn't be able to sleep.

I will interject here that, predictably, I have very strong negative countertransference against this guy, because of his adamance about "needing" the Xanax and a polypharmacy regimen in general. He also brought his disability renewal form with him to one visit, which was for him to fill out and not a doctor, but was asking me what he should put on it, since it asked about a change in his condition and whether he has discussed his ability to work with his doctor. He also was a little TOO genial, always saying "good to see you again, Dr. Trismegistus4!" and wanting to spend the appointment making small-talk chit-chat and showing me pictures of his grandchildren on his phone.

Then, at a visit almost a year ago, he mentioned having vertigo. He said this had in fact been going on for years, that when he goes out he has to sit in his car until he feels better before he goes into the store or building, and that he doesn't want to get in an accident and hurt someone else or himself. This caused me to think "crap, I REALLY should not be prescribing this guy Xanax." So, before his next visit, I steeled my nerves, tried my hardest to suppress my non-contfrontationality, and told him I was going to taper him off the Xanax, reducing to 0.5 mg once per day and 1 mg for the other 2 doses. That appointment went 10 minutes over as he argued with me and I kept trying to get him to just accept it and get out the door. He said he can't function without xanax, used to be on 5 per day, does't want to be taken off meds that "might cause suicide." I brought up doing psychotherapy, and he said he's seen therapists for years, and "they never do a damn thing, the just talk to him." Suspiciously, I noted that he hadn't gotten a prescription for Seroquel in almost 8 months, and at the time it was only a 30-day supply with 1 refill, but he insisted he had been continuing to take it by cutting old 200 mg pills in half.

I documented in my note that I had a long discussion with the patient about the risks of chronic benzodiazepine use, including dizziness, falls, memory impairment, dementia as age progresses; that he had complained to me before at numerous visits of vertigo, memory and concentration problems, and also has a history of COPD and in fact often appears when being interviewed to have increased respiratory effort; that I explained to him that I think this medicine is more harmful to him than beneficial in the long run, and also the lack of evidence of therapeutic efficacy of benzodiazepines for more than a few months; and that I attempted to reiterate these points to the patient numerous times as he continued to raise objections to coming off Xanax, saying that he "needs it," "couldn't function without it," etc. so was not clear how much the patient understood the risks. But I eventually got him to say that if he had suicidal thoughts, he would go to the ER, and got him out the door.

I've seen him twice in follow-up since then, most recently last fall. As you might have predicted, I have not been able to continue suppressing my non-confrontationality; both those appointments also went over as he continued to beg and plead that he needed more Xanax. I haven't increased it back, but I have failed to taper it any further. When I last saw him in October, he was reporting shaking "really bad" and uncontrollably all the time. He keeps bringing up the subject of suicidality. I feel he's manipulating me with it. Every time we discuss the Xanax, he says "geez, doctor, in the past I was so anxious I wanted to kill myself; I'd hate to feel like that again." And starts getting tearful. Oh, and I also found out later he was also on Tramadol and hydrocodone! Fortunately, the hydrocodone was stopped last hear, but he's still on Tramadol.

I feel utterly defeated and humiliated that this guy is continuing to exact Xanax out of me; I'm worried about the liability given his vertigo and COPD. But he basically indirectly threatens suicide every time I try to reduce it. What I'd really like to do is fire him, but I'm not sure my organization will let me.

Any thoughts on how to handle this?

---

Members don't see this ad.

 

[tr]

I think you have way too much specific identifiable information about this case to be posting on a publicly accessible, searchable forum. I suggest you go back and remove some of the excessive detail from this post.

 

[wolfvgang22]

Every second patient I inherited is like this. Here's what I do, which works better than anything else I've tried:

Lay out your plan to switch him to a long acting benzodiazepine which you will then taper slowly. Tell him it is not safe to stay on Xanax, given his complaints of falls, memory problems, and dizziness. Anyone who asks you why you are tapering him gets the answer "because it is not safe or effective for his illness and not FDA approved for his diagnoses." Tell admin he is a fall risk, which he is. After you taper him off the benzos, start working on reducing other polypharmacy.

Do not engage in bargaining with him anymore. Be pleasant at all times. Never go over time. Keep your visits with him short and to the point. Listen to him actively for a few minutes only. Then do the focused exam. Kindly offer to refer him to a different psychiatrist, since he is unhappy with your plan. The less you try to "fix" him the less he will try to manipulate you, and the better he will likely get. The last psychiatrist or four couldn't fix him either, hence the nonsensical med regimen he already has. He will only get better with therapy and taking personal responsibility for his recovery. He will never do that if you keep trying to rescue him.

If he threatens you, tell who you need to tell he threatened you and say that you will never see him again, and refer him to another psychiatrist. Document everything, especially regarding suicide risk factors, protective factors, and prognosis. If the prognosis is poor, document why.

 

[birchswing]

I didn't really track how many months since the cut but a drop from 3 mg Xanax to 2.5 mg is not insignificant. Point out that it was a successful drop (for his benefit) and for your own recognize that his irritability can be from withdrawal of a long-term benzo along with the psychological fear of losing control over the medicines he uses to control how he feels. And again suggest that continued drops could be easier on a longer acting benzodiazepine. I don't know if there is a way to do this with your patient, but I can say that knowing you are in control of the drops is helpful. It's also advised in some of the guidelines that withdrawals be patient-guided. I know I am a layman, but based on the other things you've said about his health I wonder if the vertigo is more related to his cardiac health. Benzodiazepines are even used to treat vertigo (not saying they are that successful for that or that you should keep him on them for that reason—just that the benzodiazepine wouldn't be my first guess as a cause of vertigo).

 

[clausewitz2]

For what it is worth I rotated for a while with one of the guys who literally wrote most of the UpToDate articles on vertigo and its treatment. Benzos are actually used to reduce vertigo symptoms by suppressing vestibular function. So be careful documenting - vertigo would actually be a reason to continue them.

 

[hamstergang]

I think you have way too much specific identifiable information about this case to be posting on a publicly accessible, searchable forum. I suggest you go back and remove some of the excessive detail from this post.

I agree. Much of the detail is unnecessary for this discussion but does serve to identify the patient.

 

[shahseh22]

I have, on my schedule on Friday, one of my least favorite patients. When I first saw this guy in November 2016, he was a 54 year old man with a history of depression and anxiety. He was already on Xanax 1 mg TID, as well as the ridiculous regimen of Wellbutrin 100 mg BID, nefazodone 400 mg at bedtime, trazodone 50 mg at bedtime, and Seroquel 200 mg at bedtime. It wasn't clear why his PCP was referring him at that particular time. He endorsed having been on the above regimen for years, and I would have thought PCP was punting to psych to get the Xanax off his hands, but he had been filling it for a couple of years. Before that, the patient was seeing a local psychiatrist who retired. The patient also has COPD, still smokes, and the month before I first saw him, had been to the ER with chest pain (MI was ruled out.)

Past stressors included growing up with a father who was alcoholic and physically abusive, an uncle whom he looked up to committing suicide when patient was 12, other friends who had committed suicide or died in accidents, his wife leaving him for another man and having to finish raising the kids by himself. He endorsed periods of major depression with suicidal thoughts in the past, He had been on disability for depression and anxiety for 19 years.

He was still complaining of anxiety and, of course, requesting an increase in the Xanax at that initial appointment, which I turned down. Other than that, he was strongly resistant to making any changes to his regimen (including simplifying the aforementioned polypharmacy.) Predictably, he also didn't want to switch to a longer-acting benzo as he had supposedly tried clonazepam and diazepam in the past and they allegedly "didn't work." He in fact wasn't even taking the full dose of Seroquel since he found it too sedating, so I changed that to 25 mg in the morning and 50 mg QHS, in the thought that a small AM dose would help with the daytime anxiety for which he was requesting a Xanax increase.

Over the next few visits, it became clear he didn't really understand his medication regimen, meaning, what doses he was to be taking and when. He kept playing with the Seroquel dosing on his own, and it also emerged that he was not taking the nefazodone as prescribed. I first suspected this when he said he was taking 200 mg instead of 400 mg, but then at the next visit it turned out he was taking 200 mg BID. I repeatedly went over with him what all these meds are and what they are supposed to do, but he seemed like he just wasn't getting it. I kept trying to get rid of either the nefazodone or trazdodone, but he was strongly resistant to this, being adamant he needed them both. It turned out he was taking the Wellbutrin only for smoking cessation and it was ineffective, so I eventually discontinued that. However, he believed that without all the other meds, he wouldn't be able to sleep.

I will interject here that, predictably, I have very strong negative countertransference against this guy, because of his adamance about "needing" the Xanax and a polypharmacy regimen in general. He also brought his disability renewal form with him to one visit, which was for him to fill out and not a doctor, but was asking me what he should put on it, since it asked about a change in his condition and whether he has discussed his ability to work with his doctor. He also was a little TOO genial, always saying "good to see you again, Dr. Trismegistus4!" and wanting to spend the appointment making small-talk chit-chat and showing me pictures of his grandchildren on his phone.

Then, at a visit in February 2018, he mentioned having vertigo. He said this had in fact been going on for years, that when he goes out he has to sit in his car until he feels better before he goes into the store or building, and that he doesn't want to get in an accident and hurt someone else or himself. This caused me to think "crap, I REALLY should not be prescribing this guy Xanax." So, before his next visit, I steeled my nerves, tried my hardest to suppress my non-contfrontationality, and told him I was going to taper him off the Xanax, reducing to 0.5 mg once per day and 1 mg for the other 2 doses. That appointment went 10 minutes over as he argued with me and I kept trying to get him to just accept it and get out the door. He said he can't function without xanax, used to be on 5 per day, does't want to be taken off meds that "might cause suicide." I brought up doing psychotherapy, and he said he's seen therapists for years, and "they never do a damn thing, the just talk to him." Suspiciously, I noted that it was now May 2018, and he hadn't had a prescription for Seroquel since September 2017, which was a 30-day supply with 1 refill, but he insisted he had been continuing to take it by cutting old 200 mg pills in half.

I documented in my note that I had a long discussion with the patient about the risks of chronic benzodiazepine use, including dizziness, falls, memory impairment, dementia as age progresses; that he had complained to me before at numerous visits of vertigo, memory and concentration problems, and also has a history of COPD and in fact often appears when being interviewed to have increased respiratory effort; that I explained to him that I think this medicine is more harmful to him than beneficial in the long run, and also the lack of evidence of therapeutic efficacy of benzodiazepines for more than a few months; and that I attempted to reiterate these points to the patient numerous times as he continued to raise objections to coming off Xanax, saying that he "needs it," "couldn't function without it," etc. so was not clear how much the patient understood the risks. But I eventually got him to say that if he had suicidal thoughts, he would go to the ER, and got him out the door.

I've seen him twice in follow-up since then, in August and October. As you might have predicted, I have not been able to continue suppressing my non-confrontationality; both those appointments also went over as he continued to beg and plead that he needed more Xanax. I haven't increased it back, but I have failed to taper it any further. When I last saw him in October, he was reporting shaking "really bad" and uncontrollably all the time. He keeps bringing up the subject of suicidality. I feel he's manipulating me with it. Every time we discuss the Xanax, he says "geez, doctor, in the past I was so anxious I wanted to kill myself; I'd hate to feel like that again." And starts getting tearful. Oh, and I also found out later he was also on Tramadol and hydrocodone! Fortunately, the hydrocodone was stopped last hear, but he's still on Tramadol.

I feel utterly defeated and humiliated that this guy is continuing to exact Xanax out of me; I'm worried about the liability given his vertigo and COPD. But he basically indirectly threatens suicide every time I try to reduce it. What I'd really like to do is fire him, but I'm not sure my organization will let me.

Any thoughts on how to handle this?

Wow, this is a mess. Tell him that he can't be on Tramadol and the Benzo at the same time, that would be suicide.

 

[Trismegistus4]

I think you have way too much specific identifiable information about this case to be posting on a publicly accessible, searchable forum. I suggest you go back and remove some of the excessive detail from this post.

I agree. Much of the detail is unnecessary for this discussion but does serve to identify the patient.

I don't get it. What specifically do you think the problem is? There's no protected health information in my post, no level of detail that isn't in, say, an Oliver Sacks book. Is it that someone who knows him well could stumble across the forum, realize whom the post was about, and if the patient then found out he'd feel his privacy had been violated? What detail do you think I should remove?

 

[Liquid8]

The sudden increase in SI sounds like patient manipulation, so my approach would be to clearly document mental state, risk factors, (lack of) suicidal ideation, plans etc. before even broaching the topic of a Xanax reduction. Depending on his pattern, you may need to leave his medications alone for a while so that he lets his guard down over the next few appointments.

Eg. MSE: euthymic, reactive, appropriate for majority of interview. Described +ve future plans re: doing stuff on the weekend. Denied any active DSH/suicidal intent/plans. But became acutely suicidal when topic of benzo reduction raised.

This patient does not sound like someone who is actively depressed, but like the borderline who threatens suicide when about to be discharged, only escalates when their needs are not perceived to be met.

Because of his past history of depression, you would also need to document how his suicidal response to a reduction in Xanax is different from previous MDEs. Ideally if you can reduce the dose just a little – even 0.5mg and he returns to see you, then you can always point back to that as proof that suicide didn’t happen and it wasn’t the end of the world.

If you just want him out, the other way to sack him (in an indirect way) is to refer him elsewhere for a second opinion. You don’t even have to recommend someone – let him make the choice if he wants to. If the goal is just to get rid of him, it’s less about getting someone to agree with your treatment plan, but finding someone else who will agree with him – if he finds someone like that he may decide to stick with that person instead.

 

[futuredo32]

I don't think there is too much detail. Has he seen anyone for his vertigo? Is it perhaps anxiety instead of vertigo? "Then, at a visit in February 2018, he mentioned having vertigo. He said this had in fact been going on for years, that when he goes out he has to sit in his car until he feels better before he goes into the store or building, and that he doesn't want to get in an accident and hurt someone else or himself. " This sounds like anxiety. Maybe agoraphobia ?
Either
1.Document that you have discussed the risks and benefits (and have the patient sign a form) and the patient understands the risks and consequences of staying on the medication and just let him stay at his current dose.
2. Tell him you are going to taper him off starting at his next appointment and if he wants to seek psychiatric services elsewhere he can. If he returns , follow through with your taper plan. Maybe use a compounding pharmacy that can taper more slowly than you want but at a rate that would be easier for the patient.

Maybe his anxiety is truly that bad and Xanax is the only medication that has helped and the thought of dealing with that anxiety is truly so awful to him that he thinks he would rather be dead. Nothing else may actually decrease his anxiety. I've seen a ton of patients suicidal because their anxiety is so severe. There is no absolute contraindication with Tramadol and Xanax. Does he smoke? Is his COPD worsening?

With your negative countertransference toward him, perhaps it would be better for you both if he did see another provider.

 

[LadyHalcyon]

Just to play devil's advocate, it is possible he truly does believe he may return to a really dark place without the meds. I have had many patients who become very psychologically dependent on their medications, even SSRIs. I find these patients have often been extremely depressed and/or suicidal and automatically assume they will "hit rock bottom" again if they change anything. I have also seen a similar line of thinking with patients who are not on meds but instead try to avoid any situation that may bring about a "negative" emotion. Their rationale is along the lines of "if I ever experience sadness again then....(instert catastrophic thinking)." Interestingly, I also see patients who experience frequent ambivalence toward an improvement in their mental health and functioning because "if I start to feel better and then something goes wrong, I will feel even worse than I do now because I have father to fall."

That being said, I think it's important to trust your clinical intuition. Additionally, he has provided disparate information about his adherence to his medical regimen. Do you think he would sign releases of information for you to obtain past medical records from previous providers and hospitals? I often find a well-documented pattern of drug-seeking and/or manipulative behavior emerges.

Sent from my SM-G950U using SDN mobile

 

[dl2dp2]

This sounds like a high risk patient. You should've discharged him a long time ago. Now it's a mess because you can't discharge him as he complains of increasing suicidality. He might actually make an attempt (manipulatively or not), and he might actually die of that attempt, esp. since he has ALL of the risky demographic factors (unemployed, middle aged [?white] male w/ substance use disorder), and he might need an inpatient detox--and have a seizure while waiting placement.

Frankly I think if you don't know how to handle this type of patient the best thing is referral out to subspecialist (addiction, etc) instead of futzing around to get into more trouble. I hate to do this on a public forum but I think the management was wrong from day 1. If someone doesn't understand his regimen, the next step is to get help (i.e. family meeting). Instead, you ipsilaterally do more stuff to piss him off, which exposes you to more liability. If he commits suicide (or overdoses), you are exposed to significant risk of being sued by the family who might not even be aware that he has a use disorder.

In any case, IMO to remediate all of these issues, the first step is a family meeting. If the patient refuses family meeting, it's time to refer to inpatient treatment.

 

[wolfvgang22]

This sounds like a high risk patient. You should've discharged him a long time ago. Now it's a mess because you can't discharge him as he complains of increasing suicidality. He might actually make an attempt (manipulatively or not), and he might actually die of that attempt, esp. since he has ALL of the risky demographic factors (unemployed, middle aged [?white] male w/ substance use disorder), and he might need an inpatient detox--and have a seizure while waiting placement.

Frankly I think if you don't know how to handle this type of patient the best thing is referral out to subspecialist (addiction, etc) instead of futzing around to get into more trouble. I hate to do this on a public forum but I think the management was wrong from day 1. If someone doesn't understand his regimen, the next step is to get help (i.e. family meeting). Instead, you ipsilaterally do more stuff to piss him off, which exposes you to more liability. If he commits suicide (or overdoses), you are exposed to significant risk of being sued by the family who might not even be aware that he has a use disorder.

In any case, IMO to remediate all of these issues, the first step is a family meeting. If the patient refuses family meeting, it's time to refer to inpatient treatment.

The OP isn't mismanaging this challenging patient, he inherited this mess. Give him or her a break.
I agree a family meeting is a good suggestion, if the patient will go for that, or even has family in his life. You won't be able to admit this patient. He isn't in crisis, and weaning off benzos doesn't require hospitalization.

 

[dl2dp2]

I agree a family meeting is a good suggestion, if the patient will go for that, or even has family in his life. You won't be able to admit this patient. He isn't in crisis, and weaning off benzos doesn't require hospitalization.

If he has a benzo USE disorder that's not responding to outpatient treatment, then it's a CLEAR indication for inpatient SUBSTANCE ABUSE treatment. Sure he/she inherited this mess, but it's been 6-12 months since the person is on the caseload. It's hard to chalk it up to that at this point.

 

[birchswing]

If he has a benzo USE disorder that's not responding to outpatient treatment, then it's a CLEAR indication for inpatient SUBSTANCE ABUSE treatment. Sure he/she inherited this mess, but it's been 6-12 months since the person is on the caseload. It's hard to chalk it up to that at this point.

I am not saying this as a patient who has experienced any form of inpatient treatment regarding anything let alone benzodiazepines (I am making that clarification because I know in the past I have made it clear that I had benzodiazepine dependence and want to make it clear I am not speaking from personal experience).

I will say from having spoken to a psychiatrist and a therapist who has seen patients attempt inpatient benzodiazepine withdrawal, while people are able to stop benzodiazepines many are re-instated on them several months later due to intractable protracted withdrawal symptoms that do not improve.

The inpatient process (at least local to me) for as-prescribed benzodiazepine use is the same as it is for erratic, illicit use. They do a medical detox, use 12-step groups, and then you're released. There isn't good evidence supporting medical detox for as-prescribed benzo use, nor is there good evidence for 12-step, and it's an especially confusing proposition when the medication is taken as prescribed.

I will say something I said once before that I know is controversial but I believe in, which is that I think once people are in a bad situation such as this they have a right to decide how they want to live and die.

I will use an analogy I also will assume is controversial, but I don't intend it to be. If a person had some type of progressive, eventually terminal cancer, it would be self-evident that they have a right to refuse increasingly taxing forms of treatment, such as chemotherapy.

I would argue that if a person has come to a place where they are physically tolerant and dependent on a substance and the options for withdrawing are arduous and the quality of life after may suffer, they should have a right to finish out their life in a way that they choose, whether it's with the ill effects of the benzodiazepine and the health risks it portends or the ill effects of withdrawal. I think it's even more true when the dependence has come through iatrogenic means.

Personally, I think there is a difference between that and new prescriptions for medications that will harm a patient, such as benzodiazepines. I think the reckless prescribing should stop and informed consent will help stop that. For those who have been on them for decades and were not given informed consent but face a fork in the road where either continuing or stopping them have negative consequences, I believe they should be given an informed they weren't in the first place.

I understand that the right to live and die that way interferes with the right of a physician to practice according to their own ethics, and therein lies the quandary.

If a person could continue purchasing benzodiazepines from a convenience store as they do cigarettes, neither party would be in this conflict (please don't misunderstand that as an endorsement of OTC benzos or cigarettes—I simply think that as the practice of long-term benzodiazepine therapy dies off, those still afflicted with it should choose which option they want with the understanding that they are limiting their lifespan and will face additional health risks).

Edit: Also not sure where the not responding to treatment came from. He decreased Xanax from 3 mg to 2.5 mg.

That's (theoretically) equivalent to reducing 10 mg of Valium.

I'm not sure what the time frame of that decrease is, but it's not insignificant.

It would probably be easier on Valium, or if he likes the Xanax name Xanax XR (assuming those can be split . . . not sure about that).

 

[dl2dp2]

I am not saying this as a patient who has experienced any form of inpatient treatment regarding anything let alone benzodiazepines (I am making that clarification because I know in the past I have made it clear that I had benzodiazepine dependence and want to make it clear I am not speaking from personal experience).

I agree with everything you say. However, the idea that inpatient is a possibility should have been raised a long time ago. Remember, inpatient substance abuse treatment is ALWAYS voluntary. There are people on benzo who can never be detoxed, but we can't make that decision yet. Right now we have a patient who has this very questionable set of symptoms and recent onset suicidality, and under this set of circumstances inpatient detox is a possible pathway moving forward. The problem with the management here isn't that the final result should be one (pt d/c benzo) vs. another (you write him Xanax ad infinitum), it's that it should be well documented that different options were explored and excluded for reasons A B C. Should an adverse event occur (let's say he falls and dies), you have an answer if you have to respond to a review committee (I discussed with him and family exhaustively the risks and suggested inpatient, but they refused). I've been on these committees--people try to pick you apart on what you didn't do.

 

[wolfvgang22]

I am not saying this as a patient who has experienced any form of inpatient treatment regarding anything let alone benzodiazepines (I am making that clarification because I know in the past I have made it clear that I had benzodiazepine dependence and want to make it clear I am not speaking from personal experience).

I will say from having spoken to a psychiatrist and a therapist who has seen patients attempt inpatient benzodiazepine withdrawal, while people are able to stop benzodiazepines many are re-instated on them several months later due to intractable protracted withdrawal symptoms that do not improve.

The inpatient process (at least local to me) for as-prescribed benzodiazepine use is the same as it is for erratic, illicit use. They do a medical detox, use 12-step groups, and then you're released. There isn't good evidence supporting medical detox for as-prescribed benzo use, nor is there good evidence for 12-step, and it's an especially confusing proposition when the medication is taken as prescribed.

I will say something I said once before that I know is controversial but I believe in, which is that I think once people are in a bad situation such as this they have a right to decide how they want to live and die.

I will use an analogy I also will assume is controversial, but I don't intend it to be. If a person had some type of progressive, eventually terminal cancer, it would be self-evident that they have a right to refuse increasingly taxing forms of treatment, such as chemotherapy.

I would argue that if a person has come to a place where they are physically tolerant and dependent on a substance and the options for withdrawing are arduous and the quality of life after may suffer, they should have a right to finish out their life in a way that they choose, whether it's with the ill effects of the benzodiazepine and the health risks it portends or the ill effects of withdrawal. I think it's even more true when the dependence has come through iatrogenic means.

Personally, I think there is a difference between that and new prescriptions for medications that will harm a patient, such as benzodiazepines. I think the reckless prescribing should stop and informed consent will help stop that. For those who have been on them for decades and were not given informed consent but face a fork in the road where either continuing or stopping them have negative consequences, I believe they should be given an informed they weren't in the first place.

I understand that the right to live and die that way interferes with the right of a physician to practice according to their own ethics, and therein lies the quandary.

If a person could continue purchasing benzodiazepines from a convenience store as they do cigarettes, neither party would be in this conflict (please don't misunderstand that as an endorsement of OTC benzos or cigarettes—I simply think that as the practice of long-term benzodiazepine therapy dies off, those still afflicted with it should choose which option they want with the understanding that they are limiting their lifespan and will face additional health risks).

Edit: Also not sure where the not responding to treatment came from. He decreased Xanax from 3 mg to 2.5 mg.

That's (theoretically) equivalent to reducing 10 mg of Valium.

I'm not sure what the time frame of that decrease is, but it's not insignificant.

It would probably be easier on Valium, or if he likes the Xanax name Xanax XR (assuming those can be split . . . not sure about that).

I agree.

I would add that it is unfortunate, but past over prescribing of benzos has led to a lot of problems, much like the over prescribing of opiates. Increasingly, physicians are being held responsible for adverse events when it comes to benzos and other controlled substances, particularly since evidence doesn't support long term benzodiazepine treatment for psychiatric illness, and neither do professional treatment guidelines. Increasingly, physicians are being blamed for any poor outcome. If I lose my medical license or position due to a bad outcome from prescribing a controlled substance, I have harmed myself, my family, and my other patients. There doesn't seem to be a place for the practice of what is essentially psychiatric palliative care when it comes to controlled substances like benzos.

 

[wolfvgang22]

If he has a benzo USE disorder that's not responding to outpatient treatment, then it's a CLEAR indication for inpatient SUBSTANCE ABUSE treatment. Sure he/she inherited this mess, but it's been 6-12 months since the person is on the caseload. It's hard to chalk it up to that at this point.

I see your point. I wonder if this patient has access to inpatient substance abuse treatment or a way to pay for this treatment. I know most of my patients do not have either. That's one reason I say cut the OP some slack. OP is looking for options and advice, which is commendable.

 

[MedMan80]

I agree with what wolfvgang so succinctly put, you simply provide your recommendations and if you feel that the patient should be off the Xanax then tapering to a long acting and then tapering off is reasonable. If the patient doesn't agree with your assessment then he can find another psychiatrist to manage it.

 

[ridethecliche]

Doesn't long term use of benzos also lead to increased anxiety which can subside with tapering and getting off the meds?

 

[Trismegistus4]

For what it is worth I rotated for a while with one of the guys who literally wrote most of the UpToDate articles on vertigo and its treatment. Benzos are actually used to reduce vertigo symptoms by suppressing vestibular function. So be careful documenting - vertigo would actually be a reason to continue them.

Wow, thanks, I didn't know that. I just looked it up, and you're right.

On the topic of vertigo, though, I don't know whether he's ever actually been diagnosed with vertigo. He could just be using the word colloquially, to mean dizziness.

The problem with trying to get him to transfer to someone else is twofold:

1) I'm in a large hospital system that tries to keep patients within the system. If I manage to convince him to see someone else (or get him to give up on me, by insisting on tapering Xanax) the first thing he's going to try to do is make an appointment with one of my colleagues. And I don't want to burden them by transferring a controlled-substance-seeking patient to one of them. (If he doesn't say anything to me about it but goes back to his PCP and says "I didn't like Dr. Trismegistus4, can you refer me to a different psychiatrist?" the PCP is going to enter a new psych referral order, which our schedulers will then look at and close, with the note "patient is already a patient of our practice, he just needs to call and make an appointment." Yes, this has happened with numerous patients before.)

2) The wait to see anyone on the outside is going to be at least 3 months, if not longer. Patients are usually extremely resistant to transferring outside for this reason. They would rather keep hashing it out with their psychiatrist in our system, than wait 3 months to see the solo private practice guy.

Also, he is never going to accept switching to a longer-acting benzo. I've been down this road before with numerous controlled substance patients. The "rush" or "rollercoaster" of a short-acting or immediate release med is interpreted by them as "working," and they don't get that effect with a long-acting/controlled release so they feel it "doesn't work." I have tried many times to explain this to people until I'm blue in the face, but it goes in one ear and out the other. Their mind was made up long ago that Xanax "works" while Klonopin "doesn't work," and nothing will convince them otherwise. I'm currently dealing with another patient I recently inherited on Adderall, and she felt even that wasn't "working" anymore. It sounded like she was taking it mainly for wakefulness, so I switched her to Provigil. It turned out her insurance company preferred Nuvigil, so I had to change the prescription to that for her to get it. She's already sending me messages that the Nuvigil isn't "working," and reminding me that Adderall XR never "worked" for her either, that the only thing that has ever "worked" was immediate release Adderall. Trying to talk sense into these people never works. (Talk about something that "doesn't work!")

I think people are making too much of the suicide comments. He's not experiencing a general increase in suicidal thoughts. He just brings it up indirectly in response to any attempt to taper Xanax, using the kind of statements I quoted in the OP.

I'm also not sure why @sluox brings up inpatient treatment. Maybe you're latching onto the fact that I called him a "Xanax addict" and assuming he meets criteria for a substance use disorder? Just looking at the DSM criteria, it's not clear that his use is "leading to clinically significant impairment or distress," or that he satisfies 2 of the 11 possible criteria. He's not taking the drug in larger amounts or over a longer period than was intended; he doesn't have persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use; he's not spending a great deal of time in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects, etc. He MIGHT have "recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous," if the dizziness counts, but as we've learned in this thread, not if it's vertigo. The only other two you could make a case for are "4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic" and "9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic" if it worsens his breathing, but IMO those are a stretch given that he's taking a prescription drug at what is considered to be a clinically normal dose.

Also, I'm not optimistic about getting past records because his previous psychiatrist was a solo private practice guy who is now deceased.

I think what I will do tomorrow is try @wolfvgang22's approach, hope he elects to see someone else, and if not, discuss with my medical director.

 

[nexus73]

I’m no big fan of Xanax, not a fan at all really. Just curious if everyone is totally against chronic “low dose” benzos. Like clonazepam 1 mg BID long term, in a patient with legit panic/anxiety disorder, no history of misusing, running out early, diverting etc? Assuming the patient is maintaining relative stability.

 

[birchswing]

1 mg Klonopin twice daily is theoretically (again different estimates) almost equivalent to what this patient is on (2.5 mg Xanax). Theoretically it would work out to an equivalency of 2 mg Xanax or 40 mg Valium.

I personally wouldn't consider 2 mg Klonopin to be a low dose. I've noticed over time different benzos get different reputations. Xanax was considered better for not causing depression due to its short half life. And the newer ones in generally were considered "clean" for having fewer active metabolites. I heard one psychiatrist say that Klonopin is the only benzodiazepine that is mood stabilizing, but I could never find a reference to support that.

I have no experience with Xanax, but I think more generally the problem long-term is the dosage rather than the form. It's easier to come off a longer-acting benzo. But if the goal is to have the patient on it indefinitely anyway, I'm not sure how much that matters as you can switch when coming off.

If you're asking about initiating a new prescription, I would say from personal experience try everything else first.

Apart from there not being good evidence supporting it working for anxiety long-term and in fact increasing anxiety, there is an ethical issue to consider of who (if anyone) will continue prescribing the regimen when the current psychiatrist moves, passes away, etc. I think is maybe good to be somewhat forward thinking of whether it is likely that trends are such that anyone would continue to support that patient in the future. In addition to all the regular informed consent that should be given with long-term benzodiazepine treatment, I think mentioning that "this is not a strongly evidence-supported treatment and may not be supported by future physicians" should be part of the information the patient consents to.

Because the next doctor who gets them may well be writing a thread with the title of this one.

 

[Trismegistus4]

1 mg Klonopin twice daily is theoretically (again different estimates) almost equivalent to what this patient is on (2.5 mg Xanax). Theoretically it would work out to an equivalency of 2 mg Xanax or 40 mg Valium.

I personally wouldn't consider 2 mg Klonopin to be a low dose. I've noticed over time different benzos get different reputations. Xanax was considered better for not causing depression due to its short half life. And the newer ones in generally were considered "clean" for having fewer active metabolites. I heard one psychiatrist say that Klonopin is the only benzodiazepine that is mood stabilizing, but I could never find a reference to support that.

I have no experience with Xanax, but I think more generally the problem long-term is the dosage rather than the form. It's easier to come off a longer-acting benzo. But if the goal is to have the patient on it indefinitely anyway, I'm not sure how much that matters as you can switch when coming off.

If you're asking about initiating a new prescription, I would say from personal experience try everything else first.

Apart from there not being good evidence supporting it working for anxiety long-term and in fact increasing anxiety, there is an ethical issue to consider of who (if anyone) will continue prescribing the regimen when the current psychiatrist moves, passes away, etc. I think is maybe good to be somewhat forward thinking of whether it is likely that trends are such that anyone would continue to support that patient in the future. In addition to all the regular informed consent that should be given with long-term benzodiazepine treatment, I think mentioning that "this is not a strongly evidence-supported treatment and may not be supported by future physicians" should be part of the information the patient consents to.

Because the next doctor who gets them may well be writing a thread with the title of this one.

Could you please stop posting medical opinions and management recommendations, given that you're not a physician or mental health professional?

 

[birchswing]

Could you please stop posting medical opinions and management recommendations, given that you're not a physician or mental health professional?

I'm the one who pointed out above that benzodiazepines are used to treat vertigo.

Medical literacy doesn't begin in medical school nor does it end with CMEs.

Also I didn't realize you were the OP or I wouldn't have included the line at the end about the thread title. I am bad at tracking usernames.

As for posting, I was recently asked not to speak about detailed personal experience, and I believe I have abided by that since then.

Edit: It wasn't you I was responding to, in fact. I got mixed up. I was responding to nexus73 but didn't use the quotation feature.

Edit 2: I read your longer post above about patients not switching to longer-term benzos due to not having a rush. I'm not sure if that's true but Valium is long-acting and has a very fast onset (faster than Xanax).

 

[Trismegistus4]

I’m no big fan of Xanax, not a fan at all really. Just curious if everyone is totally against chronic “low dose” benzos. Like clonazepam 1 mg BID long term, in a patient with legit panic/anxiety disorder, no history of misusing, running out early, diverting etc? Assuming the patient is maintaining relative stability.

I have a handful of such patients, whom I inherited on that regimen, continued because it was easier than arguing with them, made clear I wouldn't increase it and wouldn't give early refills, the whole "it doesn't matter if your dog eats it or you 'accidentally' drop it in the toilet" spiel, checked the PDMP, and it hasn't been a problem. I still don't really like it, but it's hard to avoid in an outpatient setting where you're part of a large system and have no control over your referrals. IIRC they're all on clonazepam BID (maybe one on HS Valium) though; maybe a couple I only recently inherited on daily Xanax and am slowly tapering. The guy I wrote about in the OP is the only one on whom I've continued TID Xanax.

 

[hamstergang]

I don't get it. What specifically do you think the problem is? There's no protected health information in my post, no level of detail that isn't in, say, an Oliver Sacks book. Is it that someone who knows him well could stumble across the forum, realize whom the post was about, and if the patient then found out he'd feel his privacy had been violated? What detail do you think I should remove?

I don't know, maybe I am wrong. I'd worry that he would at some point Google this issue and find this thread. I can't imagine it'd be good for him to see what you wrote and know it's about him.

The actual traumatic events in his past aren't relevant. The specific months aren't relevant (you could give general time frames). Maybe that still wouldn't de-identify it enough but at least then it would probably describe a few patients more or less.

 

[hamstergang]

If a person could continue purchasing benzodiazepines from a convenience store as they do cigarettes, neither party would be in this conflict

Correct, but as that's not the case we have a big issue here. The set up is such that the doctor, in giving the Rx, is taking on responsibility for the outcome of that Rx. Even if it's the patient's desire.

I've once that I can recall been able to hold firm in a situation where I gave the patient an Rx they didn't want (in terms of benzos). I told ther it was what I believed to be medically indicated and responsible, and what she wanted was something I felt to be contraindicated and irresponsible. I got her off benzos eventually.

 

[ridethecliche]

I'm the one who pointed out above that benzodiazepines are used to treat vertigo.

Medical literacy doesn't begin in medical school nor does it end with CMEs.

No, but having skin in the game means that you're speaking from a background where your actions could be scrutinized and you'd be comfortable with your e-recommendations should they ever be traced back to you. You have nothing to lose by posting your thoughts on medication management because for you its purely an intellectual exercise.

This is not to take a stance on whether you're right or wrong, but to share with you why people respond to you in the way that they do. There's a big difference between health literacy applied to oneself vs using said experience to make more generalized claims and recommendations.

 

[Trismegistus4]

I don't know, maybe I am wrong. I'd worry that he would at some point Google this issue and find this thread. I can't imagine it'd be good for him to see what you wrote and know it's about him.

The actual traumatic events in his past aren't relevant. The specific months aren't relevant (you could give general time frames). Maybe that still wouldn't de-identify it enough but at least then it would probably describe a few patients more or less.

I don't think this particular guy is the issue-googling type, but fair enough; I've removed his exact age, references to specific months and years, and the paragraph about past traumatic events.

 

[birchswing]

Correct, but as that's not the case we have a big issue here. The set up is such that the doctor, in giving the Rx, is taking on responsibility for the outcome of that Rx. Even if it's the patient's desire.

I've once that I can recall been able to hold firm in a situation where I gave the patient an Rx they didn't want (in terms of benzos). I told ther it was what I believed to be medically indicated and responsible, and what she wanted was something I felt to be contraindicated and irresponsible. I got her off benzos eventually.

I think the outcomes are a bit ill-defined at this point in time depending on the situation of the patient. I have complete agreement about not initiating benzodiazepine treatment. The state of iatrogenic physical dependence is a bit different, and I think it would vary based on several factors. I don't think there is a good solution. It depends on how much you believe in the existence of protracted withdrawal. And I understand the cancer patient analogy doesn't work entirely. But in that situation, people are allowed to refuse a medical treatment to live out their life the way they want. Our societal paternalism is low enough that they can even choose cancer causing drugs (cigarettes). I think in the case of iatrogenesis and benzodiazepines, where a person was not able to give consent to begin with, the ethics of the situation changes and becomes more similar to that of a person afflicted with a progressive disease where professional opinions vary on the outcome and where the patient is encouraged to weigh which quality of life factors are important to them. In both cases there is not settled science and treatment can be experimental. There is no universal, optimal way off benzos (which is why you'll find studies using various methods and various pharmaceutical adjuncts, not something you find in run of the mill discontinuation of say lisinopril), and the research on how patients fare after discontinuing long-term benzodiazepine research is positive, but it's also fairly small and shows many were unsuccessful in their attempts. I don't think what I'm saying though is that the ethics shift to a burden on the doctor to continue prescribing. But I'm saying in an ideal world, it would be the case that patients could decide and doctors would not be liable for that decision.

I know of one psychiatrist who wants to sue the pharmaceutical industry (who exactly I am not sure—nor am I sure how) to create a workable solution for discontinuing benzodiazepines. This person believes that the industry that created the drugs should have the burden of creating a way to stop them. I think that's pie-in-the-sky thinking for how little benzodiazepines are on the nation's radar, but the tobacco industry was required to create quitting assistance programs by the government.

So to emphasize, I am not saying the burden should be shifted onto any one doctor to practice outside of what they think is ethically right. But without having a solution to propose in order to bring this to pass, I do believe the patient should have the right to move forward the way they see fit given the benefits and risks of each path, especially in lieu of there being a universal, workable solution that is known to work for the vast majority of people. I think it's a bit uncharted at this point to come to that conclusion. For certain people, I think they would have a better life finishing it off never having withdrawn from benzodiazepines given current solutions. And I think people have a right to live the best life possible. But as I said, "I understand that the right to live and die that way interferes with the right of a physician to practice according to their own ethics, and therein lies the quandary."

 

[birchswing]

No, but having skin in the game means that you're speaking from a background where your actions could be scrutinized and you'd be comfortable with your e-recommendations should they ever be traced back to you. You have nothing to lose by posting your thoughts on medication management because for you its purely an intellectual exercise.

This is not to take a stance on whether you're right or wrong, but to share with you why people respond to you in the way that they do. There's a big difference between health literacy applied to oneself vs using said experience to make more generalized claims and recommendations.

That makes sense, and I understand it.

But this forum is public, and I have made clear that I am not a doctor. I realize some people can verify that they are doctors with the site, but even if they have done that, I doubt in a court of law a doctor is going to say, "Well I performed the surgery based on advice that was given to me by someone a web-site swore was a real doctor."

I would hope no one here who is a medical professional ultimately makes a treatment decision based on unverified postings by others who have never examined the patient in question.

Having said that, it does help to understand why people might react the way they do, so I appreciate the explanation.

 

[Trismegistus4]

That makes sense, and I understand it.

But this forum is public, and I have made clear that I am not a doctor. I realize some people can verify that they are doctors with the site, but even if they have done that, I doubt in a court of law a doctor is going to say, "Well I performed the surgery based on advice that was given to me by someone a web-site swore was a real doctor."

I would hope no one here who is a medical professional ultimately makes a treatment decision based on unverified postings by others who have never examined the patient in question.

Having said that, it does help to understand why people might react the way they do, so I appreciate the explanation.

If you truly appreciate the explanation, you'll get out of the damn thread. I know I'm not a mod, but I am the OP, and you are cluttering this thread which I started to seek advice from other mental health professionals with your off-topic posts.

 

[Liquid8]

Wow, thanks, I didn't know that. I just looked it up, and you're right.

On the topic of vertigo, though, I don't know whether he's ever actually been diagnosed with vertigo. He could just be using the word colloquially, to mean dizziness.

Given what you've already mentioned about his questionable understanding of medications, I'd be very cautious of accepting the use of any medical terminology at face value and at the very least would make sure what he says by "vertigo" is the same as what your understanding of it is. A simple "tell me more about..." with no leading comments is what I'd ask many of my patients who drop medical jargon that might be open to interpretation. What I'd want to first exclude is a postural drop, and would ask about symptoms when changing from lying/sitting/standing. If there's no issue there and he comes up with classic room spinning descriptor of vertigo, I'd be more inclined to agree that he does experience vertigo.

Obviously, if he's not being prescribed benzodiazepenes for vertigo I'd not want to give him any additional reasons to try to hang onto them.

Also, on the topic of whether an admission would be useful - I would say yes, as if the patient is genuinely wanting to come off benzos and concerned about the potential ramifications of doing so, having the additional support of an inpatient stay will generally alleviate this. You would also have additional observations of withdrawal symptoms and mental state from other clinicians to support and clarify what is going on. OP's patient doesn't want to change anything, but efforts by patients to magnify symptoms over a prolonged time can usually be seen for what they are: typically the patient will present to me as completely demoralised, but will later be observed happily chatting away to other inpatients or nursing staff. Stuff like that allows me to refer back to previous notes, and reflect on function or even gains while medication is being decreased.

 

[futuredo32]

2) The wait to see anyone on the outside is going to be at least 3 months, if not longer. Patients are usually extremely resistant to transferring outside for this reason. They would rather keep hashing it out with their psychiatrist in our system, than wait 3 months to see the solo private practice guy.

.

So treat him for three months and then let him see someone else. Is keeping him on his low dose Xanax for 3 months going to kill him? I doubt it.

 

[WisNeuro]

So treat him for three months and then let him see someone else. Is keeping him on his low dose Xanax for 3 months going to kill him? I doubt it.

Well, depending on his age and other medication factors (e.g., anticholinergics) it could be significantly raising his risk of fall and mortality risk. And, theoretically significantly raising his risk of dementia risk, based on preliminary work. So, not definitely going to kill him, but likely making his death much more likely sooner rather than later.

 

[Trismegistus4]

So treat him for three months and then let him see someone else. Is keeping him on his low dose Xanax for 3 months going to kill him? I doubt it.

Oh, I'd been assuming the way I was going to get him to go see someone else was by putting my foot down and telling him his only option with me was to switch to klonopin and do a slow taper, and hope he would be so unhappy with that he would go see someone else of his own volition. In the scenario you describe, I would need to explicitly tell him I need him to go see someone else, which as I mentioned I'm uncomfortable with since it would amount to my dumping him on one of my colleagues.

 

[dl2dp2]

I'm also not sure why @sluox brings up inpatient treatment. Maybe you're latching onto the fact that I called him a "Xanax addict" and assuming he meets criteria for a substance use disorder? Just looking at the DSM criteria, it's not clear that his use is "leading to clinically significant impairment or distress," or that he satisfies 2 of the 11 possible criteria. He's not taking the drug in larger amounts or over a longer period than was intended; he doesn't have persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use; he's not spending a great deal of time in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects, etc. He MIGHT have "recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous," if the dizziness counts, but as we've learned in this thread, not if it's vertigo. The only other two you could make a case for are "4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic" and "9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic" if it worsens his breathing, but IMO those are a stretch given that he's taking a prescription drug at what is considered to be a clinically normal dose.

If he doesn't meet a use disorder criteria perhaps it's reasonable to continue him on Xanax. The clinical content of the case is actually not atypical. As long as everyone (including family) is aware and on board with this plan moving forward and aware of the potential risks. Though, from a risk management perspective, maybe it's not a bad idea to review this with the medical director anyway. He/she might suggest a one off consultation from an addictionologist to make a call that this person doesn't require addiction treatment.

 

[clausewitz2]

I’m no big fan of Xanax, not a fan at all really. Just curious if everyone is totally against chronic “low dose” benzos. Like clonazepam 1 mg BID long term, in a patient with legit panic/anxiety disorder, no history of misusing, running out early, diverting etc? Assuming the patient is maintaining relative stability.

I recently started tapering a patient I inherited who had been on a very similar regimen for many years because a) he is pushing 70 b) walks unsteadily with a cane, c) lives alone and d) is...Pickwickian. If he had a bad fall he would basically be done for. When I mentioned the cognitive impairment and fall risks he was up for it, but it helped that we decided to do it the very slow, quasi-Ashton, convert-to-Valium-slowly-and-then-taper-by-baby-steps way.

 

[LadyHalcyon]

Have you made process comments regarding his vague suicidal threats? I'm thinking something along the lines of, "I've noticed you tend to reference suicide whenever we discuss discontinuing and/or changing your medications?"

Sent from my SM-G950U using SDN mobile

 

[WisNeuro]

d) is...Pickwickian.

I'm totally going to start using this in my behavioral obs, not for the syndrome, but just to describe appearance

 

[futuredo32]

Oh, I'd been assuming the way I was going to get him to go see someone else was by putting my foot down and telling him his only option with me was to switch to klonopin and do a slow taper, and hope he would be so unhappy with that he would go see someone else of his own volition. In the scenario you describe, I would need to explicitly tell him I need him to go see someone else, which as I mentioned I'm uncomfortable with since it would amount to my dumping him on one of my colleagues.

You can work WITH him not dictate to him, but it doesn't sound like you want to do that. If I were the patient I would be finding a different psychiatrist who would work with me. Klonopin may prevent seizures but it has been my experience than many patients on a benzo respond better to Xanax , some Ativan, some Valium and some Klonopin. What if Klonopin doesn't help his anxiety? Some patients use a compound pharmacy and taper off over years. I really think you would both be better off if he saw someone else. "Dumping him?" Yeah, you should transfer him to someone else. Not trying to be rude but your negative countertransference seems really strong and it doesn't seem you are dealing with it (it is how it comes across online, real life maybe different).

 

[futuredo32]

Well, depending on his age and other medication factors (e.g., anticholinergics) it could be significantly raising his risk of fall and mortality risk. And, theoretically significantly raising his risk of dementia risk, based on preliminary work. So, not definitely going to kill him, but likely making his death much more likely sooner rather than later.

You are making a lot of assumptions. 3 more months is going to lead to early onset dementia? Those 3 months are going to be the cause of early onset Alzheimer's? No.
We don't have the full story. What is his age? What other meds besides tramadol is he taking?

 

[WisNeuro]

You are making a lot of assumptions. 3 more months is going to lead to early onset dementia? Those 3 months are going to be the cause of early onset Alzheimer's? No.
We don't have the full story. What is his age? What other meds besides tramadol is he taking?

He's 50 something, and has reports of longstanding vertigo, enough there to justify GREATLY increased fall risk which will only increase as he ages. And, the real risk is this medication just being continued indefinitely, which is what is likely going to happen. I know you're a benzo-evangelist, but the evidence keeps accruing more and more about the negative health effects that just pile up with maintenance prescribing. We owe it to our patients to try not to kill them.

 

[futuredo32]

We don't know it IS vertigo.It could very well be anxiety or something else. If he's already in his 50s he may be past the point of early onset Alzheimer's and seriously three more months is not going to cause it. I am not a benzo-evangelist. I had no idea that was a religion. I'm Catholic. I prescribe benzos judiciously for appropriate patients as do many psychiatrists well respected psychiatrists.
I gave my input, starting to get a little rude sadly so I am out of here. Hope my two cents was helpful to someone.

 

[Attending1985]

I have, on my schedule on Friday, one of my least favorite patients. When I first saw this guy a little over 2 years ago, he was a 50-something man with a history of depression and anxiety. He was already on Xanax 1 mg TID, as well as the ridiculous regimen of Wellbutrin 100 mg BID, nefazodone 400 mg at bedtime, trazodone 50 mg at bedtime, and Seroquel 200 mg at bedtime. It wasn't clear why his PCP was referring him at that particular time. He endorsed having been on the above regimen for years, and I would have thought PCP was punting to psych to get the Xanax off his hands, but he had been filling it for a couple of years. Before that, the patient was seeing a local psychiatrist who retired. The patient also has COPD, still smokes, and the month before I first saw him, had been to the ER with chest pain (MI was ruled out.) He endorsed periods of major depression with suicidal thoughts in the past, He had been on disability for depression and anxiety for almost two decades.

He was still complaining of anxiety and, of course, requesting an increase in the Xanax at that initial appointment, which I turned down. Other than that, he was strongly resistant to making any changes to his regimen (including simplifying the aforementioned polypharmacy.) Predictably, he also didn't want to switch to a longer-acting benzo as he had supposedly tried clonazepam and diazepam in the past and they allegedly "didn't work." He in fact wasn't even taking the full dose of Seroquel since he found it too sedating, so I changed that to 25 mg in the morning and 50 mg QHS, in the thought that a small AM dose would help with the daytime anxiety for which he was requesting a Xanax increase.

Over the next few visits, it became clear he didn't really understand his medication regimen, meaning, what doses he was to be taking and when. He kept playing with the Seroquel dosing on his own, and it also emerged that he was not taking the nefazodone as prescribed. I first suspected this when he said he was taking 200 mg instead of 400 mg, but then at the next visit it turned out he was taking 200 mg BID. I repeatedly went over with him what all these meds are and what they are supposed to do, but he seemed like he just wasn't getting it. I kept trying to get rid of either the nefazodone or trazdodone, but he was strongly resistant to this, being adamant he needed them both. It turned out he was taking the Wellbutrin only for smoking cessation and it was ineffective, so I eventually discontinued that. However, he believed that without all the other meds, he wouldn't be able to sleep.

I will interject here that, predictably, I have very strong negative countertransference against this guy, because of his adamance about "needing" the Xanax and a polypharmacy regimen in general. He also brought his disability renewal form with him to one visit, which was for him to fill out and not a doctor, but was asking me what he should put on it, since it asked about a change in his condition and whether he has discussed his ability to work with his doctor. He also was a little TOO genial, always saying "good to see you again, Dr. Trismegistus4!" and wanting to spend the appointment making small-talk chit-chat and showing me pictures of his grandchildren on his phone.

Then, at a visit almost a year ago, he mentioned having vertigo. He said this had in fact been going on for years, that when he goes out he has to sit in his car until he feels better before he goes into the store or building, and that he doesn't want to get in an accident and hurt someone else or himself. This caused me to think "crap, I REALLY should not be prescribing this guy Xanax." So, before his next visit, I steeled my nerves, tried my hardest to suppress my non-contfrontationality, and told him I was going to taper him off the Xanax, reducing to 0.5 mg once per day and 1 mg for the other 2 doses. That appointment went 10 minutes over as he argued with me and I kept trying to get him to just accept it and get out the door. He said he can't function without xanax, used to be on 5 per day, does't want to be taken off meds that "might cause suicide." I brought up doing psychotherapy, and he said he's seen therapists for years, and "they never do a damn thing, the just talk to him." Suspiciously, I noted that he hadn't gotten a prescription for Seroquel in almost 8 months, and at the time it was only a 30-day supply with 1 refill, but he insisted he had been continuing to take it by cutting old 200 mg pills in half.

I documented in my note that I had a long discussion with the patient about the risks of chronic benzodiazepine use, including dizziness, falls, memory impairment, dementia as age progresses; that he had complained to me before at numerous visits of vertigo, memory and concentration problems, and also has a history of COPD and in fact often appears when being interviewed to have increased respiratory effort; that I explained to him that I think this medicine is more harmful to him than beneficial in the long run, and also the lack of evidence of therapeutic efficacy of benzodiazepines for more than a few months; and that I attempted to reiterate these points to the patient numerous times as he continued to raise objections to coming off Xanax, saying that he "needs it," "couldn't function without it," etc. so was not clear how much the patient understood the risks. But I eventually got him to say that if he had suicidal thoughts, he would go to the ER, and got him out the door.

I've seen him twice in follow-up since then, most recently last fall. As you might have predicted, I have not been able to continue suppressing my non-confrontationality; both those appointments also went over as he continued to beg and plead that he needed more Xanax. I haven't increased it back, but I have failed to taper it any further. When I last saw him in October, he was reporting shaking "really bad" and uncontrollably all the time. He keeps bringing up the subject of suicidality. I feel he's manipulating me with it. Every time we discuss the Xanax, he says "geez, doctor, in the past I was so anxious I wanted to kill myself; I'd hate to feel like that again." And starts getting tearful. Oh, and I also found out later he was also on Tramadol and hydrocodone! Fortunately, the hydrocodone was stopped last hear, but he's still on Tramadol.

I feel utterly defeated and humiliated that this guy is continuing to exact Xanax out of me; I'm worried about the liability given his vertigo and COPD. But he basically indirectly threatens suicide every time I try to reduce it. What I'd really like to do is fire him, but I'm not sure my organization will let me.

Any thoughts on how to handle this?

I’ve had the same issues as you and now I’m stuck with similar patients as a result. What I do now is to avoid this is tell patients on these regimens early on in the first visit respectfully but very clearly what I will not do in my practice (chronic benzos is one among a few others) and give them the option of seeing seeking alternative care if they don’t like my treatment philosophy. I used to try to build rapport first but it got me stuck like your situation with a few on chronic Xanax which I have just been continuing and not feeling good about. It’s really hard once you’ve continued it once to push for any changes it has to be something they know from the get go. I know this isn’t helpful with your current problem but it might avoid more of this in the future. With patients like this I document really well and cut down on frequency of visits if I’m not really helping them.

 

[MedMan80]

What do you guys do in clinic like settings where you don’t get much say in what type of patient you can have, or the patient will have nowhere else to go?

 

[futuredo32]

What do you guys do in clinic like settings where you don’t get much say in what type of patient you can have, or the patient will have nowhere else to go?

Guess I will chime in again-
In the FORMER pill mill clinic where I was working, all patients got a letter saying Dr X is leaving, it is likely your future provider will not continue you on Xyz . If you wish to find a different provider here is a list or call your insurance a few months prior to the pill mill doctors departure. IT IS A good drive for them but not impossible.
In my situation ALL of the remaining providers said we will NOT be the pill mill provider. Personally I wouldn't work at a job where I couldn't discharge a patient. The patients can ASK to see a different provider and both providers have to agree. If no one wants the patient, the patient receives 30 days of care and they are referred elsewhere. I guess if it's in the middle of nowhere- telepsychiatry?

 

[michaelrack]

Birchswing, please keep on posting. I enjoy reading your comments, and I truly have skin in the game

 

[michaelrack]

I agree with everything you say. However, the idea that inpatient is a possibility should have been raised a long time ago. Remember, inpatient substance abuse treatment is ALWAYS voluntary. There are people on benzo who can never be detoxed, but we can't make that decision yet. Right now we have a patient who has this very questionable set of symptoms and recent onset suicidality, and under this set of circumstances inpatient detox is a possible pathway moving forward. The problem with the management here isn't that the final result should be one (pt d/c benzo) vs. another (you write him Xanax ad infinitum), it's that it should be well documented that different options were explored and excluded for reasons A B C. Should an adverse event occur (let's say he falls and dies), you have an answer if you have to respond to a review committee (I discussed with him and family exhaustively the risks and suggested inpatient, but they refused). I've been on these committees--people try to pick you apart on what you didn't do.

Inpatient substance abuse treatment is not always voluntary.... when I was a resident in West Virginia (1997 -2002), it was possible to commit someone based on substance abuse and grave disability, even if there were no psych issues