Med malpractice reviewer: fall after Ativan and Tramadol prescriptions

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As a psychiatrist, I agree with the expert witness. If someone is admitted for SI, there is absolutely no way I am giving them more than a 30 day script without refills for non-controlled medications. But first, I ask the patient, call the patient's pharmacy or call the patient's family to find out if he/she has enough of his/her medications to last until psych follow-up. Most states also have prescription monitoring programs, so the physician could have pmp'ed the patient to see what the current lorazepam prescription was and when it was last filled. Just my two cents.
 
I love how they make the argument that collateral could have saved this case when quite often patients refuse to allow you to contact collateral on inpatient units
 
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We never discharged people with more than 2 weeks of meds, a whole month is pretty generous. I was surprised the psychiatrist would refill meds unrelated to psych though. There’s even an antibiotic in there.
 
Yep, usually two week prescriptions at the academic hospital I work out, but our VA usually gives 30 day supplies.
 
Oy…
The more of these I see the more hard core I become in never prescribing opioids to patients taking benzos for any reason. That said, remarkably few patients have left my practice as a result of this policy (maybe one or two per year), so from a risk-benefit perspective, even given the risk of angering patients or referral sources, the benefit seems like the clear winner.
 
Mad Jack said:
I love how they make the argument that collateral could have saved this case when quite often patients refuse to allow you to contact collateral on inpatient units
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Idk if it's different where you are, but where I am patients do not need to consent for you to call their outpatient pharmacist or outpatient psychiatrist. The only restriction would be if it were related to addiction treatment, but it sounds like the inpatient doctor here didn't know about the substance use problems. We also wouldn't need consent to call the wife and ask for information, but would need consent to convey information to her.
 
ObsequiousAplomb said:
Idk if it's different where you are, but where I am patients do not need to consent for you to call their outpatient pharmacist or outpatient psychiatrist. The only restriction would be if it were related to addiction treatment, but it sounds like the inpatient doctor here didn't know about the substance use problems. We also wouldn't need consent to call the wife and ask for information, but would need consent to convey information to her.
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How does one obtain collateral if the patient doesn't provide the information? If they don't tell you who their providers are, you won't know who to contact. If they say you can't talk to their emergency contacts, you can't. Unless you happen to have access to records in-system to know what is going on, you're kind of SOL. In my state you couldn't call the patient's wife without their consent, as that would inform their wife that they are hospitalized. Literally the only person we're allowed to contact is whomever petitioned the involuntary commitment and potentially their other providers if they are known to us, but you have to be very careful with anything regarding substance use treatment due to 42 CFR.
 
why in the world 1 month supplies?



MadJack - in those cases, the existing records and PMP are the only tools i can access. sometimes you can call the pharmacy.

i find that inpatient services dont necessarily do the foot work to call the prescribing physicians. too much other "stuff" to do, like document on the chart...
 
Mad Jack said:
How does one obtain collateral if the patient doesn't provide the information? If they don't tell you who their providers are, you won't know who to contact. If they say you can't talk to their emergency contacts, you can't. Unless you happen to have access to records in-system to know what is going on, you're kind of SOL. In my state you couldn't call the patient's wife without their consent, as that would inform their wife that they are hospitalized. Literally the only person we're allowed to contact is whomever petitioned the involuntary commitment and potentially their other providers if they are known to us, but you have to be very careful with anything regarding substance use treatment due to 42 CFR.
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There are many databases that include pharmacy records. If you don't do that then you ask the patient where they want their Rx sent. Once you know the pharmacy chain you call them. They tell you the prescriptions and the doctors who prescribe them, including the phone numbers. For controlled substances it's even easier since you should be checking the PDMP/PMP anyway.
 
ObsequiousAplomb said:
There are many databases that include pharmacy records. If you don't do that then you ask the patient where they want their Rx sent. Once you know the pharmacy chain you call them. They tell you the prescriptions and the doctors who prescribe them, including the phone numbers. For controlled substances it's even easier since you should be checking the PDMP/PMP anyway.
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PDMP is a maybe, depending on when their prescription was etc. I work in 2 states at the moment and have worked in a third, and the availability of pharmacy records is highly variable based on the state, EMR, and pharmacy being used when it comes to non-controlled substances. Smart substance using patients will not be honest about their pharmacy because they know the game and don't want you talking with their doctors. PDMP can be useful in those cases but realistically if a patient was tapered off a benzo by a prior provider how often are you going to call them and actually get a response back to discuss why that occurred? Getting callbacks from some providers is borderline impossible. Generally the only time I'm going to be able to assume it was due to abuse is if they had a suspicious history (early fills, multiple providers, etc).

I suppose all of this is to say, there's a lot of variables when it comes to collateral and it is hard to make judgments without knowing a lot of specifics we're not privy to.
 
thats ridiculous. sets up abuse by giving patients discharged a one month supply.

we wrangle about giving 1 month supplies to patients where we know patient specific details like their pharmacy, home address, cell phone number, home number, office number, PCP number, social security number, etc. we force them to come in every month/every other month to check how they are doing.

yet a hospitalist is going to give a month supply to someone who they have none of that information on?
 
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Ducttape said:
thats ridiculous. sets up abuse by giving patients discharged a one month supply.

we wrangle about giving 1 month supplies to patients where we know patient specific details like their pharmacy, home address, cell phone number, home number, office number, PCP number, social security number, etc. we force them to come in every month/every other month to check how they are doing.

yet a hospitalist is going to give a month supply to someone who they have none of that information on?
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Because they assume the patient will find a doc “on the outside” within a month to take over. How is it much different from a patient who goes to an ER with a roaring radic obviously, gets a shot of Toradol, some bs ct of the abdomen to rule out “kidney stones” and told to follow up somewhere. Oh and they are discharged with 10 percs just so they can get their palate wet a little
 
Serotonin Syndrome at its finest …
Mirtazapine with tramadol, is a no no .
Add the fact you just added a new antibiotic with Ativan. Further liver inhibition and prolonged benzo effects.

Do not mix antidepressants with tramadol.
Do not start antibiotics without reducing Benzos.
Do not add qtc prolonging drugs(many of them ) with bupi, or anti seizures , etc

Basic pharmacology and , pharmacodynamics.
Essentially every medication prescribed was conflicting
 
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10KHertz said:
Serotonin Syndrome at its finest …
Mirtazapine with tramadol, is a no no .
Add the fact you just added a new antibiotic with Ativan. Further liver inhibition and prolonged benzo effects.

Do not mix antidepressants with tramadol.
Do not start antibiotics without reducing Benzos.
Do not add qtc prolonging drugs(many of them ) with bupi, or anti seizures , etc

Basic pharmacology and , pharmacodynamics.
Essentially every medication prescribed was conflicting
Click to expand...
Speaking of basic psychopharmacology, Bactrim doesn't affect UDP glucuronyltransferase, and does not prolong the effects of Ativan. The only significant interaction Ativan has here is increased risk of sedation with the Remeron and Ultram. That was probably the intent, seeing as the patient was discharged taking three sedating medications.

Is 90 tablets of Ativan 1 mg when the instructions are to take two tablets multiple times a day really a 30 day supply? I still wouldn't do what this doctor did, but it seems more like a two week supply of the Ativan.

My real question is why a psychiatrist was discharging someone with that much Bactrim. If I were giving that long a Bactrim supply, I would absolutely be getting a medical consult because that doesn't sound like a simple UTI.
 
MitchLevi said:
SSRI + tramadol is a board Q without significant clinical representation. I've given tramadol to thousands of ppl, many of whom take an SSRI. Never seen SS, a Dx that doesn't happen overnight.

Tramadol is preferred IMO.
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I have one patient on a bupi patch and tramadol l. The patch was started to attempt to wean off of a tramadol plus oxycodone high dose regimen. What are peoples thoughts about concurrent tramadol and bupi? I’ve searched and seems like people on suboxone have used tramadol without any significant adverse effects.
 
dipriMAN said:
I have one patient on a bupi patch and tramadol l. The patch was started to attempt to wean off of a tramadol plus oxycodone high dose regimen. What are peoples thoughts about concurrent tramadol and bupi? I’ve searched and seems like people on suboxone have used tramadol without any significant adverse effects.
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All day long. No issues. Extra safety over conventional opiate therapy.
 
lobelsteve said:
All day long. No issues. Extra safety over conventional opiate therapy.
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Any concerns for seizures? I have a few patients with seizure disorder that I’ve also consider trialing on Butrans but have hesitation. One I did start because she has been difficult to manage otherwise.
 
Lots of cowboys out there . Ask your patients more question and maybe you’d see SS more. Esp in our field.
Not sure where it say all say and night … 😂
pubmed.ncbi.nlm.nih.gov

Serotonin syndrome: is it a reason to avoid the use of tramadol with antidepressants? - PubMed

Review of the available case reports of tramadol combined with antidepressant drugs in therapeutic doses indicates caution in regard to the potential for SS but does not constitute a contraindication to their use. Tramadol is only contraindicated in combination with MAOIs but not other...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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ObsequiousAplomb said:
Speaking of basic psychopharmacology, Bactrim doesn't affect UDP glucuronyltransferase, and does not prolong the effects of Ativan. The only significant interaction Ativan has here is increased risk of sedation with the Remeron and Ultram. That was probably the intent, seeing as the patient was discharged taking three sedating medications.

Is 90 tablets of Ativan 1 mg when the instructions are to take two tablets multiple times a day really a 30 day supply? I still wouldn't do what this doctor did, but it seems more like a two week supply of the Ativan.

My real question is why a psychiatrist was discharging someone with that much Bactrim. If I were giving that long a Bactrim supply, I would absolutely be getting a medical consult because that doesn't sound like a simple UTI.
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😂 yes it exits friend

Trimethoprim/Sulfamethoxazole-Induced Severe Lactic Acidosis: A Case Report and Review of the Literature - PMC

Propylene glycol (PG) is used as a solvent in numerous medications, including trimethoprim/sulfamethoxazole (TMP/SMX) and lorazepam, and is metabolized in the liver to lactic acid. Cases of lactic acidosis related to PG toxicity have been described ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
10KHertz said:
Lots of cowboys out there . Ask your patients more question and maybe you’d see SS more. Esp in our field.
Not sure where it say all say and night … 😂
pubmed.ncbi.nlm.nih.gov

Serotonin syndrome: is it a reason to avoid the use of tramadol with antidepressants? - PubMed

Review of the available case reports of tramadol combined with antidepressant drugs in therapeutic doses indicates caution in regard to the potential for SS but does not constitute a contraindication to their use. Tramadol is only contraindicated in combination with MAOIs but not other...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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What is it that you think you've proven with this post, and to whom are you referring with the term "cowboy?"

"Ask your pts more Qs?"
 
10KHertz said:
Cowboy refers to persons that believe SSRIs and tramabol are compatible all day and night .. SS is high on the differential diagnosis.

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The real cowboy here is the person who thinks the IV solvent having a potential to cause toxicity means two PO formulations without the solvent means one drug alters the metabolism of the other.

Serotonin syndrome has wide variance in presentation. The mild cases are clinically meaningless. The severe cases can be fatal. Asking for questions and searching for a syndrome that isn't clinically meaningful is an exercise in obstinate pseudo-academics. Sure, any single serotonergic medication CAN cause SS even at the starting dose. Combinations and higher doses increase that risk. When it comes to a clinically irrelevant level of SS, who cares?
 
Turned 42 yo today, and the following graphic is how I rewarded myself. I spent 44 min of a 1:41 trail run anaerobically. Your cowboy statement is ignored.
Screenshot_20220417-130435_WHOOP.jpg
 
ObsequiousAplomb said:
The real cowboy here is the person who thinks the IV solvent having a potential to cause toxicity means two PO formulations without the solvent means one drug alters the metabolism of the other.

Serotonin syndrome has wide variance in presentation. The mild cases are clinically meaningless. The severe cases can be fatal. Asking for questions and searching for a syndrome that isn't clinically meaningful is an exercise in obstinate pseudo-academics. Sure, any single serotonergic medication CAN cause SS even at the starting dose. Combinations and higher doses increase that risk. When it comes to a clinically irrelevant level of SS, who cares?Remeron is
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Remeron is no ordinary ssri friend. Read the direct interaction with tramadol, fairly significant. Being callus about this interaction is sophomoric and ignorant at best … but you’re so experienced with every day usage that it doesn’t matter , right? That’s your rebuttal?
 
I write tramadol all the time for patients on standard dose of a single SSRI. Not a single issue in 15 years.

Half of our pain population is on an SSRI, and I'm certainly not going to start them on percs just because of fearmongering by those without clinical experience such as pharamacists. Much more chance for harm by starting chronic opioids, than starting tramadol in >90% of clinical scenarios.

I am definitely more cautious if patient is a sky high dose of SSRI/SNRI and/or multiple meds strongly affecting serotonin but for the average patient on the average dose of zoloft or celexa, tramadol is and will continue to be written by me, instead of a pure opioid.

(BTW, I don't think it is appropriate to call remeron an SSRI. Remeron is far closer to a TCA, than an SSRI)
 
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MitchLevi said:
Turned 42 yo today, and the following graphic is how I rewarded myself. I spent 44 min of a 1:41 trail run anaerobically. Your cowboy statement is ignored.
View attachment 353512
Click to expand...
That’s great for you , keep it up .
Not sure what this has to do with anything…
I don’t run , I only play 4.5-5.0 usta singles
 
MitchLevi said:
Turned 42 yo today, and the following graphic is how I rewarded myself. I spent 44 min of a 1:41 trail run anaerobically. Your cowboy statement is ignored.
View attachment 353512
Click to expand...
That’s great for you , keep it up .
Not sure what this has to do with anything…
I don’t run
bedrock said:
I write tramadol all the time for patients on standard dose of a single SSRI. Not a single issue in 15 years.

Half of our pain population is on an SSRI, and I'm certainly not going to start them on percs just because of fearmongering by those without clinical experience such as pharamacists. Much more chance for harm by starting chronic opioids, than starting tramadol in >90% of clinical scenarios.

I am definitely more cautious if patient is a sky high dose of SSRI/SNRI and/or multiple meds strongly affecting serotonin but for the average patient on the average dose of zoloft or celexa, tramadol is and will continue to be written by me, instead of a pure opioid.

(BTW, I don't think it is appropriate to call remeron an SSRI. Remeron is far closer to a TCA, than an SSRI)
Click to expand...

I only play 4.5-5.0 usta singles
bedrock said:
I write tramadol all the time for patients on standard dose of a single SSRI. Not a single issue in 15 years.

Half of our pain population is on an SSRI, and I'm certainly not going to start them on percs just because of fearmongering by those without clinical experience such as pharamacists. Much more chance for harm by starting chronic opioids, than starting tramadol in >90% of clinical scenarios.

I am definitely more cautious if patient is a sky high dose of SSRI/SNRI and/or multiple meds strongly affecting serotonin but for the average patient on the average dose of zoloft or celexa, tramadol is and will continue to be written by me, instead of a pure opioid.

(BTW, I don't think it is appropriate to call remeron an SSRI. Remeron is far closer to a TCA, than an SSRI)
Click to expand...
Yes I agree remeron is legit serotoninogenic player. If people actually had read the case presented , they’d know better to not mess around with tramadol on this patient .but again a bunch of cowboys Talking trash as usual . To narcissistic to actually listen themselves talk nonsense …
 
10KHertz said:
Not sure what this has to do with anything…
Click to expand...
It's been a great day for me, and I refuse to allow your unwarranted and baseless accusation bother me. Initially it did, then I realized the absurdity of it and figured I'd move on with the rest of my day.

Surely you don't think you're the only person in this forum who has read some of the literature on tramadol and SS.

We've all read the same things as you. You're no smarter or well informed than anyone else in here.

I will continue to regularly Rx tramadol to individuals on an SSRI assuming the doses are reasonable and the pt is a good candidate for medical management.

Good day man.
 
MitchLevi said:
It's been a great day for me, and I refuse to allow your unwarranted and baseless accusation bother me. Initially it did, then I realized the absurdity of it and figured I'd move on with the rest of my day.

Surely you don't think you're the only person in this forum who has read some of the literature on tramadol and SS.

We've all read the same things as you. You're no smarter or well informed than anyone else in here.

I will continue to regularly Rx tramadol to individuals on an SSRI assuming the doses are reasonable and the pt is a good candidate for medical management.

Good day man.
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Are you okay friend? I said remeron and tramadol interact significantly. I don’t care about your heart rate …

“It has been suggested that more than 85% of physicians are unaware of the existence of SS or of which drugs or drug combinations are capable of causing it.”
 
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MitchLevi said:
I'm far too strong for stuff like that.
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Haha. I'm sure you are.

But seriously, it is the ultra-fit bikers and runners that spend a lot of time in anaerobic heart rates that get afib (3–8-fold increased risk). It's a real thing. I'm just saying, slow down to 60% max HR, not 80%.
 
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10KHertz said:
Remeron is no ordinary ssri friend. Read the direct interaction with tramadol, fairly significant. Being callus about this interaction is sophomoric and ignorant at best … but you’re so experienced with every day usage that it doesn’t matter , right? That’s your rebuttal?
Click to expand...

At what point did anyone here call Remeron an SSRI? That's such a bold, absurd strawman it really does make any argument you make seem incredibly childish. You're completely ignoring the actual content of everyone's post to make silly statements that every single person in this thread is well aware of.

Your use of "friend" here is very condescending. I've gotta ask, do you enjoy being a boorish know-it-all without any actual knowledge?

I'm not being callus about this interaction. I'm aware of the actual pharmacokinetics and pharmacodynamics. You know, like anyone who should be commenting on this topic and clearly unlike you, Mr "IV formulation same as PO, right??"
 
MitchLevi said:
Turned 42 yo today, and the following graphic is how I rewarded myself. I spent 44 min of a 1:41 trail run anaerobically. Your cowboy statement is ignored.
View attachment 353512
Click to expand...
Doing a Ragnar Relay next friday.
Can PM my garmin stats after....

Just have fun.
 
GoBeers said:
You ran 20 miles at a 5 minute clip??? Wow
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No, the 20.2 is the strain rating. I don't know the distance I did.

BTW, my only reason to post that was to say I've had a great day today and being called a "cowboy" for Rx'ing tramadol on top of an SSRI isn't gonna bother me.
 
ObsequiousAplomb said:
At what point did anyone here call Remeron an SSRI? That's such a bold, absurd strawman it really does make any argument you make seem incredibly childish. You're completely ignoring the actual content of everyone's post to make silly statements that every single person in this thread is well aware of.

Your use of "friend" here is very condescending. I've gotta ask, do you enjoy being a boorish know-it-all without any actual knowledge?

I'm not being callus about this interaction. I'm aware of the actual pharmacokinetics and pharmacodynamics. You know, like anyone who should be commenting on this topic and clearly unlike you, Mr "IV formulation same as PO, right??"
Click to expand...
Cognitive dissonance…
Did you read the case report in the thread pal?
I said pretty clearly remeron and tramadol are contraindicated, and likely caused SS. Remeron or any other atypical antipsychotic doesn’t have to be a ssri to cause SS bro…

Let’s me more clear my friend : you're an idiot to prescribe remeron with tramadol .

And since you made it personal, it is unlikely you are even close to my level of training friend. Happy to have that sword fight…
 
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MitchLevi said:
No, the 20.2 is the strain rating. I don't know the distance I did.

BTW, my only reason to post that was to say I've had a great day today and being called a "cowboy" for Rx'ing tramadol on top of an SSRI isn't gonna bother me.
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i was about to say... that would be absolute elite running.
i have a few marathons and century ride coming up this year but have not been able to find any semblance of consistency in training. just all pain no gain lol
 
GoBeers said:
i was about to say... that would be absolute elite running.
i have a few marathons and century ride coming up this year but have not been able to find any semblance of consistency in training. just all pain no gain lol
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Not sure what I can do at 20 miles. Fastest 5k is 16:20. Today total unknown. It is trails too, with decent elevation changes. Did a marathon carrying a large US flag while wearing camouflage and boots. Don't recall time.

Also, time and podium finishes. None of that matters. Have fun and do what you can. It isn't that sexy to win an event you paid to be in...
 
MitchLevi said:
Not sure what I can do at 20 miles. Fastest 5k is 16:20. Today total unknown. It is trails too, with decent elevation changes. Did a marathon carrying a large US flag while wearing camouflage and boots. Don't recall time.

Also, time and podium finishes. None of that matters. Have fun and do what you can. It isn't that sexy to win an event you paid to be in...
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oh i hear you.
mostly just checkboxes for me. i do aim to train 9 months next year for iron man arizona.

if i can do iron man, then i can tell my patients to get off their chair and do physical therapy lol
 
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