Inheriting patients on not the greatest meds..........

[futuredo32]

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One of the local psychiatrists opted to end her private practice and referred about 10 med management patients to me. I didn't know her personally. She had a good reputation by everything I have heard. I read the other thread about sleep meds and I do try sleep hygiene first but will prescribe sleepers pretty often if that is a significant problem.

Her patients that I got have been seeing her on average for 10 or more years. They are pretty much all on benzos to sleep (not something I prescribe for sleep) and one severely depressed patient who has missed 5 appointments because he "couldn't" come is on several stimulants and benzos and multiple sleep meds and has been for 20 years. He won't see a therapist, he does snore and has the body of someone likely to have OSA. I keep ordering a sleep study but he "can't" go. He is the worst case of the patients I have inherited from this psychiatrist, but I NEVER would have put these patients on benzos to sleep and this particular patient I mentioned, no wonder he needs psychostimulants to stay awake, he takes so many sleepers or vice versa. I have seen most just once and suggested med changes but they are all "sure" that this Dr who closed her practice was the miracle doctor who "cured" them when no one else could and all are totally opposed to med changes. I am just like WTF do I do? These patients have been stable on these meds for usually 10 years plus but ....................... I don't feel comfortable continuing them especially the patient with suspected OSA.
I try really hard to work WITH my patients and not dictate. I don't know how to work WITH these patients. They are all so stuck on not making any med changes. A lot are overly sedated when I see them (on Ambien Trazodone and Mirtazapine for a few) but otherwise "stable" for them. What to do? I tried motivational interviewing and they are just so used to the former psychiatrist and their usual regimen.

 

[erg923]

One of the local psychiatrists opted to end her private practice and referred about 10 med management patients to me. I didn't know her personally. She had a good reputation by everything I have heard. I read the other thread about sleep meds and I do try sleep hygiene first but will prescribe sleepers pretty often if that is a significant problem.

Her patients that I got have been seeing her on average for 10 or more years. They are pretty much all on benzos to sleep (not something I prescribe for sleep) and one severely depressed patient who has missed 5 appointments because he "couldn't" come is on several stimulants and benzos and multiple sleep meds and has been for 20 years. He won't see a therapist, he does snore and has the body of someone likely to have OSA. I keep ordering a sleep study but he "can't" go. He is the worst case of the patients I have inherited from this psychiatrist, but I NEVER would have put these patients on benzos to sleep and this particular patient I mentioned, no wonder he needs psychostimulants to stay awake, he takes so many sleepers or vice versa. I have seen most just once and suggested med changes but they are all "sure" that this Dr who closed her practice was the miracle doctor who "cured" them when no one else could and all are totally opposed to med changes. I am just like WTF do I do? These patients have been stable on these meds for usually 10 years plus but ....................... I don't feel comfortable continuing them especially the patient with suspected OSA.
I try really hard to work WITH my patients and not dictate. I don't know how to work WITH these patients. They are all so stuck on not making any med changes. A lot are overly sedated when I see them (on Ambien Trazodone and Mirtazapine for a few) but otherwise "stable" for them. What to do? I tried motivational interviewing and they are just so used to the former psychiatrist and their usual regimen.

Who the **** needs psychiatry for sleep problems for 10 years?! Therapy and sleep med specialist, my god.

 

[futuredo32]

Who the **** needs psychiatry for sleep problems for 10 years?! Therapy and sleep med specialist, my god.

I have no issue with the sleep meds in general. I have had insomnia forever, residency made it worse, I take sleepers and have since 2010 and my life is much improved. And I see a therapist . It's the AMOUNT and the fact that they are benzos. I have just never inherited patients on such a bad polypharmacy and so many at once and the fact that they are so close minded to change and for me to have like 10 patients all the same I am feeling overwhelmed. In residency I saw a lot of patients on sleepers for years. I know some don't prescribe sleepers ever, some for a short time and some indefinitely. I am just not used to getting patients on what I consider a bad combo of meds and SO resistant to change.

 

[tr]

One of the local psychiatrists opted to end her private practice and referred about 10 med management patients to me. I didn't know her personally. She had a good reputation by everything I have heard. I read the other thread about sleep meds and I do try sleep hygiene first but will prescribe sleepers pretty often if that is a significant problem.

Her patients that I got have been seeing her on average for 10 or more years. They are pretty much all on benzos to sleep (not something I prescribe for sleep) and one severely depressed patient who has missed 5 appointments because he "couldn't" come is on several stimulants and benzos and multiple sleep meds and has been for 20 years. He won't see a therapist, he does snore and has the body of someone likely to have OSA. I keep ordering a sleep study but he "can't" go. He is the worst case of the patients I have inherited from this psychiatrist, but I NEVER would have put these patients on benzos to sleep and this particular patient I mentioned, no wonder he needs psychostimulants to stay awake, he takes so many sleepers or vice versa. I have seen most just once and suggested med changes but they are all "sure" that this Dr who closed her practice was the miracle doctor who "cured" them when no one else could and all are totally opposed to med changes. I am just like WTF do I do? These patients have been stable on these meds for usually 10 years plus but ....................... I don't feel comfortable continuing them especially the patient with suspected OSA.
I try really hard to work WITH my patients and not dictate. I don't know how to work WITH these patients. They are all so stuck on not making any med changes. A lot are overly sedated when I see them (on Ambien Trazodone and Mirtazapine for a few) but otherwise "stable" for them. What to do? I tried motivational interviewing and they are just so used to the former psychiatrist and their usual regimen.

Whatever you do, do *not* give them the impression you will be willing to continue this regimen. Once you've been providing it for a while you will be really stuck to explain why you need to make a change.

If you've already MI'ed them and they are not coming around, just make your boundaries clear in a gentle and empathetic way.

Say that you do not prescribe benzos or sleepers for chronic use under any circumstances. You care a lot about your patients' well-being and you want to make sure they are receiving the gold standard treatment for their insomnia. You also want to make sure and protect them from the long-term negative effects of chronic benzo use, like tolerance, dependence, and increased dementia risk. You are referring them to a great [sleep medicine doctor, CBTi therapist] and you are going to wean them off their benzos very slowly to make the transition easy. You know that these medications have been really helpful in the short term and you understand that it is hard to let them go, but at the same time you care about them too much to keep them on these ultimately dangerous and unhelpful medications.

Then, every time you refill their benzo prescription, cut it down by 5 pills. No early refills. Whether they've been to clinic or not. It will take months to get them off but if you are consistent with it they will eventually either be off the benzo, or will have found another source in which case it is not your problem anymore.

 

[futuredo32]

Thanks. Again I DO prescribe chronic sleepers. I know some don't, get a room of ten psychiatrists and I have often seen ten different opinions. I was initially grateful for the referrals, but had I known............ I will keep working with them. I don't mind a reasonable amount of sleepers but not this quantity and not benzos. I am used to my patients either being psychotropic naïve or on a reasonable regimen or at least not so dead set against change.

 

[tr]

Thanks. Again I DO prescribe chronic sleepers. I know some don't, get a room of ten psychiatrists and I have often seen ten different opinions. I was initially grateful for the referrals, but had I known............ I will keep working with them. I don't mind a reasonable amount of sleepers but not this quantity and not benzos. I am used to my patients either being psychotropic naïve or on a reasonable regimen or at least not so dead set against change.

OK well tell them your boundaries. If you are OK with chronic trazodone but not chronic Klonopin, tell them so and cross-taper them. Don't prescribe anything you're not comfortable with just because the patient expects it. If they hate you for it and leave, so much the better for you, they are no longer your problem.

 

[SeniorWrangler]

The sooner you address it, the better, the longer you've gone along with something, the more upset people will be when you try to change it. I suggest creating a letter to give or mail to all of these patients outlining your concerns and taper plan and sharing it with them ASAP so they will have time to either get used to the idea or find a new prescriber.

 

[Crayola227]

so resistant to change... lol

doesn't that describe most patients??

sounds like you're making a transition from residency to attendinghood to boot

 

[TexasPhysician]

You won’t find a consensus report on this. Handle it however you find appropriate.

Personally I think benzos are fine prn sleep issues, especially over mirtazepine, quetiapine, etc.

 

[WisNeuro]

Personally I think benzos are fine prn sleep issues, especially over mirtazepine, quetiapine, etc.

I think more of the issue is that I never see an actual PRN prescription for this. It simply turns into maintenance benzos. At least by the time they get to me.

 

[thoffen]

You won’t find a consensus report on this. Handle it however you find appropriate.

Personally I think benzos are fine prn sleep issues, especially over mirtazepine, quetiapine, etc.

I agree with this. Personally, my issue generally is treating chronic sleep problems with an acute sleep treatment. Usually doing that deepens the sleep disorder. And I don't believe in sleep hygiene itself being sufficient for chronic insomnia. So most of the time I try to get people to do CBT-I (usually online) which people seem to never actually bite the bullet and do, yet people often end up sleeping better. Part of it is I don't simply tell them it's the right treatment. I explain why they have a chronic sleep problem and meds are an inappropriate treatment, and I explain to them (briefly) how CBT-I works. It helps that I've done it before in residency under the supervision of someone who did research in it. Either someone acknowledging their frustrations with insomnia and prior medical care for it or helping someone feel a sense of agency in their sleep habits tends to make a big difference regardless of actually doing CBT-I. Either that or they feel guilty because they aren't following my recommendation and know I'm not gonna throw more medicine at the problem. 🙂

In general, when inheriting a stable but symptomatic patient on a problematic regimen, I usually don't make changes up front. I think most people need a transitional space between a provider that was helpful and a new person that might or might not be helpful. Sometimes, also, I made a change without really having the right assessment. There is definitely the risk of someone continuing on the same bad regimen indefinitely because the confrontation never happens. I try to have discussions about why I don't like the current treatment plan and try to collaborate on what the eventual treatment plan should be and work with them toward that direction. I agree with simply making slow decreases in dose or quantity over time. This is when someone is not currently experiencing significant harm or risk but the treatment has potential harms or risks or lack of benefit in the long-term.

Definitely, though, sometimes someone is at more significant risk from the regimen they are on. If the regimen is absolutely unsafe, I think hospitalization/PHP/IOP should be explored. If more risky than unsafe, I'd offer either a more aggressive outpatient taper or assistance in finding a new provider.

 

[TexasPhysician]

I think more of the issue is that I never see an actual PRN prescription for this. It simply turns into maintenance benzos. At least by the time they get to me.

Physicians with higher volume per hour may find it easier to just Rx than spend the time providing good sleep hygiene. A good plan would be to initiate the counseling referral initially. When it gets to be a problem, I’ve even required the Rx to be contingent on following through on a plan of regular counseling for sleep hygiene. Otherwise, patients may have no motivation for change.

 

[OldPsychDoc]

I think you can try to sell this with patients as "ok, we're just meeting, but this is a good time to take a fresh look at things with a new set of eyes..."
Part of your assessment is then to figure out what meds are being prescribed for which issues, where the patient is willing to flex or not, etc., offer a little more diagnostic clarity--as in all those poor bipolar 2s who need psychoeducation about borderline PD, etc...

 

[Attending1985]

I agree with the approach of not making any drastic changes or being putative initially. In these situations the patients can be seen as victims. They were given care that was crappy by a doctor they trusted. And we all know that coming off of these medications sucks. I've found that some of these patients will end up being collaborative if they feel safe.

 

[erg923]

True clinical insomnia without some co morbid psych condition sig influencing it is rare, according to lit. Whats psychiatric disorder is not being treated adequately and why...would be my first question. Is there even basic adherence to sleep hygiene? If not, why?

 

[futuredo32]

so resistant to change... lol

doesn't that describe most patients??

sounds like you're making a transition from residency to attendinghood to boot

That was rude and not helpful. Thank you to the rest of you very much. Perhaps that describes most of your patients but not mine.

I graduated in 2015 and went straight to pp because I wanted to continue to be able to do psychotherapy.
These are much different than my other patients. These patients are expecting me to be the prior psychiatrist because they saw her for so long and it appears they idealized her, I guess it is just overwhelming because I haven't had this situation in the past and most of my patients are therapy/med management patients. I didn't make any changes on the initial visit as they were also dealing with losing their long time psychiatrist who seemed to tell them therapy was useless according to the consensus when I suggested it. I am usually really good with developing a good rapport with most patients fast and again I work WITH them which they seem to appreciate. I do quite a bit of therapy and offer to see them for therapy if I feel we have a good rapport or refer out, but not all patients are willing, not all can afford the copay for therapy, it would be a choice between eating or going to therapy and for these patients I waive their copay. I work in an odd area where there a lot of wealthy patients and a lot of poor patients and some travel an hour due to lack of providers in their area. A lot do shift work. Some are college students and can't resist the urge to cram for an exam, I think we can mostly all relate to this. Some live in dorms with noisy room mates.
It's Metro Detroit Michigan and a lot work in the auto industry where shift work is common and sleep hygiene isn't possible for a lot of aspects ie going to bed at the same time nightly waking up at the same time each morning. Some have kids that wake them during the night. Some have spouses that wake them due to their work schedules. Some are working a ton of hours to make ends meet and with the hours of all the jobs changing they can't have a regular bed time. And sleep issues are common in so many mental illnesses. The vast majority of my patients really like me and many of the patients I have are referrals from current patients which says a lot, IMO. Working with my patients and getting them to change has not been an issue too much in the past because again I work WITH them. I spend a lot of time on psychoeducation. I don't do 15 minute med checks, they are all at least 25 minutes with some therapy and again, psychoeducation. I don't push therapy, I will suggest it,sometimes turn their med appointment into a therapy session or psychoeducation session and often they become therapy patients after I explain that their med appointment was partly a therapy session. Other patients would benefit from therapy but refuse. Sometimes over time they change their mind, sometimes not. I am not a CMH and don't force people to have therapy in order to get medications. I would love it if they all were in therapy, most are either in therapy with me or another therapist. But not these new patients, they are very against therapy.
And again insomnia is part of so many psych diseases, treating the insomnia until they are in remission is necessary and some only reach partial remission. It's not my style to force them to do anything to get medication. I don't want to push them off on someone else, I wanted ideas on how to get them on a better regimen and I got a lot of good ideas as most responses were quite helpful.
Thank you for your thoughtful and insightful comments.

 

[futuredo32]

You won’t find a consensus report on this. Handle it however you find appropriate.

Personally I think benzos are fine prn sleep issues, especially over mirtazepine, quetiapine, etc.

I usually prescribe Ambien. Short term benzos often lead to middle insomnia was something that came up a lot during residency.

 

[futuredo32]

I think you can try to sell this with patients as "ok, we're just meeting, but this is a good time to take a fresh look at things with a new set of eyes..."

I like this, I am going to steal this quote if you don't mind 🙂.

 

[TexasPhysician]

I usually prescribe Ambien. Short term benzos often lead to middle insomnia was something that came up a lot during residency.

I find that is more theoretical than practical. Hypnotics have the same dementia risks as benzos in my reading with added risks of sleep walking/driving. I use a lot more benzos than Ambien.

Just my 2 cents.

 

[futuredo32]

I find that is more theoretical than practical. Hypnotics have the same dementia risks as benzos in my reading with added risks of sleep walking/driving. I use a lot more benzos than Ambien.

Just my 2 cents.

That is just what I have found and seen during residency. I guess with Klonopin it wouldn't be an issue. I educate my patients on each and everyone of the potential side effects of all new medications and how to take them and have them repeat it back to me. Most don't like trazodone due to the sleep hangover and mirtazapine for the same reason plus weight gain. Ambien tends to leave patients wake up feeling awake and refreshed. Perhaps it happens but I have yet to encounter a patient asking for higher doses of Ambien unlike benzos. Thanks again for the helpful advice to all.

 

[Crayola227]

That was rude and not helpful. Thank you to the rest of you very much. Perhaps that describes most of your patients but not mine.

I graduated in 2015 and went straight to pp because I wanted to continue to be able to do psychotherapy.
These are much different than my other patients. These patients are expecting me to be the prior psychiatrist because they saw her for so long and it appears they idealized her, I guess it is just overwhelming because I haven't had this situation in the past and most of my patients are therapy/med management patients. I didn't make any changes on the initial visit as they were also dealing with losing their long time psychiatrist who seemed to tell them therapy was useless according to the consensus when I suggested it. I am usually really good with developing a good rapport with most patients fast and again I work WITH them which they seem to appreciate. I do quite a bit of therapy and offer to see them for therapy if I feel we have a good rapport or refer out, but not all patients are willing, not all can afford the copay for therapy, it would be a choice between eating or going to therapy and for these patients I waive their copay. I work in an odd area where there a lot of wealthy patients and a lot of poor patients and some travel an hour due to lack of providers in their area. A lot do shift work. Some are college students and can't resist the urge to cram for an exam, I think we can mostly all relate to this. Some live in dorms with noisy room mates.
It's Metro Detroit Michigan and a lot work in the auto industry where shift work is common and sleep hygiene isn't possible for a lot of aspects ie going to bed at the same time nightly waking up at the same time each morning. Some have kids that wake them during the night. Some have spouses that wake them due to their work schedules. Some are working a ton of hours to make ends meet and with the hours of all the jobs changing they can't have a regular bed time. And sleep issues are common in so many mental illnesses. The vast majority of my patients really like me and many of the patients I have are referrals from current patients which says a lot, IMO. Working with my patients and getting them to change has not been an issue too much in the past because again I work WITH them. I spend a lot of time on psychoeducation. I don't do 15 minute med checks, they are all at least 25 minutes with some therapy and again, psychoeducation. I don't push therapy, I will suggest it,sometimes turn their med appointment into a therapy session or psychoeducation session and often they become therapy patients after I explain that their med appointment was partly a therapy session. Other patients would benefit from therapy but refuse. Sometimes over time they change their mind, sometimes not. I am not a CMH and don't force people to have therapy in order to get medications. I would love it if they all were in therapy, most are either in therapy with me or another therapist. But not these new patients, they are very against therapy.
And again insomnia is part of so many psych diseases, treating the insomnia until they are in remission is necessary and some only reach partial remission. It's not my style to force them to do anything to get medication. I don't want to push them off on someone else, I wanted ideas on how to get them on a better regimen and I got a lot of good ideas as most responses were quite helpful.
Thank you for your thoughtful and insightful comments.

guess you can't take a joke... about your patients

the comment "sounds like you're making a transition" was meant to say that I empathize with this being more difficult than your residency, and I wasn't trying to take a big shot at you

sure, I guess I was also ribbing you a little

loosen up

 

[DisorderedDoc417]

You won’t find a consensus report on this. Handle it however you find appropriate.

Personally I think benzos are fine prn sleep issues, especially over mirtazepine, quetiapine, etc.

I'm curious why you would go to a benzo before mirtazapine. I suppose I wouldn't consider it unless the patient was also suffering from depression, but would like to know your reasoning if you don't mind! Best.

 

[splik]

I love benzos, they are amongst the most effective drugs we have in psychiatry when used judiciously but it's a drag dealing with pts who are hooked on benzos even though it has not actually "cured" their problem but they insist on staying on them. Thankfully I don't treat patients anymore but I used to have patients on long-term benzos (all who came to me on these) sign the following contract (please feel free to use).:


I have discussed the following with my physician and read and understand that:

1. Benzodiazepines are not recommended for the long term treatment of anxiety disorder or insomnia;


2. The first line treatment for anxiety disorders is psychotherapy such as cognitive-behavior therapy aimed at teaching skills of acceptance, relaxation, recognizing triggers to anxiety, and challenging negative and distorted thoughts


3. The recommended drug treatment of anxiety disorders includes non-benzodiazepines such as fluoxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine, mirtazapine and gabapentin

4. There is no evidence supporting the use of benzodiazepines for longer than 2 to 4 weeks’ duration;


5. Benzodiazepines may worsen the long-term use course of anxiety and worsen my anxiety and sleep problems;


6. Benzodiazepines cause tolerance needing higher and higher doses to maintain the same effects;


7. Withdrawal symptoms can occur with missed doses or even at the same dose of medication I take. This can include severe anxiety, panic attacks, worsening depression, psychosis, seizures, and even death. Acute withdrawal from benzodiazepines is a potentially life-threatening consequence and can occur even if I am taking the drug as prescribed by my physician.;


8. Benzodiazepines are associated with an increased risk of death from all-causes. People who use benzodiazepines long-term die earlier than those who do not;


9. Benzodiazepines may impair my ability to drive or operate heavy machinery. I may be more at risk of accidents as a result of driving while using benzodiazepines.;


10. Benzodiazepines have been associated with dementia and may accelerate the onset of dementia. Even in people who do not develop dementia, benzodiazepines can cause problems with memory and concentration

I understand the following conditions for continued prescribing of benzodiazepines and that failure to meet these requirements will lead to being tapered of these drugs:

I will attend regular follow-up appointments to monitor my progress and review my treatment

I will not get refills on my medications without regular follow up appointments

Lost or stolen prescriptions will not be refilled without a police report

There will be no early refills

I will not share my prescription with others

I will not sell my benzodiazepines for other drugs

I will not attempt to obtain benzodiazepines from other providers outside this clinic or on the street

I will take all my medications as recommended and prescribed

I will have any random or routine drug testing required to assess my ongoing use of benzodiazepines and that I am not abusing other drugs that may be harmful to my health

 

[TexasPhysician]

I'm curious why you would go to a benzo before mirtazapine. I suppose I wouldn't consider it unless the patient was also suffering from depression, but would like to know your reasoning if you don't mind! Best.

Metabolic effects combined with lack of FDA approval.

 

[TexasPhysician]

Ambien tends to leave patients wake up feeling awake and refreshed. Perhaps it happens but I have yet to encounter a patient asking for higher doses of Ambien unlike benzos.

Interesting how different patient populations can be. I commonly hear how Ambien causes daytime sedation or requesting 20mg qhs. Temazepam and trazodone are easily my top 2 tolerated and effective sleep meds. Rozerem has been a mixed bag.

 

[tr]

I find that is more theoretical than practical. Hypnotics have the same dementia risks as benzos in my reading with added risks of sleep walking/driving. I use a lot more benzos than Ambien.

Just my 2 cents.

Yes but abuse/addiction potential is much worse with bzds.

Abuse and dependence potential for the non‐benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data

 

[st2205]

Picked up a patient (axis II) establishing after hospital DC. They stopped benzo in the hospital because they didn’t want them on that, so in its place there are three other anxiety PRNs (hydroxyzine 50 QID, propranolol 20 TID and Gabapentin 800 TID), on top of other junk (Effexor 225, Prazosin 1 am 2 hs, Seroquel 800 hs, buspar 20 TID).

Honestly, I’d rather them just be on Effexor and the benzo and get rid of all the other **** they’re using to placate them for not having a benzo. At least the benzo is one med that can be gradually reduced.

 

[TexasPhysician]

Yes but abuse/addiction potential is much worse with bzds.

Abuse and dependence potential for the non‐benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data

I have been lead psychiatrist at an addiction center and still do plenty of addiction work. Outside of alprazolam multiple/day use, it’s not common. 0-1x/day use for insomnia and we are talking zebras of a high order.

 

[randomdoc1]

What I have found quite helpful in PP is to put your policies and boundaries up front before they make an appointment. You never know what can come through your door. You avoid having to deal with angry, difficult, and disgruntled patients that are not willing to change and the ones who are may still be on problematic regimens but they are at least willing to listen to what you have to say. I have a strict stimulant policy and I tell people up front my philosophy on chronic benzos and that I practice evidence based medicine for longterm treatment of anxiety and insomnia. If they want to find someone who will just dole out whatever they ask, fine, it's their choice if they want low quality, what I call fast food healthcare. Also, be sure to check the physician review sites regularly. Eventually in your career more likely than not you may get an angry review but some sites allow you to discuss the situation directly and may opt to take down the review. Otherwise they may affect your flow of new patients. For example, healthgrades allows you to completely opt out of reviews if you work in psychiatry. Other sites allow you to review a limited number of review(s) annually with no question and of course, the absolutely ridiculous ones can be removed as well if you make a good case.

 

[boogaaloo]

I love benzos, they are amongst the most effective drugs we have in psychiatry when used judiciously but it's a drag dealing with pts who are hooked on benzos even though it has not actually "cured" their problem but they insist on staying on them. Thankfully I don't treat patients anymore but I used to have patients on long-term benzos (all who came to me on these) sign the following contract (please feel free to use).:


I have discussed the following with my physician and read and understand that:

1. Benzodiazepines are not recommended for the long term treatment of anxiety disorder or insomnia;


2. The first line treatment for anxiety disorders is psychotherapy such as cognitive-behavior therapy aimed at teaching skills of acceptance, relaxation, recognizing triggers to anxiety, and challenging negative and distorted thoughts


3. The recommended drug treatment of anxiety disorders includes non-benzodiazepines such as fluoxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine, mirtazapine and gabapentin

4. There is no evidence supporting the use of benzodiazepines for longer than 2 to 4 weeks’ duration;


5. Benzodiazepines may worsen the long-term use course of anxiety and worsen my anxiety and sleep problems;


6. Benzodiazepines cause tolerance needing higher and higher doses to maintain the same effects;


7. Withdrawal symptoms can occur with missed doses or even at the same dose of medication I take. This can include severe anxiety, panic attacks, worsening depression, psychosis, seizures, and even death. Acute withdrawal from benzodiazepines is a potentially life-threatening consequence and can occur even if I am taking the drug as prescribed by my physician.;


8. Benzodiazepines are associated with an increased risk of death from all-causes. People who use benzodiazepines long-term die earlier than those who do not;


9. Benzodiazepines may impair my ability to drive or operate heavy machinery. I may be more at risk of accidents as a result of driving while using benzodiazepines.;


10. Benzodiazepines have been associated with dementia and may accelerate the onset of dementia. Even in people who do not develop dementia, benzodiazepines can cause problems with memory and concentration

I understand the following conditions for continued prescribing of benzodiazepines and that failure to meet these requirements will lead to being tapered of these drugs:

I will attend regular follow-up appointments to monitor my progress and review my treatment

I will not get refills on my medications without regular follow up appointments

Lost or stolen prescriptions will not be refilled without a police report

There will be no early refills

I will not share my prescription with others

I will not sell my benzodiazepines for other drugs

I will not attempt to obtain benzodiazepines from other providers outside this clinic or on the street

I will take all my medications as recommended and prescribed

I will have any random or routine drug testing required to assess my ongoing use of benzodiazepines and that I am not abusing other drugs that may be harmful to my health

There's so much wrong with this. It reminds me of the quashed suicide contracts.

 

[Attending1985]

There's so much wrong with this. It reminds me of the quashed suicide contracts.

What’s wrong with this? It’s a detailed informed consent with treatment expectations for a controlled substance.

 

[thoffen]

I have been lead psychiatrist at an addiction center and still do plenty of addiction work. Outside of alprazolam multiple/day use, it’s not common. 0-1x/day use for insomnia and we are talking zebras of a high order.

Generally I think the issue is that there are people who will escalate doses and combine meds in ways that get patients in trouble. I'd agree that using Z-drugs within their labeling isn't a big risk for addiction. Doesn't make it the right thing to do, of course. Otherwise, for example, I have a patient that's come to me on something like 10mg of Ambien, 2mg of konopin, and averaging about 2mg of xanax PRN on top of that. While I don't suspect this patient is using these drugs outside of the way they are prescribed, I'm simultaneously confronted with all this GABA-ergic stuff with a patient who is still having severe anxiety and insomnia and no sense of agency in confronting these symptoms.

I like @splik 's informed consent list, but really how many psychiatrists are regularly seeing patients that need only a short-term anxiety or insomnia treatment or where someone else hasn't already treated them in problematic ways?

 

[TexasPhysician]

Otherwise, for example, I have a patient that's come to me on something like 10mg of Ambien, 2mg of konopin, and averaging about 2mg of xanax PRN on top of that.

Genius! Klonopin for daytime anxiety, Xanax for break-through anxiety. Ambien for nighttime anxiety. Add some Norco and Seroquel and we are set.

 

[thoffen]

Genius! Klonopin for daytime anxiety, Xanax for break-through anxiety. Ambien for nighttime anxiety. Add some Norco and Seroquel and we are set.

You forgot the Adderall for daytime somnolence. But, seriously, it's not that bad. If patients would not realistically benefit from my program or work with me on this stuff, I will refer them out, and my staff does a good job screening these patients without my intervention anyway. With inpatients, you get what you get, but at least they can't get anything there I don't prescribe, and I'm not going to be doing their outpatient care anyway.

 

[Shikima]

Who the **** needs psychiatry for sleep problems for 10 years?! Therapy and sleep med specialist, my god.

you rang?

 

[futuredo32]

guess you can't take a joke... about your patients

the comment "sounds like you're making a transition" was meant to say that I empathize with this being more difficult than your residency, and I wasn't trying to take a big shot at you

sure, I guess I was also ribbing you a little

loosen up

Sorry, I have been overly sensitive waiting for the board results ............ apparently with good reason. Thank you for clarifying.

 

[Liquid8]

Even if you've been working for a while, it is still frustrating - ended up getting one of these patients the other day. From the word go it's immediately obvious that the patient has borderline, yet their previous psychiatrist was prescribing them a ridiculously high amount of dexamphetamine for a somewhat questionable ADHD diagnosis. Of course there was nothing in their referral letter than pointed to any of this.

Was able to reason with them that if they were taking such a high dose and the problems are ongoing, it's probably not the right medication they need to be on. Not sure if they will return, as they were sacked by another psychiatrist for not keeping appointments.

 

[tr]

I have been lead psychiatrist at an addiction center and still do plenty of addiction work. Outside of alprazolam multiple/day use, it’s not common. 0-1x/day use for insomnia and we are talking zebras of a high order.

The physiologically addictive properties of benzos also interfere with their clinical utility, beyond concerns about outright misuse.

Benzos are fantastically useful for anxiety/panic when taken sporadically (<1x/week or less often). More frequently than that and you are just producing tolerance and dependence, even in the absence of addictive behaviors. Then they don't even work for the underlying issue anymore, just for the withdrawal/rebound.

Rebound insomnia is worse with benzos than with zolpidem

Ware, J. C., Walsh, J. K., Scharf, M. B., Roehrs, T., Roth, T., & Vogel, G. W. (1997). Minimal rebound insomnia after treatment with 10-mg zolpidem. Clinical neuropharmacology, 20(2), 116-125.
Lader, M. (1998). Withdrawal reactions after stopping hypnotics in patients with insomnia. CNS drugs, 10(6), 425-440.

Also, fwiw the sleep architechture produced by zolpidem is much closer to the physiologically normal pattern than you get with benzos

Declerck, A. C., Ruwe, F., O'Hanlon, J. F., & Wauquier, A. (1992). Effects of zolpidem and flunitrazepam on nocturnal sleep of women subjectively complaining of insomnia. Psychopharmacology, 106(4), 497-501.
Uchimura, N., Nakajima, T., Hayash, K., Nose, I., Hashizume, Y., Ohyama, T., ... & Maeda, H. (2006). Effect of zolpidem on sleep architecture and its next-morning residual effect in insomniac patients: a randomized crossover comparative study with brotizolam. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(1), 22-29.

 

[SeniorWrangler]

That is just what I have found and seen during residency. I guess with Klonopin it wouldn't be an issue. I educate my patients on each and everyone of the potential side effects of all new medications and how to take them and have them repeat it back to me. Most don't like trazodone due to the sleep hangover and mirtazapine for the same reason plus weight gain. Ambien tends to leave patients wake up feeling awake and refreshed. Perhaps it happens but I have yet to encounter a patient asking for higher doses of Ambien unlike benzos. Thanks again for the helpful advice to all.

Z-drugs are not so benign either.

 

[TexasPhysician]

Rebound insomnia is worse with benzos than with zolpidem

Ware, J. C., Walsh, J. K., Scharf, M. B., Roehrs, T., Roth, T., & Vogel, G. W. (1997). Minimal rebound insomnia after treatment with 10-mg zolpidem. Clinical neuropharmacology, 20(2), 116-125.
Lader, M. (1998). Withdrawal reactions after stopping hypnotics in patients with insomnia. CNS drugs, 10(6), 425-440.

Also, fwiw the sleep architechture produced by zolpidem is much closer to the physiologically normal pattern than you get with benzos

Declerck, A. C., Ruwe, F., O'Hanlon, J. F., & Wauquier, A. (1992). Effects of zolpidem and flunitrazepam on nocturnal sleep of women subjectively complaining of insomnia. Psychopharmacology, 106(4), 497-501.
Uchimura, N., Nakajima, T., Hayash, K., Nose, I., Hashizume, Y., Ohyama, T., ... & Maeda, H. (2006). Effect of zolpidem on sleep architecture and its next-morning residual effect in insomniac patients: a randomized crossover comparative study with brotizolam. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(1), 22-29.

I don’t disagree with your reasoning. Those are fair reasons to consider Ambien.

Ambien has higher rates of somnambulism and related activities. Medicolegally - that concerns me, but potentially unfounded.

I have seen much higher rates of overall side effects compared to hs benzos. I’ve seen addiction to Ambien too. Additionally, benzos still require some effort by patients to fall asleep. This helps me reinforce the importance of sleep hygiene and patients seem to buy into it better than with Ambien.

 

[tr]

I don’t disagree with your reasoning. Those are fair reasons to consider Ambien.

Ambien has higher rates of somnambulism and related activities. Medicolegally - that concerns me, but potentially unfounded.

I have seen much higher rates of overall side effects compared to hs benzos. I’ve seen addiction to Ambien too. Additionally, benzos still require some effort by patients to fall asleep. This helps me reinforce the importance of sleep hygiene and patients seem to buy into it better than with Ambien.

Yeah the PM activities with Ambien are definitely common and troubling. I counsel everyone about the potential for this to happen and ask them to be aware of signs that it is occurring. Keeping dose to the minimum effective helps too. It's a problem but for me it doesn't outweigh the other advantages of the drug.

I haven't had much pushback on sleep hygiene, most people seem thankful for the information, although implementation can be spotty of course. I usually address sleep hygiene first and present the option of a sleeper as secondary.

 

[DisorderedDoc417]

What is common? Do patients do this when first placed on the med, or does it happen after taking it for some period of time? We probably put 500+ patients on ambient every year on our inpatient service and I’ve never seen it.

 

[tr]

I've heard of this happening, but how often does it happen? Patients will occasionally report somnambulism, but the interesting thing is that we probably see 1000 people try this medication during their inpatient stay every year and it never happens on



What is common? Do patients do this when first placed on the med, or does it happen after taking it for some period of time? We probably put 500+ patients on ambient every year on our inpatient service and I’ve never seen it.

I'd say maybe 1 in 10-20 patients report this. The trick is figuring out whether it is happening. Actual somnambulism is rare. More common are things like sitting up in bed briefly or having conversations they don't remember later. Often people won't realize it's happening until their bed partner alerts them or they see activity records on their phones.

 

[DisorderedDoc417]

I'd say maybe 1 in 10-20 patients report this. The trick is figuring out whether it is happening. Actual somnambulism is rare. More common are things like sitting up in bed briefly or having conversations they don't remember later. Often people won't realize it's happening until their bed partner alerts them or they see activity records on their phones.

Appreciate your response, thank you.

 

[Shikima]

What is common? Do patients do this when first placed on the med, or does it happen after taking it for some period of time? We probably put 500+ patients on ambient every year on our inpatient service and I’ve never seen it.

I've seen it frequently enough to monitor for it. Can happen with lunesta and sonata to a lesser degree.

 

[thoffen]

I'd say maybe 1 in 10-20 patients report this. The trick is figuring out whether it is happening. Actual somnambulism is rare. More common are things like sitting up in bed briefly or having conversations they don't remember later. Often people won't realize it's happening until their bed partner alerts them or they see activity records on their phones.

To me it's like Dementia. Things can be going wrong for a while, but you won't find it if you don't look for it, and you might receive symptoms that you interpret differently if it doesn't enter your differential.

 

[hallowmann]

...Otherwise, for example, I have a patient that's come to me on something like 10mg of Ambien, 2mg of konopin, and averaging about 2mg of xanax PRN on top of that...

Throw on 3 different stimulants (including both long and short acting taken simultaneously) because the patient's "ADHD makes me sleepy" and you've got one of the gems I recently saw.

You forgot the Adderall for daytime somnolence...

Seriously, practically saw the same person.

 

[cbrons]

I’m betting a fair amount of the people ya’ll are prescribing “prn benzos” for sleep have an undiagnosed sleep breathing disorder, and that includes the not fat ones too.

 

[Trena]

I am a nurse practitioner and also a patient who has been on Xanax for panic disorder/GAD since 2013. I now take the XR version which is amazing. And have Alprazolam .5 mg on hand for any break through attacks.

So, I see things from both sides of the aisle. I never give a benzo for sleep. I use Ambien or refer to a sleep specialist. But I never change a patients medications if they have been on them for years and I review their records.

I feel quality of life is important. A person has a right to decide their treatment. I make sure they understand how addictive benzo's are. I ask how many alcoholic drinks they drink and I check to see if they are on any opiates. If all that checks out I figure, the benzo's are making them happy and that is all that matters. Now, if they drink or are on opiates I take them off. But a benzo is hard to OD on without mixing other drugs.

Now, I was taught by a very well respected psychiatrist who studied only anxiety spectrum disorders. And nearly every patient was on a benzo. He was my doctor and retired. And I understand how scary that is.

I have been on several drugs, none of them did work. Some people need a benzo for panic disorder. And the studies that they cause dementia are not totally convincing.

With that said, any new patient I see or I put on a benzo I require them to stop once per week and I do a quick check to count pills. I do not charge for this. After they are a regular and follow the rules I will see them every 6 months for RX renewal.

Could I send them out for CBT? Yes. I offer it. But I had no time for CBT. Take a pill or do a drill. I took a pill. So far I take 4 mg a day and have no adverse side effects.

Benzodiazepines are not bad. It is the laziness of the prescribers. The government makes us go through a lot of extra steps and some are too lazy. So suddenly all benzodiazepines are bad.

No. They are extremely safe drugs if taken alone, easy to spot an addict if you stay involved, and work incredibly well for their intended purpose which happens to be panic disorder or GAD that does not respond to SSRI's. When a patient says they have tried everything I look at their chart. If they are truthful I do not look at them as an addict. I tried everything too. I went with panic disorder nearly my entire life before I finally took a Xanax. It is possible they are not lying.

 

[Trena]

What is common? Do patients do this when first placed on the med, or does it happen after taking it for some period of time? We probably put 500+ patients on ambient every year on our inpatient service and I’ve never seen it.

In my experience people get up and do things or have conversations they cannot remember. I always advise that they have family report to them if this happens, notify me immediately, and depending on the severity, I will change over to Vistaril.

I used it many times back around 2002 for sleep and I had a habit of not falling asleep and hallucinating. So be careful some people do like to trip off of Ambien if they figure out refusing to sleep causes hallucinations. I had no idea. I was dating an ARMY PA at the time and when I was watching snakes crawl up the wall he informed me that Ambien was doing it.