Ideas for creating a clinic policy on controlled substances

[SpongeBob DoctorPants]

I've been asked to help with creating a clinic policy pertaining to controlled substances. To date, there has not been any kind of policy whatsoever, and each provider in the clinic (whether physician or mid-level) has just kind of done things their own way. We are aiming to develop a policy which will serve as a standard for the safe, effective, and appropriate prescribing of controlled substances. This may also help some providers who feel stuck continuing the medications certain patients may be on, and don't want to feel like the "bad guy" by taking away those meds which the patient wants but are inappropriate. Part of the reason we are doing this is because a lot of patients are on inappropriate combinations of medications, such as benzos and opioids, benzos and stimulants, benzos and other benzos, any of the preceding examples plus hypnotics, or all of the above in some patients, and in some cases with concurrent substance use such as alcohol and cannabis. Some providers have their patients sign medication contracts and some don't. Some order drug screens and some don't. Having more consistency among the providers in our clinic would likely be a good thing. If you could develop a policy which all the providers in your clinic were expected to follow, what would you include in it? If you have worked with a controlled substance policy before, what are some pros and cons you have found to having one?

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[NickNaylor]

I haven’t worked in a clinic where there was a rigid, strict policy around prescribing controlled substances. In our outpatient clinic in residency we did have controlled substances “contracts,” but really all these did was formalize basic safe prescribing practices and provide a mechanism for formally documenting that you have discussed - and the patient agrees to - boundaries around prescriptions for these substances. They weren’t required, and I personally only used them with patients that I thought were at risk of engaging in shenanigans around safe prescribing practices. Similarly we didn’t have a strict policy around checking UDS, and I don’t think I once ordered a random UDS for a patient receiving a controlled substance. This is probably the one thing that is most amenable to a formal policy IMO.

I don’t know if a “policy” is the best way to address potentially dangerous medication combinations, like the things you mentioned above. If anything, I would think the better way to address this is simple education for the physicians/midlevels in the clinic rather than a “policy.” There may be situations - albeit rare - where use of these combinations may be indicated and appropriate, and a policy may be too rigid to allow for situations like that.

Addressing things like being unwilling to maintain boundaries around prescription of controlled substances (being the “bad guy,” as you say) is, similarly, not something I think is best addressed with a policy but, instead, education. Being “the bad guy” is a necessary part of the job, and if someone is uncomfortable with being in that role, I’m not sure that the correct response is a blanket policy that places limits on clinical decisions.

Do you have access to data in the clinic? If so, are there specific folks in the clinic that seem to have a higher proportion of the cases that you’re referring to? If so, one approach might be sharing that data with them.

 

[FlowRate]

Agree w/ Nick about how it sounds like an attempt to enact policy where professional skill is what's needed.

I am interested in hearing more about what people do (or don't do) with UDS. I'm often tempted to make certain drugs (stimulants, benzos) contingent on clean UDS but the counter argument is that you should have a trusting relationship with your patients and talk to them about it if you don't trust them.

 

[NewmansOwn]

Fresh out of residency and working outpatient at a large VA.

As a general principle, I think inviting administration to institute broad policies is a short-term solution unlikely to yield long-term gains. And a slippery slope, at that -- once you let a foot in the door, etc...

That said, I've inherited a number of patients from an older psychiatrist retiring who are on the kind of irresponsible regimens you describe. I do think a policy addressing some of the lowest hanging fruit (i.e., no BZDs and opioids) which truly have very few exceptions might be warranted.

Tricker areas involve situations like stimulants + THC. On the one hand, you're volitionally using a recreational substance that impairs your concentration, the very symptom we're ostensibly trying to treat with said stimulant. On the other hand, substance use is increased in ADHD and there's even some scant literature that marijuana ameliorates symptoms of ADHD. These are situations which require not so much a broad policy (as previous posters have said) as deft clinical judgment, good interpersonal skills and therapeutic alliance building, and a balance between nuance and decisiveness. I put stimulant + BZD into this category as well -- I'm highly repelled by and skeptical of both, but will at least hear the patient out and give the previous doctor the benefit of the doubt in chart review to the extent possible.

By far the most important thing is that your leadership has your back with inevitable grumblings. I am fortunate that mine does. However, were I a graduating resident reading these forums considering an outpatient job, I would be sure to ask any potential employers -- Am I inheriting patients from any departing providers? Then I would ask non-leadership physicians their opinion, off the record, of the retiring doc. Had I done this, I would have had a big heads up.

 

[SpongeBob DoctorPants]

Thank you for everyone's input so far. You have some excellent points.

Do you have access to data in the clinic? If so, are there specific folks in the clinic that seem to have a higher proportion of the cases that you’re referring to? If so, one approach might be sharing that data with them.

That said, I've inherited a number of patients from an older psychiatrist retiring who are on the kind of irresponsible regimens you describe. I do think a policy addressing some of the lowest hanging fruit (i.e., no BZDs and opioids) which truly have very few exceptions might be warranted.

I should add that those currently practicing in our clinic tend to do a good job with prescribing appropriately, but one of the reasons a policy is being considered is that someone recently left our practice who had a tendency to prescribe a stimulant, a benzodiazepine (or two), and a hypnotic to almost every patient (sometimes even to adolescents), and in some cases started all of these together on the first encounter with a patient. The rest of us are now inheriting these patients, and almost all of them are on inappropriate medication combinations, such as those illustrated in my original post. It was proposed that a policy be created, in part, to give our prescribers something to fall back on when they encounter resistance from a patient if they recommend tapering off of a certain medication.

I am interested in hearing more about what people do (or don't do) with UDS. I'm often tempted to make certain drugs (stimulants, benzos) contingent on clean UDS but the counter argument is that you should have a trusting relationship with your patients and talk to them about it if you don't trust them.

Personally, over time I have become more and more likely to order a UDS at my first encounter with a patient if they are wanting to be prescribed a controlled substance, at least with my adult patients. Interestingly, I recently had a new patient who wanted to remain on Vyvanse, and I said that I would be ordering a UDS; she replied by saying that she was expecting that... so I imagine other providers are doing this as well. Not all of my patients complete the UDS as requested, though; I think some of them simply forgot, while others seem to drop out of care perhaps because they may have lied about their substance use. In some cases, such as when a patient insists that they can't function without their stimulant medication but are actively using cannabis, I will usually still prescribe the medicine but require that they stop the cannabis use, and I will order monthly drug screens along with a cannabis level, and will discontinue the medication if the UDS and/or cannabis level does not change over time as expected.

 

[FlowRate]

Personally, over time I have become more and more likely to order a UDS at my first encounter with a patient if they are wanting to be prescribed a controlled substance, at least with my adult patients. Interestingly, I recently had a new patient who wanted to remain on Vyvanse, and I said that I would be ordering a UDS; she replied by saying that she was expecting that... so I imagine other providers are doing this as well. Not all of my patients complete the UDS as requested, though; I think some of them simply forgot, while others seem to drop out of care perhaps because they may have lied about their substance use. In some cases, such as when a patient insists that they can't function without their stimulant medication but are actively using cannabis, I will usually still prescribe the medicine but require that they stop the cannabis use, and I will order monthly drug screens along with a cannabis level, and will discontinue the medication if the UDS and/or cannabis level does not change over time as expected.

There are some PCPs in our system who require UDS as part of continuing CS until pt gets connected with psych. Seeing other people do it feels empowering that it wouldn't be completely "out there" if I chose to, as well.

 

[Sushirolls]

This is what I do in my private practice that tends towards higher functioning patients:

First visit, ALL patients get a UDS. I perform the test myself, result it too, all immediately before bringing the patient into my office, and discuss results during the appointment. Patient doesn't wish to provide a sample (despite a UDS policy statement they E-sign before scheduling an appointment) I will complete the consult, and let them know at the end we are not a good fit and refer elsewhere.

All patients getting ongoing controlled substances get a UDS at each appointment, and they know I reserve the right to call in for random UDS and even pill counts.

All patients I am prescribing controlled substances to I look up their pharmacy database report during each and every appointment, and document that I did.

Using cannabis? No controlled substance until it clears.

Benzos? I don't prescribe (unless for RBD, catatonia, plane phobia or 1 time Rx for acute stress disorder). All other benzos are tapered off. Z sleep meds, tapered off. I don't prescribe Z sleep drugs.

My routine UDS recently picked up a Cocaine positive in stimulant patient, and confirmed by GC/MS testing. My counter transference I would have never suspected, but that's part of the reason why I test.

I had one patient recently protest at time of visit and first follow up. That patient several months later is actively addressing their chemical dependency issues now. I had another patient protest before the visit, but it was part of the OCD / Anxiety ruminations, with no issues at time of consult. I've had geriatric grandmothers praise me for testing them, because their kids or grandkids had developed various SUDs and they were grateful to know some one is testing people.

 

[Sushirolls]

Agree w/ Nick about how it sounds like an attempt to enact policy where professional skill is what's needed.

I am interested in hearing more about what people do (or don't do) with UDS. I'm often tempted to make certain drugs (stimulants, benzos) contingent on clean UDS but the counter argument is that you should have a trusting relationship with your patients and talk to them about it if you don't trust them.

Trust? Patients lie big and small all the time. I've lied to my own doctors in withholding pertinent positives on a simple Review of Symptoms. First time consults in psych, IMO, it should be standard. Substance abuse, even cannabis, is prevalent in all life stages and all patients, and it can be a good discussion point with patients. Simply put to let them know you care enough to say hey, I trust, but I verify. Part of the disease process of SUDs includes the symptom of lying...

I've had too many patients over the years I inherited from colleague/colleague hand offs who were using substance X and didn't admit to it until things got really bad, or I picked up as new patients and they revealed that they were using substance Y, and never told their previous psychiatric provider about it. It's a simple test that bills out at ~$30, and depending on the insurance can net ~$6-20, and depending on the test, costs $3-6.

 

[Jules A]

I'm glad to learn this isn't about your colleagues being unable to set reasonable boundaries with patients which I have seen and is unfortunate. Although it is exhausting and frustrating when this type of transition happens it is usually short lived. There will be those who are convinced this is the only way, those who know they were getting over and the jig is up and those who are just trusting patients who had a lousy prescriber. I treat everyone as if they didn't understand the concerns, attempt to educate them and go as slowly as reasonably possible with the clear message that this will have to happen if they remain under my care. If the employer is supportive of discharging patients or having patients seek care elsewhere if they decline to consider safe prescribing practices that is the key to cleaning this up quickly.

Since this is a new issue due to a certain prescriber perhaps a simple notice given to all patients at their initial appointment with a new provider would be sufficient. Maybe something like an information sheet outlining there the classes of medications ie. benzos, Z sleep drugs, stimulants etc that carry specific concerns and indicating they will be handled on a case by case basis at the discretion of your provider in consideration of recommended guidelines and your safety?

 

[Armadillos]

This is what I do in my private practice that tends towards higher functioning patients:

First visit, ALL patients get a UDS. I perform the test myself, result it too, all immediately before bringing the patient into my office, and discuss results during the appointment. Patient doesn't wish to provide a sample (despite a UDS policy statement they E-sign before scheduling an appointment) I will complete the consult, and let them know at the end we are not a good fit and refer elsewhere.

All patients getting ongoing controlled substances get a UDS at each appointment, and they know I reserve the right to call in for random UDS and even pill counts.

All patients I am prescribing controlled substances to I look up their pharmacy database report during each and every appointment, and document that I did.

Using cannabis? No controlled substance until it clears.

Benzos? I don't prescribe (unless for RBD, catatonia, plane phobia or 1 time Rx for acute stress disorder). All other benzos are tapered off. Z sleep meds, tapered off. I don't prescribe Z sleep drugs.

My routine UDS recently picked up a Cocaine positive in stimulant patient, and confirmed by GC/MS testing. My counter transference I would have never suspected, but that's part of the reason why I test.

I had one patient recently protest at time of visit and first follow up. That patient several months later is actively addressing their chemical dependency issues now. I had another patient protest before the visit, but it was part of the OCD / Anxiety ruminations, with no issues at time of consult. I've had geriatric grandmothers praise me for testing them, because their kids or grandkids had developed various SUDs and they were grateful to know some one is testing people.

Why no Z drugs? Avoiding seems to run afoul of most sleep medicine guidelines?

 

[Sushirolls]

https://aasm.org/resources/clinicalguidelines/040515.pdf Link to the American Academy of Sleep Medicine insomnia guidelines.

CBTi is first line and listed as "standard". Meta-analysis after meta analysis supports this.

"When pharmacotherapy is utilized, the choice of a specific pharmacological agent within a class, should be directed by: (1) symptom pattern; (2) treatment goals; (3) past treatment responses; (4) patient preference; (5) cost; (6) availability of other treatments; (7) comorbid conditions; (8) contraindications; (9) concurrent medication interactions; and (10) side effects. (Consensus)"

The summation of those 10 points, I don't prescribe Z drugs in my professional opinion, thus its not run afoul of "consensus" statements. All the recommendations on meds are "consensus" level in this Society level publication. So for sure not running afoul of any guidelines.

One must also see that consensus guidelines made up by sleep medicine doctors means there is limited Psychiatrist representation on that panel. As most of the field is still dominated by Pulm/CC and Neurology. My discussions with sleep docs, they loathe insomnia, and don't focus on it as much as say psychiatrists. Naturally, we have depressed, anxious, SUDs, etc population and not just a 'pure' insomnia only patient. As a Psychiatrist, Z drugs are off my pharmacotherapy armament.

 

[clausewitz2]

https://aasm.org/resources/clinicalguidelines/040515.pdf Link to the American Academy of Sleep Medicine insomnia guidelines.

CBTi is first line and listed as "standard". Meta-analysis after meta analysis supports this.

"When pharmacotherapy is utilized, the choice of a specific pharmacological agent within a class, should be directed by: (1) symptom pattern; (2) treatment goals; (3) past treatment responses; (4) patient preference; (5) cost; (6) availability of other treatments; (7) comorbid conditions; (8) contraindications; (9) concurrent medication interactions; and (10) side effects. (Consensus)"

The summation of those 10 points, I don't prescribe Z drugs in my professional opinion, thus its not run afoul of "consensus" statements. All the recommendations on meds are "consensus" level in this Society level publication. So for sure not running afoul of any guidelines.

I think you should read this more closely. When they start suggesting specific agents for insomnia in the very document you linked, first-line are the z-drugs and rameleton.

Z-drugs are better supported by published research than most of the drugs that are handed out like candy for this (e.g. trazodone).

I'm not saying everyone should get as much Ambien as they want but if you refuse to treat insomnia with z-drugs categorically you are kind of categorically refusing to treat insomnia if you are not personallly offering appropriate psychotherapy.

Anecdotally I can tell you that saying that z-drugs should not be prescribed in his presence is a really good way to make Daniel Buysse quite heated.

 

[Sushirolls]

I'm not saying everyone should get as much Ambien as they want but if you refuse to treat insomnia with z-drugs categorically you are kind of categorically refusing to treat insomnia if you are not personallly offering appropriate psychotherapy.

Nope. That is a poor summary/conclusion, and falls under Logical Fallacies.

I did see that it say Z and Bzds as first line, short term. The preamble still includes those 10 points to consider when selecting pharmacotherapy and that's why I put it in post.

You are welcome to prescribe them. This documents supports their use - short term. However, I don't support their use professionally, and personally I wouldn't want them recommended even for my own family. I tend to practice with the mindset, if I don't want it for my own kin, I won't recommend it for my patients.

 

[clausewitz2]

Nope. That is a poor summary/conclusion, and falls under Logical Fallacies.

I did see that it say Z and Bzds as first line, short term. The preamble still includes those 10 points to consider when selecting pharmacotherapy and that's why I put it in post.

You are welcome to prescribe them. This documents supports their use - short term. However, I don't support their use professionally, and personally I wouldn't want them recommended even for my own family. I tend to practice with the mindset, if I don't want it for my own kin, I won't recommend it for my patients.

Rhetorically strong and logically fallacious are not at all the same thing. It's fine if you disagree but philosophy buzzwords are not an argument.

I am in agreement with you about short term use. This is how I have always used them and have never prescribed enough to allow someone to take them on a nightly basis for a prolonged period of time. @Armadillos is right though that sleep medicine specialists, at least in our shop, are very comfortable with and persuaded of the efficacy of longer term treatment.

The kin mindset is probably good but I think it can mislead if dealing with people whose values are sufficiently different from yours.

 

[Merely]

Nope. That is a poor summary/conclusion, and falls under Logical Fallacies.

I did see that it say Z and Bzds as first line, short term. The preamble still includes those 10 points to consider when selecting pharmacotherapy and that's why I put it in post.

You are welcome to prescribe them. This documents supports their use - short term. However, I don't support their use professionally, and personally I wouldn't want them recommended even for my own family. I tend to practice with the mindset, if I don't want it for my own kin, I won't recommend it for my patients.

What do u give for sleep if no z drug

 

[WisNeuro]

I did see that it say Z and Bzds as first line, short term.

Except that in almost every circumstance, these drugs become a lifetime prescription. Can't remember the last time in reviewing med histories of my patients that I actually saw a z-drug prescribed short term.

 

[clausewitz2]

Except that in almost every circumstance, these drugs become a lifetime prescription. Can't remember the last time in reviewing med histories of my patients that I actually saw a z-drug prescribed short term.

True enough. I think that if you are prescribing stimulants or benzos or z-drugs you have to be very comfortable with saying "no, we're not going to do that anymore" and make sure you don't have a strong need to be liked it avoid being the "bad guy."

You can get in real trouble with controlled substances if you are a people pleaser. Fortunately no one has ever accused me of being agreeable so I am comfortable using them as the tools they are meant to be.

 

[Sushirolls]

What do u give for sleep if no z drug

Depends on the patient. I don't have a first line. More often then not, I refer to sleep medicine to get a sleep study to get the suspected OSA treated.
Why sedate when the sleep architecture is poor?
Snores ---> 95% of the time I refer to sleep medicine for OSA work up.

CBTi and where to go for that, but once declined:
Trazodone, doxepin, remeron, neurontin, are frequently used depending on nuances of patient.
Lesser so atarax or seroquel.

 

[NickNaylor]

What do u give for sleep if no z drug

I have a lot of luck with low dose TCAs (ideally doxepin, if this isn't covered or otherwise not available, then amitriptyline), and there was an ASAM "guideline" out there somewhere that recommended doxepin as the first-line pharmacotherapy agent. Trazodone is my second-line agent. Gabapentin and quetiapine come next, though I really try my hardest to avoid antipsychotics if they're being used only for insomnia. If none of those are effective and there otherwise wasn't a clear indication for one thus far, then it's time for a sleep study.

I am similarly averse to Z-drugs though will use them occasionally. However, I treat them as functional BZDs because they effectively are. To me, that means prescribing with the intent of short-term use and having a clear plan at the time of prescription to ultimately taper and discontinue the agent in short order. I also tell the patients the patients that this is my practice. If I think there's a significant risk of the medication being used for long-term (even if that's not the intent), I won't even offer it. If patients protest, I discuss that these medications are only indicated for short-term use, can result in withdrawal if used for long-term use, etc. etc.

 

[birchswing]

If this psychiatrist was regularly giving multiple benzos and stimulants to teenagers on first visits, was there anything anyone in the office could have done in terms of reporting him? Or at least not agreeing to work with him? How bad does it have to be for the state to step in if you did report it? In my mind those are abused children.

 

[downwithDTB]

My concern is not that I wouldn't be responsible and taper off the benzo/z drug, but that it so often becomes "the only thing that worked" and sets the patient off on a quest to have someone else prescribe it. It's not like I'm the the only doctor these folks will ever have.

 

[SpongeBob DoctorPants]

If this psychiatrist was regularly giving multiple benzos and stimulants to teenagers on first visits, was there anything anyone in the office could have done in terms of reporting him? Or at least not agreeing to work with him? How bad does it have to be for the state to step in if you did report it? In my mind those are abused children.

Fair questions. I think we all suspected he prescribed a lot of controlled meds because whenever the rest of us covered refill requests for his patients while he was out of the office, it was usually for Xanax or Adderall. None us really knew the extent of just how many of his patients got put on these meds until he left and now we are cleaning up the mess.

Speaking of children, I just addressed a med order request for a couple of pediatric patients he was treating. One was a 15-year-old on Adderall and Valium, and the other an 11-year-old on Adderall and Xanax. My first thought was, WTF?! Maybe, in rare circumstances, something like this might be appropriate for someone. But on almost every patient, including children? Obviously this doctor has some prescribing issues, but I don't really know how something like this could have been prevented unless someone was appointed to look over every provider's prescribing practices.

 

[SpongeBob DoctorPants]

My concern is not that I wouldn't be responsible and taper off the benzo/z drug, but that it so often becomes "the only thing that worked" and sets the patient off on a quest to have someone else prescribe it. It's not like I'm the the only doctor these folks will ever have.

This is also my concern. And when someone gets put on Xanax BID as the primary treatment for their anxiety, without trying antidepressants first... they are almost guaranteed to become one of those patients who say "nothing else works for me!"

 

[Armadillos]

Except that in almost every circumstance, these drugs become a lifetime prescription. Can't remember the last time in reviewing med histories of my patients that I actually saw a z-drug prescribed short term.

Those patients prescribed short term benzo or z drug don’t end up seeing neuropsychologists. In fact if you consider the overall outpatient psychiatric population probably approaching <1% of patients have seen a neuropsychologist.

Probably at least weekly I rx someone a predetermined short course of a benzo or Z drug, and I have yet to refill one that I told them on initial prescribing I wouldn’t. It really isn’t rocket science to say no to a refill request, but these meds really can be quite helpful and improve quality of life in short term.

 

[WisNeuro]

Those patients prescribed short term benzo or z drug don’t end up seeing neuropsychologists. In fact if you consider the overall outpatient psychiatric population probably approaching <1% of patients have seen a neuropsychologist.

That would assume that the population seeing a neuropsychologist would be qualitatively different than the patient population who sees general PCPs and/or psychiatry. I'm sure there are people out there who get short term scripts, but I would wager that they are the exception, rather than the rule.

 

[Mass Effect]

CBTi and where to go for that, but once declined:
Trazodone, doxepin, remeron, neurontin, are frequently used depending on nuances of patient.
Lesser so atarax or seroquel.

You'd rather give Seroquel than Ambien? Not me.

Also, I'm surprised you give benzos for ASD. I know the literature is a bit mixed, but I consider benzos in ASD to be as bad as benzos in PTSD.

 

[clausewitz2]

This is also my concern. And when someone gets put on Xanax BID as the primary treatment for their anxiety, without trying antidepressants first... they are almost guaranteed to become one of those patients who say "nothing else works for me!"

Xanax was originally studied as an antidepressant and is at least as effective as SSRIs for depression, so while I agree that leading with this is a bad idea and I share your negative countertransference when people say things like "nothing else works", some of them may be correct. Just hard to figure out who has benefits outweighing the downsides.

 

[clausewitz2]

You'd rather give Seroquel than Ambien? Not me.

Our big time sleep guru says he has put one person on Seroquel in 20+ years for sleep.

Yeah, this only makes sense from a very narrow medicolegal perspective. You'll get sued if your patient sleep-drives into a pond but not if they just get fat and diabetic.

 

[clausewitz2]

That would assume that the population seeing a neuropsychologist would be qualitatively different than the patient population who sees general PCPs and/or psychiatry. I'm sure there are people out there who get short term scripts, but I would wager that they are the exception, rather than the rule.

No idea how it is in your neck of the woods but at least in our system there is a huge selection bias that I am quite certain makes the neuropsych testing population different.

I have seen probably close to 1000 patients at this point and I have never met anyone who had neuropsych testing who was not a) a small child b) over 70 or c) had sustained multiple head traumas and sought care at a concussion clinic. This corresponds to the three neuropsychologists we actually have working for us.

Most general psychiatry patients don't fit into those categories.

 

[WisNeuro]

No idea how it is in your neck of the woods but at least in our system there is a huge selection bias that I am quite certain makes the neuropsych testing population different.

I have seen probably close to 1000 patients at this point and I have never met anyone who had neuropsych testing who was not a) a small child b) over 70 or c) had sustained multiple head traumas and sought care at a concussion clinic. This corresponds to the three neuropsychologists we actually have working for us.

Most general psychiatry patients don't fit into those categories.

Most general psychiatry patients don't eventually age into geriatric? Or have a stroke, or have MS, or epilepsy? Same population, just skewed towards when they are older, depending on the clinic and it is generalist or specific. I would say that the majority of my patients are also seeing a psychiatrist. When I was in the VA, it was almost all of them.

 

[Merovinge]

Xanax was originally studied as an antidepressant and is at least as effective as SSRIs for depression, so while I agree that leading with this is a bad idea and I share your negative countertransference when people say things like "nothing else works", some of them may be correct. Just hard to figure out who has benefits outweighing the downsides.

This is completely rubbish in children. There is good evidence for harm with BZDs in children related to abuse, diversion, overdose, and lack of efficacy as well as concerns for increasing later life substance abuse. AACAP literally has guidelines for community members to consider a second opinion if your child has been Rxed a BZD for >1 month.

http://www.aacap.org/app_themes/aacap/docs/press/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and_adolescents_2012.pdf

 

[clausewitz2]

Most general psychiatry patients don't eventually age into geriatric? Or have a stroke, or have MS, or epilepsy? Same population, just skewed towards when they are older, depending on the clinic and it is generalist or specific. I would say that the majority of my patients are also seeing a psychiatrist. When I was in the VA, it was almost all of them.

Right, I am sure the majority of your patients are seeing a psychiatrist, but a vanishingly small proportion of mine ever see a neuropsychologist or ever have any formal testing done. I am saying that your patients who see a psychiatrist are a smallish proper subset of the population of psychiatric.

Most general psychiatry patients are not geriatric when I see them and most of them do not have MS or epilepsy, no.

Also I assume people often get referred to you when they seem to be having memory and attentional issues, which, again, stacks the deck in favor of people on chronic benzos especially if they are not doing well on them.

So you are not seeing an unbiased sample is my point.

 

[clausewitz2]

This is completely rubbish in children. There is good evidence for harm with BZDs in children related to abuse, diversion, overdose, and lack of efficacy as well as concerns for increasing later life substance abuse. AACAP literally has guidelines for community members to consider a second opinion if your child has been Rxed a BZD for >1 month.

http://www.aacap.org/app_themes/aacap/docs/press/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and_adolescents_2012.pdf

Good to know. I would never give Xanax to a child (I am an adult person) but now I especially will not. Thanks for the guidelines!

 

[WisNeuro]

Right, I am sure the majority of your patients are seeing a psychiatrist, but a vanishingly small proportion of mine ever see a neuropsychologist or ever have any formal testing done. I am saying that your patients who see a psychiatrist are a smallish proper subset of the population of psychiatric.

Most general psychiatry patients are not geriatric when I see them and most of them do not have MS or epilepsy, no.

Also I assume people often get referred to you when they seem to be having memory and attentional issues, which, again, stacks the deck in favor of people on chronic benzos especially if they are not doing well on them.

So you are not seeing an unbiased sample is my point.

The incidence and prevalence of dementias would suggest a fairly wide swath of the general public who would be the ones referred to a general neuropsych clinic. Outside of a few specific referral sources, I would say that the patient population is fairly representative of the treatment seeking population as a whole. Good amount of overlap in this Venn diagram.

 

[Mass Effect]

Right, I am sure the majority of your patients are seeing a psychiatrist, but a vanishingly small proportion of mine ever see a neuropsychologist or ever have any formal testing done. I am saying that your patients who see a psychiatrist are a smallish proper subset of the population of psychiatric.

Most general psychiatry patients are not geriatric when I see them and most of them do not have MS or epilepsy, no.

Also I assume people often get referred to you when they seem to be having memory and attentional issues, which, again, stacks the deck in favor of people on chronic benzos especially if they are not doing well on them.

So you are not seeing an unbiased sample is my point.

This. Throughout residency, I could count the number of patients I saw who had neuropsych testing or seen a neuropsychologist on my hand. Outside a behavioral neurology/neuropsych clinic, most general psych patients have never had neuropsych testing. It isn't indicated in the majority of psychiatric illnesses.

 

[WisNeuro]

It isn't indicated in the majority of psychiatric illnesses.

It is not, but everyone with a psychiatric illness ages, just like the rest of us.

 

[Mass Effect]

The incidence and prevalence of dementias would suggest a fairly wide swath of the general public who would be the ones referred to a general neuropsych clinic. Outside of a few specific referral sources, I would say that the patient population is fairly representative of the treatment seeking population as a whole. Good amount of overlap in this Venn diagram.

What? Are you saying that the prevalence of dementia somehow translates into numbers for an outpatient general psychiatry population? Am I misunderstanding?

 

[Mass Effect]

It is not, but everyone with a psychiatric illness ages, just like the rest of us.

And? I see several schizophrenic patients who are in their 70s. It still doesn't mean I've sent them for neuropsych testing.

 

[WisNeuro]

What? Are you saying that the prevalence of dementia somehow translates into numbers for an outpatient general psychiatry population? Am I misunderstanding?

I do believe there is a misunderstanding. I am not saying that people are referred for a neuropsych eval due to their MH issue, I am saying that people with MH issues eventually turn into geriatric adults, where a majority of the referrals will be made.

 

[WisNeuro]

And? I see several schizophrenic patients who are in their 70s. It still doesn't mean I've sent them for neuropsych testing.

Never said all geriatric MH patients got testing, just that the referral base is generally a representative sampling. Even so, we are far afield of the original idea, which is that Z-drugs are rarely used and prescribed as intended.

 

[Mass Effect]

I do believe there is a misunderstanding. I am not saying that people are referred for a neuropsych eval due to their MH issue, I am saying that people with MH issues eventually turn into geriatric adults, where a majority of the referrals will be made.

But what does that have to do with @clausewitz2 saying that most of her patients (or the majority of general psych population) do not see a neuropsychologist? I'm so confused, but I guess it doesn't matter since this is far from the point of the thread at this point.

 

[WisNeuro]

But what does that have to do with @clausewitz2 saying that most of her patients (or the majority of general psych population) do not see a neuropsychologist? I'm so confused, but I guess it doesn't matter since this is far from the point of the thread at this point.

It has nothing to do with that, and that is not what I said. I never said most general psych patients would see a neurpsych, that's absurd. I said that my referral base is representative of that population in general. Mileage will vary depending on general vs specialty clinics.

 

[FlowRate]

It's been a while since my outpatient neuro subspecialty sub-I but I think a lot of Z drug use for insomnia is targeted at specific types of insomnia (early awakening, etc.) Sleep onset insomnia is best treated with CBT-i but very few patients actually engage in that, hence why we prescribe so many antihistamines/benzos/Z's (as a field.)

 

[the5thelement]

I found this from a search on google.

This BENZODIAZEPINE medication__________________________ is being used to manage or control symptoms of ____________________________________. My specific goals with this treatment are to _____________________________________________________________________________. I understand that the use of this medication can cause addiction and carries other risks such as drug interactions, sedation, confusion, poor memory, increased response time and impaired coordination which may increase the risk of motor vehicle accidents and falls. If I am over 65 years of age, I may be especially sensitive to these side-effects. In most situations, benzodiazepines are not recommended for use beyond 4-6 weeks. Given the risks associated with this class of medications, my doctor may reduce or safely stop prescribing benzodiazepines to me at any time during the course of my treatment based on how I respond to treatment and whether continued use could likely harm me. While on benzodiazepine medication, I agree to abide by the following conditions:

1. Receiving medications from a single prescriber. Dr.____________ will be the only doctor(s) who will prescribe the BENZODIAZEPINE medication_________________ for me. I will not seek to obtain benzodiazepines from any other prescriber. In case of a situation where I receive a BENZODIAZEPINE from another prescriber, I will notify my doctor as soon as possible.

2. Taking the medication as prescribed. I will take the medication at the dose and frequency ordered by my doctor. I will not increase the dose or frequency of my medication on my own. I understand that only a small supply of extra doses may be prescribed each month upon my doctor’s discretion. I agree to keep track of my use of these medications and how well they are working for me to share with my doctor at appointments, e.g. by maintaining a sleep diary.

3. NOT consuming other sedating medications or Alcohol with this medication. Use of benzodiazepines with other medications that may cause drowsiness such as opioid pain relievers (including non-prescription codeine) or with alcohol can be serious and life-threatening. Naloxone will not reverse the effects of benzodiazepine overdose. I will not combine my medication with other drugs without consulting my doctor first nor will I combine my benzodiazepine medication with alcohol.

4. NOT abruptly stopping my medication. Discontinuing benzodiazepines suddenly after extended use can cause potentially serious withdrawal symptoms. The likelihood of experiencing withdrawal can be reduced by tapering or gradually reducing the dose. I will consult with my doctor before stopping my medication to discuss a tapering plan.

5. Maintaining regular appointment attendance and participating in consultations. I understand that I need to be present at all appointments with my doctor. I must also be willing to fully participate in other treatments or consultations, such as psychotherapy, recommended by my doctor.

6. Receiving medications from a single pharmacy. I will fill my prescriptions at a single pharmacy of my choice which will be _________________________________________. If I decide to move to a different pharmacy, I will notify my doctor.

7. Storing and disposing of the medication safely. I will store my medications in a secure location at all times. I will not share or give my prescribed benzodiazepine medication to another person nor will I accept these medications from anyone else. If I have benzodiazepine medication remaining that I no longer need (e.g. in the case that my medication is discontinued or changed), I will take it to my pharmacy for safe disposal. I understand that I may not obtain an early refill or replacement supplies for lost medication.

8. Being responsible for medication supply and refilling on time. I will manage my medication supply by planning and booking my appointments in advance. If I run out of medication early (e.g. by missing an appointment or taking more than prescribed), extra doses may not be prescribed in which case I will have to wait until my next prescription is due. I will bring my pill bottles with any remaining pills of the medication to each appointment.

9. Complying with clinic adherence monitoring policies. I understand that my doctor may ask me for a urine drug screening sample or a count of my pills at any time. These measures are performed for all patients to improve the safety of prescribing benzodiazepines. Further refills/prescriptions will be tied to completion of requested screening.

10. Consent to share information with other health care professionals if medically necessary. I agree that my doctor has the authority to share information with other health professionals involved in my care if necessary. My pharmacy will be receiving a copy of this treatment agreement.

11. Termination of this agreement. If my doctor determines that the medication is causing me more harm than the relief it provides, my doctor has the right to discontinue my benzodiazepine medication in a safe way. I also acknowledge that I could lose my right to treatment from my doctor if I break any part of this agreement.

 

[Armadillos]

It has nothing to do with that, and that is not what I said. I never said most general psych patients would see a neurpsych, that's absurd. I said that my referral base is representative of that population in general. Mileage will vary depending on general vs specialty clinics.

Yeah but presumably folks having cognition issues bad enough to be referred to neuro psych testing are significantly more likely to be on chronic benzos than general psych patients because either A) the benzos are the thing causing the cognitive problems or B) benzos are trying to treat symptoms that were unknown to be from a dementia “prodrome”

No matter how you try to slice it, a neuropsychologist is not seeing a sample representative of a general psych practice.

This is relevant because your frequently quite critical of MDs in general in regards to benzos and anticholinergics, but your selection is incredibly biased. It would be like an oncologist complaining that in their experience PCPs don’t ever help anyone to quit smoking.

 

[WisNeuro]

Yeah but presumably folks having cognition issues bad enough to be referred to neuro psych testing are significantly more likely to be on chronic benzos than general psych patients because either A) the benzos are the thing causing the cognitive problems or B) benzos are trying to treat symptoms that were unknown to be from a dementia “prodrome”

No matter how you try to slice it, a neuropsychologist is not seeing a sample representative of a general psych practice.

This is relevant because your frequently quite critical of MDs in general in regards to benzos and anticholinergics, but your selection is incredibly biased. It would be like an oncologist complaining that in their experience PCPs don’t ever help anyone to quit smoking.

I think you have a skewed view of referral sources to general neuropsychology clinics and also what people are referred for.

 

[clausewitz2]

I think you have a skewed view of referral sources to general neuropsychology clinics and also what people are referred for.

I'm sure I have no idea what the overall population of your clinic looks like. I do know what a general adult psychiatry clinic population looks like in my neck of the woods and I know a vanishingly small proportion of them have ever undergone any formal psychological testing.

There is a very small chance your patients constitute an unbiased sample of my patients. I am not sure why this is controversial. Perhaps your system has the resources for much more widespread access and everyone gets tested who could benefit from it, in which case, fine, we operate on different clinical planets.

 

[Sushirolls]

I think you should read this more closely. When they start suggesting specific agents for insomnia in the very document you linked, first-line are the z-drugs and rameleton.

Z-drugs are better supported by published research than most of the drugs that are handed out like candy for this (e.g. trazodone).

I'm not saying everyone should get as much Ambien as they want but if you refuse to treat insomnia with z-drugs categorically you are kind of categorically refusing to treat insomnia if you are not personallly offering appropriate psychotherapy.

Anecdotally I can tell you that saying that z-drugs should not be prescribed in his presence is a really good way to make Daniel Buysse quite heated.

Recent discussion with a Sleep Med doc about meds for (chronic) insomnia: Person laughed, and said all of them have weak recommendations, and that I found the wrong article, had me sit down at a computer, pull up right on the AASM website the current recommendations. I guess the one I posted wasn't it. Go figure. There is no 'first line' med.

 

[clausewitz2]

Recent discussion with a Sleep Med doc about meds for (chronic) insomnia: Person laughed, and said all of them have weak recommendations, and that I found the wrong article, had me sit down at a computer, pull up right on the AASM website the current recommendations. I guess the one I posted wasn't it. Go figure. There is no 'first line' med.

That article is more of a summary of the 2017 paper than anything; look what the one and only citation is (spoiler - it's the paper you previously linked).

You are right that there is no first line in the sense of "SSRI or wellbutrin for MDD". The current recommendations do, while noting weak evidence all around, come out in favor of multiple z-drugs, doxepin, and surovexant while recommending AGAINST trazodone and melatonin.

The person I name-checked earlier up-thread who is quite insistent on the utility of z-drugs, properly used, as part of his clinical practice is the second author of this piece (and also an author of the previous guidelines). I can thus speak to the authorial intent at least partially. While Buysse certainly emphasizes psychological treatments wherever possible, a z-drug is certainly his first choice barring clear contraindications when it comes time to prescribe.

I think it's legitimate to disagree with expert guidelines and not slavishly follow them, but I think it is important to recognize when you are diverging from what some idealized specialist would do. I personally would need very strong evidence to justify refusing categorically to use something that such an idealized specialist would routinely turn to.

 

[Jules A]

This is also my concern. And when someone gets put on Xanax BID as the primary treatment for their anxiety, without trying antidepressants first... they are almost guaranteed to become one of those patients who say "nothing else works for me!"

I agree. It is stressful for the new prescriber and the patient during the taper, no matter how conservative. However unlike downwithDBT I'm not concerned they will seek care elsewhere as often happens. If I am not a good fit that is fine with me. I will encourage them to explore their options. As we all know there will always be someone else willing to write whatever.