Ideas for creating a clinic policy on controlled substances

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Specialists routinely turned to opioids for chronic pain and that's turned out super awesome.

Having read through a lot of the most recent guidelines, many the meta analysis argue that the NNT < NNH across benzos and benzo-agonists. Looking at their (sleep med society) recs and evidence for specific drugs, the benefits are generally "minimal" and the harms considered are only those from short term RTCs, not the known long term consequences of gaba agonists. All of the evidence is weak at best and only for short term use but doesn't account for whether "short term use" means that people in real life actually stop taking them. Finally, the primary end points are all sleep time/quality, but there is no evidence of benefit on the secondary effects of insomnia which is what we actually care about! In fact, for some of the drugs you're more likely to have daytime somnolence than on placebo (hi Belsomra). So you can't sleep? Let's make you extra tired!

Remember, even clinical specialists have an inherent conflict of interest. If you're a sleep specialist and don't have anything to prescribe for many of your patients, do you stay in business? Can you make the same living doing CBTi only?

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Specialists routinely turned to opioids for chronic pain and that's turned out super awesome.

Having read through a lot of the most recent guidelines, many the meta analysis argue that the NNT < NNH across benzos and benzo-agonists. Looking at their (sleep med society) recs and evidence for specific drugs, the benefits are generally "minimal" and the harms considered are only those from short term RTCs, not the known long term consequences of gaba agonists. All of the evidence is weak at best and only for short term use but doesn't account for whether "short term use" means that people in real life actually stop taking them. Finally, the primary end points are all sleep time/quality, but there is no evidence of benefit on the secondary effects of insomnia which is what we actually care about! In fact, for some of the drugs you're more likely to have daytime somnolence than on placebo (hi Belsomra). So you can't sleep? Let's make you extra tired!

Remember, even clinical specialists have an inherent conflict of interest. If you're a sleep specialist and don't have anything to prescribe for many of your patients, do you stay in business? Can you make the same living doing CBTi only?

"Short term use" can certainly mean "I am not going to prescribe them forever".

We need to be careful dismissing classes of medications based on a paucity of long term maintenance studies. This is a flaw in the evidence base of most psychiatric medications.

Why isn't sleep quality or sleep latency something we care about, exactly?
 
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Why should we care about sleep only unless there are a secondary consequences? Given that there is no consensus on the number of hours of sleep an individual "needs," getting a "right" amount should be titrated according to secondary sx like fatigue, concentration, mood, ect. If someone sleep more but has worse mood, more fatigue and impaired concentration, I would not call this a treatment success.

While we have minimal long term RTC data on many meds, we have decent retrospective data on many and in schizophrenia antipsychotics look darn good and across the board benzo agonists not as much, although I don't know about for insomnia specifically.

Person with OSA might start CPAP and have more conscious awakenings, delayed sleep onset and shorter overall duration of sleep, with increased mood, energy and fewer HA. This is a remarkable success. Person with onset insomnia who falls asleep marginally quicker and sleeps more hours with more fatigue. Success? Heck no. Unless you told me that they had some improvement in some major health outcome.
 
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Why isn't sleep quality or sleep latency something we care about, exactly?
Sleep time and sleep latency are not good proxies for sleep quality. Most of the medications used to induce sleep also cause potentially unhelpful changes in sleep structure. And nobody's going to approve putting everyone with insomnia on Xyrem.
 
Why should we care about sleep only unless there are a secondary consequences? Given that there is no consensus on the number of hours of sleep an individual "needs," getting a "right" amount should be titrated according to secondary sx like fatigue, concentration, mood, ect. If someone sleep more but has worse mood, more fatigue and impaired concentration, I would not call this a treatment success.

While we have minimal long term RTC data on many meds, we have decent retrospective data on many and in schizophrenia antipsychotics look darn good and across the board benzo agonists not as much, although I don't know about for insomnia specifically.

Person with OSA might start CPAP and have more conscious awakenings, delayed sleep onset and shorter overall duration of sleep, with increased mood, energy and fewer HA. This is a remarkable success. Person with onset insomnia who falls asleep marginally quicker and sleeps more hours with more fatigue. Success? Heck no. Unless you told me that they had some improvement in some major health outcome.

I mean, yes, obviously in anything in medicine you have to balance desired treatment effects and side effects. If a medication is causing more harm than good, stop that medication. Sleep is one of many things that affect quality of life, it does not strictly supercede everything else. We do know, however, that adequate and regular sleep is protective in a number of disorders and that especially in the elderly chronic insomnia significantly raises suicide risk.

It does strike me though that what you said about sleep could apply equally well to do someone's mood or anxiety. Anxiety in isolation will not kill you or seriously injure you, and neither will anhedonia. The vast majority of people with a mood disorder do not commit suicide or kill anyone else so why treat depression?

Antipsychotics at a population level probably decrease mortality but that is not much consolation to the person who has a sudden cardiac death due to their haldol. You also have studies like Wunderink et al 2008 that suggest that you might get better functional outcomes in the long run if you give people a chance to come off them when the acute phase as passed, though I am aware this is not a consistent finding. I don't tell every person diagnosed with schizophrenia that I meet that they coming off their meds might make sense and I do not tell them that they absolutely should stay on them forever. I in fact use clinical judgment, grounded in the evidence that exists, to figure out who should give it a shot and who probably shouldn't.

In the face of spotty evidence, you have to reason, and categorical prohibitions without exception are the opposite of reasoning (sit down, Kant)

Sleep time and sleep latency are not good proxies for sleep quality. Most of the medications used to induce sleep also cause potentially unhelpful changes in sleep structure. And nobody's going to approve putting everyone with insomnia on Xyrem.

Yes, they certainly are not. I was responding to a post that asserted sleep quality per se is not something we care about. And sometimes it is a struggle to get Xyrem for people with actual narcolepsy, let alone anyone else.
 
Yes, they certainly are not. I was responding to a post that asserted sleep quality per se is not something we care about. And sometimes it is a struggle to get Xyrem for people with actual narcolepsy, let alone anyone else.
I misread their post as being time to sleep onset and quantity (vs "quality") which is, to a degree, I think what they were trying to say. And it's not that those are unreasonable endpoints but isn't the idea of treating sleep disorders to make people feel less fatigued/sleepy/impaired during the day? If that endpoint isn't met, how much do those other metrics really matter?

TBH I can't recall if "sleep quality" has a precise definition in the sleep literature or if it's an overarching phrase with a bunch of more specific components (duration, onset, feeling rested in the morning, fragmentation/sleep stages/awakening/AHI).
 
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I believe one index sleep people use is the Pittsburgh Sleep Quality Index for research evaluation of quality.
 
I misread their post as being time to sleep onset and quantity (vs "quality") which is, to a degree, I think what they were trying to say. And it's not that those are unreasonable endpoints but isn't the idea of treating sleep disorders to make people feel less fatigued/sleepy/impaired during the day? If that endpoint isn't met, how much do those other metrics really matter?

TBH I can't recall if "sleep quality" has a precise definition in the sleep literature or if it's an overarching phrase with a bunch of more specific components (duration, onset, feeling rested in the morning, fragmentation/sleep stages/awakening/AHI).

I agree with you, that is the endpoint that matters. And for medications that can demonstrably improve things we can measure fairly objectively, and that some people report qualitative benefits from of the kind we are talking about, all I am saying is that what this entails is that a fair amount of the time will be reasonable to prescribe short term z-drugs if you are trying to treat chronic insomnia. A fairly limited claim!
 
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.

I would probably agree. My current area has a particularly high population of boarded neuropsychs, particularly in the adult realm. We have a dearth of peds providers, but that's another story.
 
I’ve got to say by the time I got to the end of this thread I forgot what the original topic was.
 
So on my schedule today I'm seeing an adolescent female who was previously treated by the doctor who left our practice, and she's currently on two SSRIs (Prozac 20 mg and Zoloft 150 mg daily), lithium 300 mg nightly, two benzodiazepines (Xanax 1 mg bid and Restoril 45 mg nightly), two hypnotics (Ambien 10 mg nightly and Ambien CR 12.5 mg nightly), and a stimulant (Adderall 30 mg bid).

As far as I can tell from the notes, three years ago she was only on the Prozac, and since then (mostly in the past 2 years) all the others were added. I checked the state database and verified that she has been filling the controlled meds every single month. There is just so much wrong with this patient's medication regimen I don't know where to begin. She is likely dependent on the benzos and hypnotics at this point, so it will take a while to work off of those. Honestly I don't know how anyone could function on 45 mg of Restoril and 22.5 mg of Ambien every night, plus 2 mg of Xanax everyday. Maybe that's why the Adderall was added...
 
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So on my schedule today I'm seeing an adolescent female who was previously treated by the doctor who left our practice, and she's currently on two SSRIs (Prozac 20 mg and Zoloft 150 mg daily), lithium 300 mg nightly, two benzodiazepines (Xanax 1 mg bid and Restoril 45 mg nightly), two hypnotics (Ambien 10 mg nightly and Ambien CR 12.5 mg nightly), and a stimulant (Adderall 30 mg bid).

As far as I can tell from the notes, three years ago she was only on the Prozac, and since then (mostly in the past 2 years) all the others were added. I checked the state database and verified that she has been filling the controlled meds every single month. There is just so much wrong with this patient's medication regimen I don't know where to begin. She is likely dependent on the benzos and hypnotics at this point, so it will take a while to work off of those. Honestly I don't know how anyone could function on 45 mg of Restoril and 22.5 mg of Ambien every night, plus 2 mg of Xanax everyday. Maybe that's why the Adderall was added...

Sadly I would imagine we have all seen something along these lines and I continue to wonder at what point does it become appropriate to contact the board? This regimen is egregious made even more disconcerting due to the patients age.
 
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Sadly I would imagine we have all seen something along these lines and I continue to wonder at what point does it become appropriate to contact the board? This regimen is egregious made even more disconcerting due to the patients age.
I have started to wonder about that, too, given that I have inherited a number of patients now, particularly children, on benzodiazepines and stimulants, as well as multiple SSRIs, etc. Knowing what I know now, I personally would not recommend going to this physician, but at what point does it become appropriate to contact the board? While his prescribing practices may be rather unusual, I doubt it would be enough to affect his licensure.

After meeting with the patient and her mother today, however, I was somewhat relieved when I learned she isn't actually taking the Ambien and Restoril together, but rather takes one for a couple of weeks and then switches to the other when it loses effectiveness; apparently she has had some rather difficult-to-treat insomnia and this is working for her. Also, she isn't actually taking the Ambien CR but only uses the regular Ambien. I was left wondering, though, why they were filling each of these meds for a 30-day quantity every month, and mom said it was because the pharmacy had them on auto-refill.... so I guess they have a bunch of extras now, including the Ambien CR which she doesn't even take. :shrug: I also educated them about the risk of dependence from using Xanax on a daily basis long term, and they were reportedly never told about this before. At least they were agreeable to having her gradually taper off, though naturally there is some anxiety about doing so. Oh, and regarding the Adderall... she had been diagnosed with ADHD and this medication helped with her focus, but it seems that the inattentive symptoms didn't really begin until age 15 or so, when she was terribly depressed and her grades started falling; previous to that point she had always been a straight A student, so I doubt it's really ADHD. Now that her mood is stable, I am hoping her concentration will naturally improve as I taper her off Xanax and maybe she won't need the Adderall much longer, either.
 
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I've never been to England, but knowing what I know about the NHS, I would imagine things like this don't happen there too often.

The reason I think that is they seem to practice rather rubric-based medicine. It seems by unfailingly abiding my certain guidelines and having universal care people on the average have better outcomes but perhaps in more exotic cases appropriate treatment is denied. I've had a couple of British expatriates as doctors and found them unpleasant and used to systems in which they could treat patients rather perfunctorily (both were elderly and I assume came to the US after long stints in the UK to goose up their savings before a very late retirement). Bedside manner was not their forte, and from what I've read that's par for the course in the NHS.

It seems that in the US, more creativity is allowed. But some of the creativity looks more like finger-painting (as evidenced in this thread and my own experience) than it does like the Sistine Chapel.

So it raises the question of whether these proposed policies not be clinic based but nationalized?

It also raises the question of whether group knowledge is more intelligent than individual knowledge. The results could vary based on whether you look at the aggregate or edge cases. And if group knowledge is more intelligent than individual knowledge and prescribing is a matter of following a rubric, what is the purpose of the doctor's expertise?

Of course, poorly following a rubric could also lead a very non-thinking doctor to some of these "finger-painting" messes unless there is a system in place to override an inability to follow the intent of the document. I mean by that if you had poor comprehension it might be possible to use some sort of guideline for treatment to find that a particular patient had many different mental illnesses and provide treatment for all of them.
 
I have started to wonder about that, too, given that I have inherited a number of patients now, particularly children, on benzodiazepines and stimulants, as well as multiple SSRIs, etc. Knowing what I know now, I personally would not recommend going to this physician, but at what point does it become appropriate to contact the board? While his prescribing practices may be rather unusual, I doubt it would be enough to affect his licensure.

After meeting with the patient and her mother today, however, I was somewhat relieved when I learned she isn't actually taking the Ambien and Restoril together, but rather takes one for a couple of weeks and then switches to the other when it loses effectiveness; apparently she has had some rather difficult-to-treat insomnia and this is working for her. Also, she isn't actually taking the Ambien CR but only uses the regular Ambien. I was left wondering, though, why they were filling each of these meds for a 30-day quantity every month, and mom said it was because the pharmacy had them on auto-refill.... so I guess they have a bunch of extras now, including the Ambien CR which she doesn't even take. :shrug: I also educated them about the risk of dependence from using Xanax on a daily basis long term, and they were reportedly never told about this before. At least they were agreeable to having her gradually taper off, though naturally there is some anxiety about doing so. Oh, and regarding the Adderall... she had been diagnosed with ADHD and this medication helped with her focus, but it seems that the inattentive symptoms didn't really begin until age 15 or so, when she was terribly depressed and her grades started falling; previous to that point she had always been a straight A student, so I doubt it's really ADHD. Now that her mood is stable, I am hoping her concentration will naturally improve as I taper her off Xanax and maybe she won't need the Adderall much longer, either.

Our controlled registry program has a button when you’re checking history to “report suspicious prescribing” or something similar. Not sure where the reports go.

This regimen is at least 2 standard deviations from the mean on a bell shaped curve.
 
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With younger patients you will likely get less push back when attempting to address the frivolous polypharm so thats a plus. When I see two SSRIs or SSRI with SNRI unless in the case of a taper or the few skilled psychiatrists I know I generally figure the former prescriber sucked. I have only maintained one patient on a combo of Effexor 187.5mg and Lexapro at 2.5mg which I loathe but they have repeatedly failed at discontinuing the Lexapro or increasing Effexor to maximize. They have however recently gotten a great therapist and I suspect that as their anxiety and personality vulnerabilities reduce we can lose the Lexapro.
 
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With younger patients you will likely get less push back when attempting to address the frivolous polypharm so thats a plus. When I see two SSRIs or SSRI with SNRI unless in the case of a taper or the few skilled psychiatrists I know I generally figure the former prescriber sucked. I have only maintained one patient on a combo of Effexor 187.5mg and Lexapro at 2.5mg which I loathe but they have repeatedly failed at discontinuing the Lexapro or increasing Effexor to maximize. They have however recently gotten a great therapist and I suspect that as their anxiety and personality vulnerabilities reduce we can lose the Lexapro.
Yes, I agree it should be very rare for someone to be on two SSRIs or an SSRI and an SNRI long term. Interestingly, I actually inherited another pediatric patient recently who was on two SSRIs (I believe it was Prozac and Lexapro), and when I mentioned to the patient and her mother that this was a rather unusual medication combination, the mother stated, "Yes, we know! The pharmacist says that to us every time we pick up the meds." When I asked why she was still taking both of them together, the mother said they had that conversation with the previous prescriber, and he told her, "It's working, isn't it?" They were fine with me discontinuing the medication which was at the lower dose and increasing the other if needed.

In the case of the patient I described earlier, I was told that she was initially on Prozac, which was raised to 40 mg but at that dose her symptoms worsened, so it was lowered to 20 mg and Zoloft was added, which was eventually raised to 150 mg. She has never tried taking only Zoloft, or raising it up to 200 mg. In this case the patient and mother were rather worried about tapering off the Prozac, but I explained that it will be part of my treatment plan.
 
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I have started to wonder about that, too, given that I have inherited a number of patients now, particularly children, on benzodiazepines and stimulants, as well as multiple SSRIs, etc. Knowing what I know now, I personally would not recommend going to this physician, but at what point does it become appropriate to contact the board? While his prescribing practices may be rather unusual, I doubt it would be enough to affect his licensure.

After meeting with the patient and her mother today, however, I was somewhat relieved when I learned she isn't actually taking the Ambien and Restoril together, but rather takes one for a couple of weeks and then switches to the other when it loses effectiveness; apparently she has had some rather difficult-to-treat insomnia and this is working for her. Also, she isn't actually taking the Ambien CR but only uses the regular Ambien. I was left wondering, though, why they were filling each of these meds for a 30-day quantity every month, and mom said it was because the pharmacy had them on auto-refill.... so I guess they have a bunch of extras now, including the Ambien CR which she doesn't even take. :shrug: I also educated them about the risk of dependence from using Xanax on a daily basis long term, and they were reportedly never told about this before. At least they were agreeable to having her gradually taper off, though naturally there is some anxiety about doing so. Oh, and regarding the Adderall... she had been diagnosed with ADHD and this medication helped with her focus, but it seems that the inattentive symptoms didn't really begin until age 15 or so, when she was terribly depressed and her grades started falling; previous to that point she had always been a straight A student, so I doubt it's really ADHD. Now that her mood is stable, I am hoping her concentration will naturally improve as I taper her off Xanax and maybe she won't need the Adderall much longer, either.

I don't know about reporting to the board (I'd be tempted to, but hate to have someone's licensure, should it be in jeopardy, on my shoulders), but I would be tempted to pick up the phone and talk to the prescriber myself and ask for details about how they got there.

I also wonder in a patient like this how beneficial it would be to taper everything (not at once), but have a treatment goal of a complete wash-out so you can appropriately add back what, if anything, she actually needs rather than what is being prescribed to treat side effects from other meds.
 
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