Little anecdotal example of what happens when psychologists prescribe..

[Gavanshir]

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Source: https://www.reddit.com/r/Drugs/comments/41pjr5/my_psychologist_wrote_me_a_script_for_xanax/

This happened yesterday, and I'm still totally blown away by it.

She said, "You're wiping your hands on your jeans a lot, is that because they're sweaty?"

"Yeah, it's always been an issue. My pediatrician, years ago, said I have hyperhidrosis."

"Hyperhidrosis is usually a result of anxiety, do you find you sweat more when you're anxious?"

"No, I mean, they're sweaty all the time, since I was a kid. I hate shaking people's hands because I always have to wipe them on my pants beforehand."

"That SOUNDS like anxiety to me. I'm going to go ahead and write you a prescription for xanax."

Having been a drug user for a while, I know a thing or two about xanax. It blew me away that she'd write a script for it so flippantly, so I decided to feign ignorance and ask a couple follow-up questions to see how ****ing stupid and/or insidious she actually was.

"So, can I take this every day?"

"Absolutely."

"Even with the adderall you've prescribed?"

"I don't see why not."

This isn't the only time I've had a psych write me a prescription for something addictive without putting much thought into it. FAR from the only time. But it definitely struck me as the most dangerous and uninformed behavior I've seen from a mental healthcare professional. Ignoring how dangerous xanax is, hyperhidrosis is NOT caused by anxiety and, in fact, it's impossible to pinpoint an underlying cause in most cases. So even if xanax were as innocuous as thin mints, it wouldn't have helped me.

I wish I had the balls as an informed person to call her out, and let her know how disgusting I think she is and how I hope she's not actively ruining people's lives with benzos, but I always think of that kind of stuff after the fact. I just kind of said, "Huh. Well, thank you!" And now I have a bottle of xanax to either dispose of or use sparingly, and an upcoming appointment with a new psychologist.

If you know someone who's been prescribed xanax by a mental healthcare professional, it'd be good to make sure they've had the dangers spelled out for them correctly, if at all.

Have a good one, you ****ing degenerates.

EDIT: Since a couple people have questioned whether they were a psychologist or a psychiatrist, and because it's an interesting thing to know, I'll include an explanation up here. They were a "prescribing psychologist". Meaning if you you're a psychologist in a few states, mine included, and have received clinical training, you can take extra schooling in psychopharm and become licensed to prescribe medication. But because you haven't completed medical school or residency, you're still not considered a psychiatrist. Here's a website with more info.

 

[Doctor Bagel]

If true, it's appalling. However, I'm wondering if the poster is confusing psychologists and psychiatrists and was actually seeing a psychiatrist or a psychiatric NP. As prescribing psychologists are fairly rare, it would be odd move from one prescribing psychologist to another prescribing psychologist.

 

[Gavanshir]

If true, it's appalling. However, I'm wondering if the poster is confusing psychologists and psychiatrists and was actually seeing a psychiatrist or a psychiatric NP. As prescribing psychologists are fairly rare, it would be odd move from one prescribing psychologist to another prescribing psychologist.

Indeed it was a psychologist, I've edited my post with his addendum.

 

[birchswing]

If you browse reddit you could find hundreds, if not more, stories of bad prescribing. It seems a lot of people who post on /r/askdocs are on seemingly irrational mixes of meds, and most don't see psychologists.

I don't really have an opinion on psychologists prescribing or not prescribing or not, but I do think there should be more belief in standardized prescribing guidelines. You can find good guidelines from a lot of sources. I like uptodate.com and aafp.org a lot. Aafp has amazing tables. Up to date is really easy to read, too.But there is a lot of deviation from what is typical and not necessarily with good reason.

The other day on /r/askdocs someone asked about what to do about a child who is bedwetting and a certified doctor wrote back saying to use a TCA. I know TCAs can be used for this, but the answer is endemic of a problem of all types of doctors handing out a pill before doing a little investigation and arriving at the least a tentative diagnosis—and in this case the doctor suggesting a third-line treatment, assuming there really was frank enuresis.

You could replace askdocs and the ilk with free subscriptions to uptodate.com. We need a democritization of legitimate sources medical knowledge so that more people, like the one the OP referred to, know when they are being given bad info. And we not only need that information disseminated but accepted as legitimate. Because I find that sometimes as a patient you will find something evidence-based but because it's from "the Web" it doesn't hold legitimacy with a doctor who might, for example, "have had really good experiences with patients taking Xanax" or whatever the case may be. The doctor's really good experiences with something that has no evidence to support it shouldn't take precedence. In essence, what I am proposing is more loyalty to consensus and standardization above the whims any particular doctor might have, which isn't to say there aren't really good reasons to deviate from the norm. But there are really good reasons to start with the norm. I have no reason to believe that's a problem with prescribing psychologists.

 

[vistaril]

The problem with this story serving as a useful anecdote is that this happens all the time with prescribing psychiatrists......

 

[WisNeuro]

The problem with this story serving as a useful anecdote is that this happens all the time with prescribing psychiatrists......

Yeah, I was going to say. I have seen this type of thing a lot. And I've never lived in an RxP state. I am for the RxP as an idea, but against how it's currently implemented. But yeah, I don't think anyone has any room to point fingers at a profession for benzo and stimulant prescribing habits. Unless, there does happen to be a real life adult onset ADHD, and we've just been missing it all these years 🙂

 

[smalltownpsych]

Yeah, I was going to say. I have seen this type of thing a lot. And I've never lived in an RxP state. I am for the RxP as an idea, but against how it's currently implemented. But yeah, I don't think anyone has any room to point fingers at a profession for benzo and stimulant prescribing habits. Unless, there does happen to be a real life adult onset ADHD, and we've just been missing it all these years 🙂

Yes, only the initials stand for Amphetamine Deficiency Histrionic Disorder. The histrionics tend to occur after the patient in a court ordered substance program is told they can't get a prescription for adderall. "I can't function without my meds! I have a serious mental illness! My rights are being violated! Who do you think you are? Well at least give me Xanax then you heartless bastard!"

 

[whopper]

I'd say about more than 50% of the doctors out there are bad prescribers.

E.g. too much Xanax given out for too long, sleep-meds instead of sleep hygiene as a first-line treatment, sleep-meds for people with obstructive sleep apnea, stimulants for overweight people to control appetite instead of diet and exercise, a medication for bipolar disorder when the person clearly doesn't have it.

 

[HarryMTieboutMD]

Agree with most of the above. Bad prescribing is not exclusive to non physicians and psychiatrists... A large amount of doctors are reckless with prescribing (including non psychiatric and non narcotic medication). And I have seen plenty of non psychiatrists screw up basic meds like SSRIs...

 

[WisNeuro]

Agree with most of the above. Bad prescribing is not exclusive to non physicians and psychiatrists... A large amount of doctors are reckless with prescribing (including non psychiatric and non narcotic medication). And I have seen plenty of non psychiatrists screw up basic meds like SSRIs...

Or a PCP prescribing a clearly demented 80-something some maintenance xanax for his mild anxiety. That one actually made me pretty angry.

 

[Shikima]

Just saw a 52 y/o F who was demanding Adderall because she was Dx with ADHD and all her children have it and her biggest concern is related to the lack of focus and concentration.


....Nevermind that she's going through a divorce and will be going to court soon, had to close her business, and is in the process of selling 5 different houses.

 

[WisNeuro]

Just saw a 52 y/o F who was demanding Adderall because she was Dx with ADHD and all her children have it and her biggest concern is related to the lack of focus and concentration.


....Nevermind that she's going through a divorce and will be going to court soon, had to close her business, and is in the process of selling 5 different houses.

Pssh, that's just normal, every day life stress.

 

[downwithDTB]

I once had an ER doc insist that I leave with a huge bottle of oxy for 6/10 pain resolved to 2/10 at discharge. He wouldn't let me leave without the script, even though I said that I didn't even need a Tylenol.

 

[Shikima]

Damn those patient satisfaction questionnaires.

 

[smalltownpsych]

Just saw a 52 y/o F who was demanding Adderall because she was Dx with ADHD and all her children have it and her biggest concern is related to the lack of focus and concentration.


....Nevermind that she's going through a divorce and will be going to court soon, had to close her business, and is in the process of selling 5 different houses.

I am surprised that she didn't just take her kids Adderall or maybe she was and it just wasn't quite getting it done anymore.

 

[calvnandhobbs68]

These anecdotal examples are useless because you can find tons of anecdotes about terrible doctors in all specialties. The psychiatrists and ER docs mentioned above, the egregious examples of the oncologists who gave people chemotherapy who didn't have cancer, the ophthalmologist who did cataract surgery on people who didn't need cataracts, etc etc. They aren't going to prove anything because you can always find lazy/corrupt/evil people in any group and physicians aren't immune to being people.

 

[Shikima]

These anecdotal examples are useless because you can find tons of anecdotes about terrible doctors in all specialties. The psychiatrists and ER docs mentioned above, the egregious examples of the oncologists who gave people chemotherapy who didn't have cancer, the ophthalmologist who did cataract surgery on people who didn't need cataracts, etc etc. They aren't going to prove anything because you can always find lazy/corrupt/evil people in any group and physicians aren't immune to being people.

And yet medical boards do nothing.

 

[birchswing]

And yet medical boards do nothing.

Eventually the DEA will:

http://www.upi.com/Top_News/US/2016...deaths-arrested-after-DEA-raid/2871452973380/

The psychiatrist is accused of being complicit in 36 patient deaths--and has no medical board disciplinary history.

 

[splik]

state medical boards are more interested in bullying mentally ill doctors or making money off drug addicted doctors than they are in dealing with rogue physicians.

 

[HarryMTieboutMD]

state medical boards are more interested in bullying mentally ill doctors or making money off drug addicted doctors than they are in dealing with rogue physicians.

Sentiments like this discourage doctors with addiction problems from seeking the help that they need and enable those around them to keep issues covered up. With the exception of fines in certain circumstances (which are usually warranted), the state board itself doesn't make money off of impaired physicians. The state PHPs, which require money to operate, are an invaluable resource and have helped thousands of physicians with substance disorders return to work, and more importantly, Recover. The PHP model is one of the most successful in all of addiction, with ~80% five year abstinence rate (without medication assisted treatment in most cases, though there is some good prelim data using naltrexone in opioid dependent anesthesiologists). The PHP requires evaluation by an approved addiction medicine physician/psychiatrist or multidisciplinary team, referral to an approved treatment center with which the PHP is comfortable, continuous group monitoring throughout the duration of the contract, and frequent drug testing, all of which cost money, but again, the results speak for themselves. Also required is 12 Step involvement (though contrary to what some people think, PHPs are not authoritarian and will work with doctors on this issue... most of the time it largely centers on the physician's denial, ego, etc... the idea is to have community support). Also IDAA/Caduceus meetings are strongly encouraged. http://www.ncbi.nlm.nih.gov/pubmed/19161896 (btw the authors on this paper are some of the all time greats, including William White who is an astute historian and the authority on the history of addiction treatment in America).

Sure, one can be cynical and say, "well they only stay clean because their license is on the line," but that a physician with rigorous monitoring and accountability, while they might not fully embrace the idea of Recovery and use again after five years (I don't think there is data yet on post monitoring relapse rates, though I talked with Lisa Merlo a couple of years ago, and she said she is starting to collect it), the physician is able to stay abstinent and return to work, thus restoring productivity and functionality. I was talking to Paul Earley (medical director at Talbott, also renowned in the field), and he said that if one were to throw him against a wall and decide between intensive residential treatment and rigorous drug testing, he would pick the drug testing... it works and works well.

And so many physicians are so fortunate that 47 state medical boards trust the PHPs and basically leave all treatment and monitoring decisions up to them. The board's job is to protect the public (or protect themselves), and the fact that they entrust such a responsibility (with the potential for huge PR disasters) to an organization soeaks volumes. I really think everyone involved in treating impaired physicians (and really addiction in general) is doing a thankless job.

 

[Shikima]

state medical boards are more interested in bullying mentally ill doctors or making money off drug addicted doctors than they are in dealing with rogue physicians.

Operative word; Bully.

 

[HarryMTieboutMD]

it is a conflation to say that all PHPs are created equal. There are some programs that are clearly excellent and humane (the Colorado model, which several states PHP is built on) would be an example. But there are definitely some shady practices going, I have heard of some terrible stories from a reputable source. Massachusetts is a state that one very reputable psychiatrist has accused of doing some shady things for their own pecuniary gain.

also many state medical boards overreach by asking invasive questions that they have no business asking regarding past psychiatric history. it is these state medical boards that are stigmatizing physicians who have experienced mental health program and who deter medical students and physicians from seeking help.

Of course there are going to be management differences between PHPs and areas in which improvement can occur, but actually, there are more similarities than differences: http://www.ncbi.nlm.nih.gov/pubmed/19482236. And irrespective of how "reputable" a source might be, this is an incredibly sensitive area in which many of the physicians enrolled might consider their "coercion" into the programs to be a great injustice (contrary to the truth). The truth is most people who claim that the PHP is scamming them/is being unfair/is dictatorial are in denial, ungrateful that these entities exist, and have severe senses of entitlement. Contrary to what people claim on various message boards, a positive drug screen that may or may not be a lab error is not necessarily an end all be all, but it does mandate some intervention, or else the PHP isn't doing its job. Also, in most cases positive drug tests do indicate relapse... and if one suspects tampering there is always a chain of custody form. And poppy seeds, hot boxing, drenching yourself in hand sanitizer are not viable excuses for positive drug tests (the EtG/EtS issue has been refined and is pretty reliable last time I checked).

Also, psychiatrists are among the most difficult patients to treat- clinical familiarity with addiction and thinking they know everything, resentment at the possibility of being evaluated/treated by non psychiatrist addiction medicine MD, emphasis on 12 Step Recovery (which psychiatry has in one way or another derided since the incipiency of AA, despite Bill W giving an address to the APA), etc etc. Anyway, I would trust the thinking, experience, and work of Mark Gold, Bob Dupont, Tom McClellan, Paul Earley (irrespective of financial interests, these are truly innovative and iconoclastic thinkers and have undeniably shaped our understanding of addiction), etc on this issue far more than some of the disgruntled "voices in the crowd" who claim "injustice" (read- false bravado)

Agreed on the point about overly intrusive psychiatric questions "have you been psychiatrically hospitalized or treated for a substance use disorder in the last 5 years?" is sufficient enough, and even that's probably overkill

 

[whopper]

Eventually the DEA will:

http://www.upi.com/Top_News/US/2016...deaths-arrested-after-DEA-raid/2871452973380/

The psychiatrist is accused of being complicit in 36 patient deaths--and has no medical board disciplinary history.

Yeah but I think we can all agree it's ridiculous that it has to get to this level for a regulatory body to do something. I've said this several times. State medical boards hardly do anything with bad doctors. I've only seen them go after ones that are egregiously and over-the-top wrong. E.g. A doctor that inappropriately sexually molested literally several dozen patients. Had that doctor limited it to only say 20 he would've still gotten away with it.

In widely reported and recent case where an oncologist was pumping people without cancer with chemotherapy meds while telling them they had cancer he had been doing it for years and more than one medical professional reported him yet they did nothing for years. When asked why they mentioned that those medical professionals had other options. No they did not. You call the police about this thing the police don't know what's going on in a patient-harm sense and often times won't make an arrest. It's a HIPAA violation to openly state the problem to a third party outside the chain of a medical practice or a state health board such as the medical board.

 

[Shikima]

What role do state medical boards have in regulating normal life of people with those who do conscious and unconsciously run afoul of the law?

 

[whopper]

They can take away someone's license or put them on some type of probation. I've seen them do this and some states have a public outlet such as a website or e-mails stating who got kicked out and put on probation.

In defense of state medical boards they're not some type of organization with the man-power to take away a license with any type of efficiency, but IMHO maybe they should be given the number of bad practice cases I've seen and stats showing that physician caused deaths and serious injuries are actually much higher than people believe.

IMHO they ought to hire nurses or trained investigators (E.g. a 3 months crash course on medical practice) to go to doctor's offices and pose as patients and do things such as ask for Xanax, opioids, or simply see how the doctor performs over a series of 5 follow ups. If the doctor screws up he/she gets a warning. These people should randomly see doctors, say 1 in 50 by the end of the year. IMHO this would cause enough fear/incentive for doctors to do a better job while not feeling overly paranoid and doctors should only get in trouble for clear and obvious mistakes. This is purely speculation on my part but the monetary cost to do this would likely be worth it.

 

[Shikima]

What about state boards and the private lives of physicians - arrested for unpaid parkings and the likes?
In essence, how far does this go?

 

[vistaril]

it is a conflation to say that all PHPs are created equal. .

eh...there may be a few that operate a little differently, but the vast majority follow the EXACT SAME MODEL. Like down to the wording in the contracts.

Slight addendum/modification to what Harry said though- the studies that show the success of phps aren't as impressive as they seem for a couple of reasons. First, not all the people caught up in the program are really addicts/alcoholics. Most are, but a good percentage aren't(and just did something stupid and the state board/php had to do something). Second, a lot of people in these programs do have a lapse(and in some cases a relapse) that just isn't ever caught. most phps still aren't using peth as a screening tool for alcohol use d/o patients(but rather only if missed etgs, dilutes, positive etgs and a denial, etc). If every program were to shift to using screening peths(say biannually) tommorrow, you would have a lot more people in the program with a positive test. What etg does do is prevent alcohol use d/o patients from engaging in daily drinking(unless they are cheating the test). But as a random screen if you don't test on weekends? Easy to get around...it's not an '80 hr test' in the vast vast majority of cases.

i think there are a lot of valid criticisms of phps....but they do a lot of good too.

 

[whopper]

What about state boards and the private lives of physicians - arrested for unpaid parkings and the likes?

I've never seen anything concerning this but I think if a doctor were part of an organization that organization might take offense and take action.

(Though it seems that Columbia U. doesn't seem to have a problem with Dr. Oz whoring himself out to the highest paying supplement company).

State boards usually do ask if the person has ever been arrested for anything so in applying I do think this would be held against the person. Also some state medical boards and several organizations require a background check and legal problems can show up on a background check.

 

[WisNeuro]

(Though it seems that Columbia U. doesn't seem to have a problem with Dr. Oz whoring himself out to the highest paying supplement company).

SHUT UP!!! Green coffee beans cured my cancer and bunions! It also did my taxes last year.

 

[Shikima]

I've never seen anything concerning this but I think if a doctor were part of an organization that organization might take offense and take action.

(Though it seems that Columbia U. doesn't seem to have a problem with Dr. Oz whoring himself out to the highest paying supplement company).

State boards usually do ask if the person has ever been arrested for anything so in applying I do think this would be held against the person. Also some state medical boards and several organizations require a background check and legal problems can show up on a background check.

So, why would state boards be concerned about this but not Dr. Oz whoring himself out with incorrect information, or physicians whom are the prescribing candyman or grossly mismanging with the lack of evidence based treatment.

 

[clausewitz2]

So, why would state boards be concerned about this but not Dr. Oz whoring himself out with incorrect information, or physicians whom are the prescribing candyman or grossly mismanging with the lack of evidence based treatment.

In my current state, at least, at least two psychiatrists lost their licenses in the past year for overly generous prescribing. Of course, situations were fairly egregious:

1. Psychiatrist prescribed himself and his secretary opiods and benzos, and coerced her into sleeping with him as a condition of continuing to supply the drugs

2. Psychiatrist wrote prescriptions for large doses of opiods for 73 people without any documentation that he had ever seen them in any clinical context. This was actually a sad case, as the gentleman in question had documented dementia and it looks like it started with his skeezy son-in-law, then his son-in-law's friends, etc.

So yeah, at least here candymen may get disciplined, but only if things get quite bad.

 

[vistaril]

So, why would state boards be concerned about this but not Dr. Oz whoring himself out with incorrect information, or physicians whom are the prescribing candyman or grossly mismanging with the lack of evidence based treatment.

because there are differences of opinion on what is and is not appropriate in the first place *and* this is all along a continuum.

for example, maybe the patient I just saw and have on Ativan 1mg TID you wouldn't have on Ativan. That's a difference of opinion, but nobody would argue that I should be investigated for it.

But what about if I had the patient on Ativan 3mg QID(12mg daily)? And he has a history of abusing opiates and benzos. And he is also on other sedating and abusable drugs, some from me and some from other providers. That's probably a case where some people think the prescriber should be investigated right? Well ok....but then the problem is you would have medical boards trying to make calls along a continuum that would be very dicey. It would be a complete cluster****. Thats why you typically only see these guys get in trouble for prescribing crazy amounts of opiates and bzds only if there is also some deviant behavior which goes along with it(like writing bunches of oxy and xanax and soma for the young girl you are sleeping with as well).....

The above poster is right- candyman do get disciplined. But it has to be very very very egregious. The average joe schmoe med mgt psychiatrist who sees a ton of patients daily and has most of them on xanax 2 TID is completely safe(in terms of board investigating). And probably should be. But it's when that joe schmoe has the patient on xanax 2 TID + soma + some opiates....oh and they are sleeping together and when they break up he cuts her off...*that* is when the board may have to get involved 🙂

 

[DD214_DOC]

Source: https://www.reddit.com/r/Drugs/comments/41pjr5/my_psychologist_wrote_me_a_script_for_xanax/

This happened yesterday, and I'm still totally blown away by it.

She said, "You're wiping your hands on your jeans a lot, is that because they're sweaty?"

"Yeah, it's always been an issue. My pediatrician, years ago, said I have hyperhidrosis."

"Hyperhidrosis is usually a result of anxiety, do you find you sweat more when you're anxious?"

"No, I mean, they're sweaty all the time, since I was a kid. I hate shaking people's hands because I always have to wipe them on my pants beforehand."

"That SOUNDS like anxiety to me. I'm going to go ahead and write you a prescription for xanax."

Having been a drug user for a while, I know a thing or two about xanax. It blew me away that she'd write a script for it so flippantly, so I decided to feign ignorance and ask a couple follow-up questions to see how ****ing stupid and/or insidious she actually was.

"So, can I take this every day?"

"Absolutely."

"Even with the adderall you've prescribed?"

"I don't see why not."

This isn't the only time I've had a psych write me a prescription for something addictive without putting much thought into it. FAR from the only time. But it definitely struck me as the most dangerous and uninformed behavior I've seen from a mental healthcare professional. Ignoring how dangerous xanax is, hyperhidrosis is NOT caused by anxiety and, in fact, it's impossible to pinpoint an underlying cause in most cases. So even if xanax were as innocuous as thin mints, it wouldn't have helped me.

I wish I had the balls as an informed person to call her out, and let her know how disgusting I think she is and how I hope she's not actively ruining people's lives with benzos, but I always think of that kind of stuff after the fact. I just kind of said, "Huh. Well, thank you!" And now I have a bottle of xanax to either dispose of or use sparingly, and an upcoming appointment with a new psychologist.

If you know someone who's been prescribed xanax by a mental healthcare professional, it'd be good to make sure they've had the dangers spelled out for them correctly, if at all.

Have a good one, you ****ing degenerates.

EDIT: Since a couple people have questioned whether they were a psychologist or a psychiatrist, and because it's an interesting thing to know, I'll include an explanation up here. They were a "prescribing psychologist". Meaning if you you're a psychologist in a few states, mine included, and have received clinical training, you can take extra schooling in psychopharm and become licensed to prescribe medication. But because you haven't completed medical school or residency, you're still not considered a psychiatrist. Here's a website with more info.

You were so disgusted by this that you refused to fill the prescription! Oh, wait...