Managing patient expectations

[wolfvgang22]

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Like many, if not all of you, I inherit lots of patients who have been prescribed benzos for either insomnia or anxiety for a long time, often at high dose. A colleague of mine does a good job of slowly weaning her patients off benzos, but then they "fire" her and my employer then sends these benzo seeking patients to me because they request to see a different doctor (one of the joys of working at the VA.)

Usually, I decline to restart benzos, which results in drama on the part of the patient. I try to stay empathetic, but it is miserable having to deal with the bargaining, complaining, begging, and other manipulative attempts by these patients to obtain benzos. Sometimes they threaten violence, but mostly these patients are just verbally or emotionally abusive, and file complaint after complaint to the hospital. Each complaint takes time for me to address, which is also a miserable experience, having to defend safe practices. It causes me a lot of burn out symptoms. Despite my resentment toward these patients and my employer for putting me in this position, I maintain high patient satisfaction, but it is by far the hardest and most draining thing I do. Involuntary psychiatric holds are easier!

How do you handle such patients, and how do you manage your own thoughts and feelings in such a situation?

 

[Sushirolls]

If its leading to burn out and jeopardizing your longevity at the job, then change, quit, and/or open your own practice. You will then be able to set the expectation before patients even set foot in the office. Make it very clear to your employer you will not budge an this is good clinical practice.

Strive to improve the process/policy in the department of what is acceptable patient transfer. Review with the dept heads how psych is different and very rarely should transfers be permissible. I've had jobs in the past where there were meetings and all requests to transfer were discussed with other psych in department. Benzos were not a reason to transfer.

If you aren't willing or needing to change up jobs, stay the course, its a hard road to go, but its worth it in the end. I routinely tell patients the myriad of negatives of benzos and why they need to be tapered. Reassure them of your experiences tapering people on outpatient basis, and how fast it can go on an inpatient basis. Set the expectations that this taper will happen as long as they are seeing you and there is no debate, but again reassure you will make it smooth and comfortable as possible. Use phrases like how if they were your mother, aunt, sister, uncle, you would expect this for your own family. Set the rules up front that using up that months prescription faster then as prescribed will either lead to weekly prescriptions, a faster taper over several days similar to inpatient level speeds, with daily prescriptions sent to the pharmacy. Remind patients there is no debate, this isn't up for negotiation and it will happen. Discuss how sleep, and other things like anxiety may slightly worsen, once off the pills but in coming months after cessation things will improve and majority of patients express gratitude for getting there. These anger/emotional/demanding responses are part of the brain chemistry changes seen even with opioids. Can't really negotiate with it.

For my own sanity, I tell the patients as long as I'm the expected person to prescribe these pills the taper is going to take place. They can change doctors if they want or ask their PCP to prescribe it for them if they wish, but don't get their hopes they will, but in the preservation of my clinical judgement and the integrity of the medical profession, it will not be me with a long term chronic Rx.

Historically my outpatient panels had 0 benzo patients except those in taper, or those who were on it for RBD, or those who only used 2-4 pills a year for air plane flights.

With my current private practice I have 0, and its really not an issue, and I feel less of that burnout you describe - I'm happier.

 

[uname943]

When drug seeking patients complain, "my doctor always changes!!"… they should look at themselves in the mirror.

Your employer is abusing you. It is IMMORAL that these patients pressure you to prescribe something you don't think is indicated.

The VA needs psychiatrists, so you have the bargaining power. Tell your supervisors to deal with this problem. Or it will get 100% worse when you leave with the standard 2 weeks notice. Don't get exploited.

 

[wolfvgang22]

Thank you for affirming I'm doing a lot of the right things. I'm always open to learning more ideas, too, if you have any.

I refused to accept the transfer of such a patient today to my clinic after your posts. I was also able to receive significant changes in my work schedule and expectations recently. (It helped that I already had another job lined up and wasn't bluffing about leaving and have also received excellent evaluations for several years.) This success led to me question a few other things in the clinic. Unfortunately I'm in a bit of an isolated location and the only other local psychiatrist is an administrator, who is an excellent physician but has a different set of pressures in the administrative role.

Thanks for the support!

 

[birchswing]

Sometimes I wonder about the idea of psychiatrists inducing a benzodiazepine dependency in themselves and going through a taper to gain a certain type education that is impossible to attain any other way.

That experiment, however, would be so damaging, indefensible, and—depending on the length—cause the psychiatrist to lose valuable years of their life, that I would never wish it on them. That such an experiment would be so deleterious should give pause in considering how any patient has gotten to the point of benzodiazepine dependence and what the most humane way of treating that disease is.

These aren't drug seeking people who are causing you stress. They have a chemical-induced disease—iatrogenic at that—that is distressing and is distressing to witness. The negative response you feel is understandable. It reminds me of that movie The Beach. So long ago the details might be off. These people who see themselves as entirely enlightened live in a commune on a secluded island. It's a type of utopia. A man is attacked by a shark and loses a limb. He's in absolute agony and expected to die. But he doesn't die. He just keeps screaming in pain. Eventually the people of this commune take him far out into the woods so that they can continue living without hearing the screams.

If it were me (as a practitioner), I would get into the weeds of the research. It's a black hole. Heather Ashton ran a clinic for about a decade back in the 1980s and there is such a dearth of work on benzodiazepines that nothing has come since. I'd look into anticonvulsants, baclofen, acamprosate, theanine, etc. I'd delve into the message boards and YouTube.

Benzodiazepine disease is like outer space for psychiatry. Anyone who does a little bit of work and makes a little bit of progress is a pioneer.

Think what it is like for a patient. They know their bodies are messed up, and they know doctors know very little about it. Some almost religiously hold onto the views of Ashton from decades ago that there is no permanent damage after withdrawal. Some listen to more recent claims by Frederick Von Stieff that you have one set of neurotransmitters and the GABA-A receptors will never work correctly again.

I think the widespread nature of this problem paints over how poorly understood it is and how poor the solutions are.

I would consider anyone who works in this area to be like a Malcom Sayer (the doctor from Awakenings).

The current state of the art is primordial. There is nothing clean or elegant about the current solutions that place the onus almost entirely on the patient of learning from other patients. It's not something to retreat from but to see as the beginning. If it were me, I wouldn't assume that anything that has been done to this point is particularly enlightened. I would see myself not as standing on the shoulders of giants but as on the shoulders of idiots and realizing that you are writing the first page. Freud never claimed to cure anybody. He was doing the equivalent of landing on the moon, gathering rock samples. That's where psychiatry should be with regard to benzodiazepine disease.


EDIT: For your specific problem (it sounds like the patients have already been tapered off but continue to have cravings?), I googled and found some case studies about baclofen successfully used in benzodiazepine patients:

Baclofen in the short-term maintenance treatment of benzodiazepine dependence - PMC

Benzodiazepine (BZD) dependence is a significant public health problem. Apart from the long-term tapering doses of BZD, no others drugs are available for the maintenance treatment of BZD dependence. Baclofen has been used in alcohol and other drug ...

www.ncbi.nlm.nih.gov

 

[Candidate2017]

How do you handle such patients, and how do you manage your own thoughts and feelings in such a situation?

Metaphorically, I lie back, take it and ask for more because I'm a resident. I dissociate while I think about how I will screen and structure my private practice to avoid continuing taking it and curse the attendings who are billing off me.

Literally, I try to align with them by focusing on their other problems. I shrug, firmly make it known I care about them and can't do anything other than wean them off. When I find myself in a loop talking about negative effects of long term benzo use and they are also in a loop explaining why benzos are the only thing that work, I get up from my chair, open the door and tell them to come back in 4 weeks.

 

[Liquid8]

When patients claim that current dosages are not working or demand a high dose, I often start a conversation about how there are a limited number of receptors available for drugs to act on, and increasing the dose won’t cause any benefits after the receptor sites are saturated and simply leads to more side effects. Sometimes I use a visual description – the site where the drug works is an empty glass, and the drug is water. It can fill the glass to a certain capacity, after which it just overflows and makes a mess.

If I can rely on government or public health decisions to divert blame I will. Used to have a guy who would come in and say he’d tried Xanax 2mg bars 2-3 at a time but these weren’t effective and he wanted something stronger. I’d tell him that they’ve stopped making the 2mg tablets available due to safety concerns. He could only have the 1mg tablets, but they’d also reduce the maximum quantity – down from 50 to 10 per packet so it wouldn’t last very long. Emphasised that this meant it would be for short term use only, so wouldn’t be sustainable.

While I take the stance that my hands are tied, in the back of my mind I knew that I could have provided him with a private script for a larger amount of 2mg tablets, but this was a patient who refused to consider taking trying an antidepressant or doing any CBT and generally wasn’t that trustworthy. It wasn’t something I could justify clinically, and knowing the patient, I don’t even raise this possibility.

 

[birchswing]

When patients claim that current dosages are not working or demand a high dose, I often start a conversation about how there are a limited number of receptors available for drugs to act on, and increasing the dose won’t cause any benefits after the receptor sites are saturated and simply leads to more side effects. Sometimes I use a visual description – the site where the drug works is an empty glass, and the drug is water. It can fill the glass to a certain capacity, after which it just overflows and makes a mess.

If I can rely on government or public health decisions to divert blame I will. Used to have a guy who would come in and say he’d tried Xanax 2mg bars 2-3 at a time but these weren’t effective and he wanted something stronger. I’d tell him that they’ve stopped making the 2mg tablets available due to safety concerns. He could only have the 1mg tablets, but they’d also reduce the maximum quantity – down from 50 to 10 per packet so it wouldn’t last very long. Emphasised that this meant it would be for short term use only, so wouldn’t be sustainable.

While I take the stance that my hands are tied, in the back of my mind I knew that I could have provided him with a private script for a larger amount of 2mg tablets, but this was a patient who refused to consider taking trying an antidepressant or doing any CBT and generally wasn’t that trustworthy. It wasn’t something I could justify clinically, and knowing the patient, I don’t even raise this possibility.

4-6 mg Xanax sporadically or daily?

If daily, don't see how CBT or anti-depressants could bridge that gap.

 

[Liquid8]

4-6 mg Xanax sporadically or daily?

If daily, don't see how CBT or anti-depressants could bridge that gap.

If a patient reports that they are not experiencing any symptomatic relief at high doses of regular xanax, the normal conclusion is that they have developed tolerance and the most logical step is not to continue increasing medication but to wean them off. The rationale is that they will still be experiencing anxiety with or without the medication, and most would prefer to not be on medication especially if it’s not actually doing anything. The standard process involves switching to a long acting benzodiazepine with gradual reductions and most patients I see are open to this.

Patients I get referred with a primary anxiety disorder may have been referred for therapy in the past, but most have never been trialled on antidepressants at sufficient dosage or duration for anxiety – this much more than what is necessary for managing depression. This is to be expected, as my referrals come from GPs and while they might try a few antidepressants at starter doses most won’t have gone beyond that. Once this is explained, most patients are open to this. It is usually the blatant refusal to consider alternatives to alprazolam that serves as an obvious warning sign.

These days I rarely consider prescribing alprazolam unless alternatives medication options – and these are multiple including other benzodiazepene, antipsychotics, antidepressants and augmentation strategies - have been exhausted.

 

[Ironspy]

Like many, if not all of you, I inherit lots of patients who have been prescribed benzos for either insomnia or anxiety for a long time, often at high dose. A colleague of mine does a good job of slowly weaning her patients off benzos, but then they "fire" her and my employer then sends these benzo seeking patients to me because they request to see a different doctor (one of the joys of working at the VA.)

Usually, I decline to restart benzos, which results in drama on the part of the patient. I try to stay empathetic, but it is miserable having to deal with the bargaining, complaining, begging, and other manipulative attempts by these patients to obtain benzos. Sometimes they threaten violence, but mostly these patients are just verbally or emotionally abusive, and file complaint after complaint to the hospital. Each complaint takes time for me to address, which is also a miserable experience, having to defend safe practices. It causes me a lot of burn out symptoms. Despite my resentment toward these patients and my employer for putting me in this position, I maintain high patient satisfaction, but it is by far the hardest and most draining thing I do. Involuntary psychiatric holds are easier!

How do you handle such patients, and how do you manage your own thoughts and feelings in such a situation?

Your clinic needs a benzo policy. If VA admin fight you focus on how it's "unsafe patient care" etc. This should not be a negotiation with each individual patient as the clinic should have a straightforward policy. I wouldn't work at a place like this

 

[wolfvgang22]

Your clinic needs a benzo policy. If VA admin fight you focus on how it's "unsafe patient care" etc. This should not be a negotiation with each individual patient as the clinic should have a straightforward policy. I wouldn't work at a place like this

Yeah, I agree. The primary focus in the VA here is on veteran satisfaction, and my department is near top in the nation for VA mental health on patient satisfaction surveys because of the insane amount of effort and time I spend in negotiations with each patient weaning off benzos on my enormous panel. I have people who were on 250mg of valium since 1968. I've become skilled at keeping patients happy as I wean them, but my own mental health got really bad from the strain. I've learned my capacity for empathy has a limit.

 

[Armadillos]

This is really hard somewhere like a VA, where it was “you” (that VA, not you personally) who created the benzo problem, so now the VA can’t just kick these folks to the curb when patient behaves exactly how you expect someone addicted to benzos would. And now you personally feel stuck dealing with the problem, I agree with others that this is too big of an issue to go at alone.

Your facility needs to make sort of policy that the admins are onboard with so when complaints come it’s not a surprise or big deal.

 

[birchswing]

I have people who were on 250mg of valium since 1968.

Whoa.

I'm surprised there were pharmacies willing to fill that.

 

[uname943]

Yeah, I agree. The primary focus in the VA here is on veteran satisfaction, and my department is near top in the nation for VA mental health on patient satisfaction surveys because of the insane amount of effort and time I spend in negotiations with each patient weaning off benzos on my enormous panel. I have people who were on 250mg of valium since 1968. I've become skilled at keeping patients happy as I wean them, but my own mental health got really bad from the strain. I've learned my capacity for empathy has a limit.

What I'm hearing is that the VA doesn't truly value your job satisfaction. You aren't a priority. Your admirable efforts aren't reciprocated by either the VA or your drug seeking patients, making this a one-way relationship. It's good that you looked and found other job opportunities.

High patient satisfaction is substantially more financially rewarding in a private practice. It's certainly going to be better appreciated outside your current job.

 

[Stagg737]

Yeah, I agree. The primary focus in the VA here is on veteran satisfaction, and my department is near top in the nation for VA mental health on patient satisfaction surveys because of the insane amount of effort and time I spend in negotiations with each patient weaning off benzos on my enormous panel. I have people who were on 250mg of valium since 1968. I've become skilled at keeping patients happy as I wean them, but my own mental health got really bad from the strain. I've learned my capacity for empathy has a limit.

This is really hard somewhere like a VA, where it was “you” (that VA, not you personally) who created the benzo problem, so now the VA can’t just kick these folks to the curb when patient behaves exactly how you expect someone addicted to benzos would. And now you personally feel stuck dealing with the problem, I agree with others that this is too big of an issue to go at alone.

Your facility needs to make sort of policy that the admins are onboard with so when complaints come it’s not a surprise or big deal.

This is interesting because the primary VA I rotate through has a really strict policy with benzos. No one gets a new prescription and all but one of the outpt docs are actively titrating all their patients off of benzos. Even the people who've been stable on .5mg of Clonazepam Daily for 20 years aren't getting it refilled anymore, and the attendings I've talked to have said it's part of a new policy at our location. It's nice being able to say I'm not going to start someone on benzos because "that's the policy", but it's also frustrating telling those long-time stable users that the resident is weaning them off because the VA says so.

 

[Jules A]

It is exhausting and demoralizing to be criticized, threatened and constantly have to argue about what you know to be safe and appropriate practice. I have done it in short spurts for a significant higher rate than my usual in the cases of a psychiatrist retiring or being sanctioned and therefore dumping a large caseload of these patients on the community. I can not imagine having to deal with that on a regular basis. I try to remember that most of them are nice people who just had a bad prescriber and generally speaking the ones who are overtly nasty know what they are demanding is wrong and I will gently add that in if pushed. It also helps if you have access to skilled therapists and groups. Good luck.

This BTW is one of my favorite patient handouts from the VA interestingly enough. *First page only.

https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_%20Risk_Discussion_Guide.pdf

 

[wolfvgang22]

It is exhausting and demoralizing to be criticized, threatened and constantly have to argue about what you know to be safe and appropriate practice. I have done it in short spurts for a significant higher rate than my usual in the cases of a psychiatrist retiring or being sanctioned and therefore dumping a large caseload of these patients on the community. I can not imagine having to deal with that on a regular basis. I try to remember that most of them are nice people who just had a bad prescriber and generally speaking the ones who are overtly nasty know what they are demanding is wrong and I will gently add that in if pushed. It also helps if you have access to skilled therapists and groups. Good luck.

This BTW is one of my favorite patient handouts from the VA interestingly enough. *First page only.

https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_%20Risk_Discussion_Guide.pdf

Thanks, I really like this pdf! We have been given similar ones, but this one is better.

 

[downwithDTB]

Great page. Surprised that the VA wouldn't mention the associations with completed suicide...

As a super anti-benzo (except for cataonia) psychiatist, I will say that while the evidence against their use seems almost overwhelming, I've seen almost no quality research on the harms/benefits of stopping them, particularly for geriatric patients and/or patients who do not want to be tapered. Would love to read on that topic.

 

[Trismegistus4]

I feel somewhat vindicated the consensus in this thread seems to be that the only effective way to deal with this problem is to avoid taking these patients on in the first place. I am switching to all-inpatient work soon, but the only way I would ever do outpatient again is if I had full control over the practice and could decline referrals. I would find out why a person wanted to make an initial appointment with me and if it had anything to do with wanting to continue a chronic daily scheduled controlled substance, I would simply tell them I don't do that, recommend they go elsewhere, and hang up the phone.

Like the OP, though I don't work for the VA, I have had a lot of benzo-addicts dumped on me (usually by a psychiatrist out in the community retiring or ceasing to take Medicare, or just patients who moved here from out of town, present to a PCP in my system, who is understandably uncomfortable and tells them "I'll continue that prescription only until you can get in with a psychiatrist.") It has been incredibly exhausting and left me totally burned out.

People seem to want to let these patients off the hook by calling the problem "iatrogenic" and blaming it on the doctor who first gave them a benzo. While it's possible some of them saw an old-school doc who gave them the classic "here, take this" and they themselves were totally innocent, ISTM a lot of people got started prescription benzos by requesting them from a doc after trying a friend's or buying some off the street, so the patients are not blameless.

 

[Sushirolls]

What I'm hearing is that the VA doesn't truly value your job satisfaction. You aren't a priority. Your admirable efforts aren't reciprocated by either the VA or your drug seeking patients, making this a one-way relationship. It's good that you looked and found other job opportunities.

Some other person on SDN, or out in internet blog-o-sphere coined the phrase, "The hospital won't love you back."

There is variability even within the VA system, as other persons have pointed out that some were able adopt policies. The same thing exists even in some health systems. I've worked at one where there were no such policies and entirely clinician driven. I even offered to be a designated person to take the internal consults to provide concrete taper recommendations, or assume prescribing to complete the taper - it fell on deaf ears with the admin (medical and suits). I've heard of one health system in my area that has an aggressive limited/anti-benzo policy, which amazed me. The solution really is "prevention is worth a pound of cure" and not prescribing them in the first place.

At heart I am against the institutional policies that dictate practice, but when it comes to a controlled addictive substance like the opioids and benzos, I'm a bit more receptive to these such policies and any road blocks to them. Required prescription monitoring reports for each visit and refill? UDS for each refill visit? Random pill counts and random UDS at any point?

 

[Sushirolls]

I am switching to all-inpatient work soon, but the only way I would ever do outpatient again is if I had full control over the practice and could decline referrals.

Inpatient isn't immune to the benzo headache either. Patients will come to you on X mg of Y Benzo. Now you have to tell that patient, the taper is happening, and you may or may not be able to complete the taper. Then you also need to get an ROI to call their prescriber to let them know to stop refills or finish the reduced taper. And you need to call the pharmacy to cancel out the old/active prescriptions. All of that still will elicit many unhappy patients, and they too will out their discharge surveys. Most of the prescribers won't be reached, and those that are some don't care, or actually have no qualms about prescribing the X mg of Y benzo. A smaller fraction actually are appreciative and thank you for doing what they failed to do or didn't have the resolve to do. Then another long term issue, is you get patient Z off the benzos, then their next admission 1 month later, still off (yeah! success!), then admission 3 months, later still off, and at 9 months later is back on the benzo. Then this cycle repeats over the next few years. You take them off, and then some one at their community mental health clinic (which is a revolving door of ARNPs) restarts the benzo.

The other issue with inpatient, is how do the units work? I.e. are their other doctors and how often do they come on your unit? Who does call at night and the admission orders? Who rounds on the weekends? All these different points of other clinician contact could be the difference of starting orders that unleash the benzos as fresh starts... where you then have to tell the patients in the next day or two, nope, no more benzo - not as bad but still a pain.

The other issue is standard order sets. Who created them? And all gets to comment on their revisions? A lot of liberal benzo orders and even ambien PRNs may already be on there. I once lost a political battle to get rid of ambien off a standard order set to a psych a unit within a health system. Two older psychiatrists further up the political hierarchy overrided my attempts to get it off the standard admission order set.

 

[Jules A]

At heart I am against the institutional policies that dictate practice, but when it comes to a controlled addictive substance like the opioids and benzos, I'm a bit more receptive to these such policies and any road blocks to them. Required prescription monitoring reports for each visit and refill? UDS for each refill visit? Random pill counts and random UDS at any point?

Include stimulants and I'd be on board with restrictions and additional admin tasks in an effort to reduce inappropriate prescribing. Generally speaking in my area it is usually psychiatrists, aged ones, prescribing the cornucopia of uppers and downers not midlevels. Although PCPs of all disciplines are generally problematic across the board.

 

[Trismegistus4]

Inpatient isn't immune to the benzo headache either. Patients will come to you on X mg of Y Benzo. Now you have to tell that patient, the taper is happening, and you may or may not be able to complete the taper. Then you also need to get an ROI to call their prescriber to let them know to stop refills or finish the reduced taper. And you need to call the pharmacy to cancel out the old/active prescriptions. All of that still will elicit many unhappy patients, and they too will out their discharge surveys. Most of the prescribers won't be reached, and those that are some don't care, or actually have no qualms about prescribing the X mg of Y benzo. A smaller fraction actually are appreciative and thank you for doing what they failed to do or didn't have the resolve to do. Then another long term issue, is you get patient Z off the benzos, then their next admission 1 month later, still off (yeah! success!), then admission 3 months, later still off, and at 9 months later is back on the benzo. Then this cycle repeats over the next few years. You take them off, and then some one at their community mental health clinic (which is a revolving door of ARNPs) restarts the benzo.

The other issue with inpatient, is how do the units work? I.e. are their other doctors and how often do they come on your unit? Who does call at night and the admission orders? Who rounds on the weekends? All these different points of other clinician contact could be the difference of starting orders that unleash the benzos as fresh starts... where you then have to tell the patients in the next day or two, nope, no more benzo - not as bad but still a pain.

The other issue is standard order sets. Who created them? And all gets to comment on their revisions? A lot of liberal benzo orders and even ambien PRNs may already be on there. I once lost a political battle to get rid of ambien off a standard order set to a psych a unit within a health system. Two older psychiatrists further up the political hierarchy overrided my attempts to get it off the standard admission order set.

I'm aware you still have to deal with benzo-related issues on inpatient, but to me the biggest headache is the weight on my conscience of having continuity of care with patients I'm still prescribing benzos for. On inpatient, no matter how difficult and uncomfortable the discussion of initiating a taper may be, I do it, eventually discharge them or reach the end of my 7 days on, and they're not my problem anymore. Then I can sleep better at night. That's what I care about.

Plus, in my experience, although these discussions are difficult on inpatient too, they're still easier than on outpatient, since the patient is a captive audience and basically has to accept what you're doing.

 

[birchswing]

I feel somewhat vindicated the consensus in this thread seems to be that the only effective way to deal with this problem is to avoid taking these patients on in the first place. I am switching to all-inpatient work soon, but the only way I would ever do outpatient again is if I had full control over the practice and could decline referrals. I would find out why a person wanted to make an initial appointment with me and if it had anything to do with wanting to continue a chronic daily scheduled controlled substance, I would simply tell them I don't do that, recommend they go elsewhere, and hang up the phone.

Like the OP, though I don't work for the VA, I have had a lot of benzo-addicts dumped on me (usually by a psychiatrist out in the community retiring or ceasing to take Medicare, or just patients who moved here from out of town, present to a PCP in my system, who is understandably uncomfortable and tells them "I'll continue that prescription only until you can get in with a psychiatrist.") It has been incredibly exhausting and left me totally burned out.

People seem to want to let these patients off the hook by calling the problem "iatrogenic" and blaming it on the doctor who first gave them a benzo. While it's possible some of them saw an old-school doc who gave them the classic "here, take this" and they themselves were totally innocent, ISTM a lot of people got started prescription benzos by requesting them from a doc after trying a friend's or buying some off the street, so the patients are not blameless.

If they can buy them off the street why are they bothering psychiatrists? The people I've encountered are far too anxious to use anything not prescribed. Look at the message boards and YouTube. The Benzodiazepine Information Coalition is right now doing a study based on the hundreds of thousands of posts on benzobuddies.org

Also, whenever I have delved into recreational drug abuse forums to see what the scuttlebutt is, the users there seem to often be more knowledgeable that benzos are a no-go or to use them in limited circumstances to avoid tolerance.

I don't think benzo prescribing is just old-school, though I think it leans that way. I believe the current shift is a direct result of the opioid epidemic and the concomitant use of benzodiazepines in cases of overdose. Decades of prior prescribing despite the same evidence available today regarding harm seems to suggest it was a different factor that changed minds than available evidence. I think people were comfortable/ignorant of harms before and got spooked by regulations, even though they don't directly ban prescribing or even concomitant prescribing.

I strongly believe iatrogenesis is the major cause of benzodiazepine tolerance. There has never been any strong popularity of benzodiazepine designer analogues suggesting this is not a class of drugs people use to have a good time or get high. This is all-in-all a bad-time class of drugs.

 

[Trismegistus4]

If they can buy them off the street why are they bothering psychiatrists? The people I've encountered are far too anxious to use anything not prescribed. Look at the message boards and YouTube. The Benzodiazepine Information Coalition is right now doing a study based on the hundreds of thousands of posts on benzobuddies.org

Also, whenever I have delved into recreational drug abuse forums to see what the scuttlebutt is, the users there seem to often be more knowledgeable that benzos are a no-go or to use them in limited circumstances to avoid tolerance.

I don't think benzo prescribing is just old-school, though I think it leans that way. I believe the current shift is a direct result of the opioid epidemic and the concomitant use of benzodiazepines in cases of overdose. Decades of prior prescribing despite the same evidence available today regarding harm seems to suggest it was a different factor that changed minds than available evidence. I think people were comfortable/ignorant of harms before and got spooked by regulations, even though they don't directly ban prescribing or even concomitant prescribing.

I strongly believe iatrogenesis is the major cause of benzodiazepine tolerance. There has never been any strong popularity of benzodiazepine designer analogues suggesting this is not a class of drugs people use to have a good time or get high. This is all-in-all a bad-time class of drugs.

They prefer not to buy them off the street because that's more expensive.

The majority of them are not abusing benzos recreationally. They sincerely, legitimately believe that they need them for their allegedly severe anxiety and that they're the "only thing that works."

 

[birchswing]

They prefer not to buy them off the street because that's more expensive.

The majority of them are not abusing benzos recreationally. They sincerely, legitimately believe that they need them for their allegedly severe anxiety and that they're the "only thing that works."

I have a selection bias in that the people I encounter online believe that they are sick because of their benzodiazepines and believe they have ceased working. I think the only thing they would say they work for is benzodiazepine withdrawal itself.

I have come across a select few people in other psychiatry chats who say they have had control of their anxiety with a stable dose of a benzodiazepine over many decades. But the majority of forums favor people who believe their anxiety and other maladies have worsened because of the drugs. Again, selection bias. I'm curious whether you encounter patients who seem to be the select few where a stable dose of a benzodiazepine actually is effective over many decades (do they want an increased dose or to remain on the same dose?) or perhaps people who describe withdrawal symptoms as anxiety.

Another thing I find interesting is how with the opioid epidemic, there has been a pattern described by which a person becomes addicted to a prescribed opioid and when they can no longer obtain it, they use heroin. However, I have not heard such a pattern taking place with people prescribed benzodiazepines and switching to alcohol. Again it could be my selection bias where I see people in forums who avoid alcohol religiously (along with a laundry list of other substances thought to worsen withdrawal). But I also wonder if it's because there isn't a more similar equivalent like there is between prescribed opioids and heroin. From what I've read alcohol hits quite a number of receptors compared to the selective nature of benzodiazepines. I have never used alcohol so I have no idea what its effects feel like. But I am assuming it must be a good deal different for people to continue pursuing benzodiazepines when alcohol is so freely available.

 

[Stagg737]

I have a selection bias in that the people I encounter online believe that they are sick because of their benzodiazepines and believe they have ceased working. I think the only thing they would say they work for is benzodiazepine withdrawal itself.

Unless you're interacting with a pretty narrow group of individuals on these sites I wouldn't believe what many of them are saying. The patients I've encountered who truly feel that way are almost universally happy to be tapered off of them (though certainly anxious about it). The ones who weren't said they wanted to get off them because they weren't working, but when offered would become upset because they're anxiety is "so much worse" when they don't take the benzo (aka it's still working) and just didn't have the insight/awareness to their situation that they think they do.

The only way I could really see them being 100% honest online is if they're either not telling their prescribers that they don't like being on them or the prescribers are actively encouraging them to continue taking them. Both are certainly possible, but I think a lot of those people will say they want off but are still in the pre-contemplative or contemplative stage of getting off of them and aren't actually ready to get off of them.