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

[clausewitz2]

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

This is very much the exception; I think the only other state where this is possible is NC. In PA even mentioning substance use at the commitment hearing significantly increased the chances of the commitment being overturned.

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[splik]

This is very much the exception; I think the only other state where this is possible is NC. In PA even mentioning substance use at the commitment hearing significantly increased the chances of the commitment being overturned.

actually most states have civil commitment laws that include substance use disorders. it is just in practice they tend not to be used. MA is often mentioned as the state when involuntary substance abuse treatment commonly happens. In CA the civil commitment laws allow for involuntary treatment of chronic alcoholism, and we now have a new type of conservatorship in the 3 major cities for involuntary treatment of substance use disorders. one of the reasons it is not often done is because there is no good evidence supporting involuntary substance abuse treatment. however there has been a lot of pressure to revisit this option because of the supposed "opioid epidemic".

 

[clausewitz2]

actually most states have civil commitment laws that include substance use disorders. it is just in practice they tend not to be used. MA is often mentioned as the state when involuntary substance abuse treatment commonly happens. In CA the civil commitment laws allow for involuntary treatment of chronic alcoholism, and we now have a new type of conservatorship in the 3 major cities for involuntary treatment of substance use disorders. one of the reasons it is not often done is because there is no good evidence supporting involuntary substance abuse treatment. however there has been a lot of pressure to revisit this option because of the supposed "opioid epidemic".

Good to know, PA and none of the states the residents in my class came from had these so I guess my perspective was skewed.

 

[Candidate2017]

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.

I cursed at my program for filling my clinic schedule with these benzo patients and would dread coming to clinic, until I began to figure out on my own what you wrote. I'm now grateful of being thrown in the deep end. One thing that helped was being gentle but firm and clear (at the initial eval and every visit) that the plan is to taper if they continue to see me.

 

[psyguru]

I would switch him to xanax er and taper off. I would also require him to see a therapist and give him 1 week scripts. He may then find another psychiatrist. Also taper off seroquel. Seems to me it has more side effect than benefit. In my view seroquel is only worth the side effects for schizophrenia or bipolar or psychosis. Have you considered ssri?

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[Attending1985]

It seems like people like this will do equally terrible on vs off meds so I try to get them off as many as possible if not all and save the system money.

 

[FlowRate]

It seems to me that this case is missing the pieces of 1. treatment goals and 2. therapeutic alliance. Within the first two visits, you should have outlined your diagnosis and treatment plan. If the patient was not OK with it, he could always go back to his PCP. That's how you save yourself from endlessly taking patients on crazy regimen and then being stuck continuing them.

That doesn't mean you have to stop people cold turkey, it just sets the expectations of a gradual taper before the momentum of continuation can build up.

Obviously this is limited if there's some sort of institutional rule set / pressures that don't give you this kind of freedom.

actually most states have civil commitment laws that include substance use disorders. it is just in practice they tend not to be used. MA is often mentioned as the state when involuntary substance abuse treatment commonly happens. In CA the civil commitment laws allow for involuntary treatment of chronic alcoholism, and we now have a new type of conservatorship in the 3 major cities for involuntary treatment of substance use disorders. one of the reasons it is not often done is because there is no good evidence supporting involuntary substance abuse treatment. however there has been a lot of pressure to revisit this option because of the supposed "opioid epidemic".

Unfortunately, it's much easier to get out of a Section 35 (compulsory substance abuse tx) than a Section 12 (psych) because most of the compulsory substance abuse facilities don't have the ability to manage acute psychiatric issues.