Need psych advice on BENZOS

[deleted185747]

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I'm a pain physician and I prescribe opioids carefully. I have inherited many patients on benzos (usually ativan 1mg po TID prn anxiety) sometimes temazepam qhs as well.

My question is how does a psychiatrist evaluate/decide if a patient should be on benzos or not?

Thanks

 

[TheRiddler]

how does a psychiatrist evaluate/decide if a patient should be on benzos or not?

Very carefully.

 

[birchswing]

I know this is controversial (also you should know I am not a doctor), but from what I have read, patients should be told good information about benzodiazepines, but withdrawal should also be patient-directed (and slow). On the other hand, I think a doctor could play a helpful role in assuaging a patient's fears about withdrawal, as many patients cannot find benzo competent doctors, self-seek information, and while much of it is helpful, much of it is also quite frightening and full of horror stories about withdrawal. I can't speak from the benefit of my experience, but those are general assessments I can give.

I've also seen cases in my life of people who were prescribed them PRN and have truly used them that way, and it has been helpful to them. It is the indefinite, daily therapy that confounds me, as it has no proven benefits for anxiety, is actually shown to worsen anxiety, and causes a lot of unintended problems.

 

[shan564]

My question is how does a psychiatrist evaluate/decide if a patient should be on benzos or not?

They probably shouldn't. I can only think of three really good reasons to be taking scheduled benzos daily - (1) if the patient has been on benzos for decades and they just haven't started tapering them yet, (2) if the patient has a weird neurological/neuropsychiatric illness that only responds to benzos, like stiff person syndrome, or (3) if the patient is terminally ill.

If the patient is actually taking Ativan TID for an anxiety disorder, the benzo is probably doing more harm than good. The patient is probably suffering from chronic cognitive attenuation and impaired neuroplasticity that's getting in the way of their ability to recover from the illness from a cognitive-behavioral perspective. And they've probably developed enough GABAergic resistance so that the Ativan is now just treating Ativan deficiency. The patient gets anxious right before the next Ativan dose, but that anxiety is probably from benzo withdrawal.

When patients come in taking something like Ativan TID, most of the attendings I've worked with will switch them to a longer-acting benzo (usually clonazepam, since it's a bit cleaner than the other options) and then taper off the drug as aggressively as possible without producing serious withdrawal symptoms. The longer-acting benzos tend to self-taper to some extent, so that's usually not hard to do. Some patients have trouble sleeping, so we might keep them on a small dose of clonazepam qHS. Once the patient is past the withdrawal period, then they can use a benzo PRN and it'll be much more effective, since their GABA receptors are sensitive again. But I'd only prescribe PRN benzos if it's clear that the patient is capable of actually using them on a PRN basis... often, I think that the Ativan originally gets written as "TID PRN," and eventually the patient is just taking it TID.

I think this is especially tricky to navigate in a chronic pain patient, since they're often using opioids to manage their anxiety, which is way worse than managing anxiety with benzos. If it's a patient who is terminally ill, I'd probably actually encourage a bit of benzo use to decrease opioid use.

There is no easy answer to your question because different psychiatrists treat benzos differently. A lot of people are OK with using them on a short-term and/or PRN basis. Some psychiatrists will just say that all patients should be switched to a long-acting benzo and then tapered aggressively. I don't think that many psychiatrists would try to defend the decision to leave a patient on TID Ativan unless there are exceptional circumstances.

 

[splik]

1. benzodiazepines should not really be prescribed PRN for anxiety (sleep is different). prn benzos tend to worsen anxiety as they increase anticipatory anxiety and prevent exposure to the anxiety-provoking stimulus and thus habituation. benzos should be scheduled for acute severe anxiety, and not used for more than 2-4 weeks. the evidence for benefit beyond 6 weeks is not there, and they appear to worsen anxiety after this point. the other problem with PRN is you really don't know what the patient is doing with them more so than scheduled - how many pills are they taking? how many are they selling etc?

2. patients often become dependent on benzos well within the therapeutic range and often unintentionally. in these cases slow tapers are required, and negotiating with the patient. don't force patients on a taper given benzodiazepine withdrawal can be very uncomfortable, and even life-threatening. patients can also develop psychotic reactions including become violent and suicidal on withdrawal from benzos.

3. how fast you taper depends on how often you see the patient. I had a pt in the ICU who was previously taking 30mg xanax a day, and rapidly tapered her off benzos in 4 days without event. but she was in the ICU. On an inpatient unit you could also attempt rapid, but not ultra-rapid tapers. If you are seeing someone weekly as an outpatient you could reduce the dose every week. if you are see a patient every month, then reducing the dose more frequently than qmonth may be problematic.

4. there is never a reason to use xanax. ever. just don't do it.

5. in terms of patients you inherit - this is difficult. the combo of opiates and benzodiazepines should make everyone uncomfortable. you need to be able to justify it. if you don;t feel comfortable prescribing benzos then don't prescribe them. there is no reason you HAVE to.

6. if you are continuing long-term benzodiazepine therapy you should be informing and documenting that the patient is informed there is no evidence of benefit, and their risk of death is significantly greater from all causes. if they are receiving opiates as well they should be warned of the increased risk of death from unintentional overdose. they should be switched to the equivalent dose of diazepam and PRNs should be converted to scheduled. they should be advised not to take extra doses. consider giving no refills.

7. patients with significant anxiety that does not appear related to benzodiazepine withdrawal, other substance abuse/intoxication, or another medical condition (e.g. hyperthyroidism) should be offered an SSRI typically at a lower dose than for depressive illness (e.g. 10mg prozac, 12.5-25mg zoloft). consider using the GAD-7 self-report tool to assess anxiety symptoms. they should be warned of possible increase in anxiety during initial 2 weeks of treatment and benzos should be continued to begin with.

8. gabapentin is sometimes used for anxiety. this drug has abuse potential too, possible street value, and has been associated with a potentially life-threatening withdrawal syndrome. beware.

9. personally i think temazepam for sleep is no worse than ambien, and may actually more benevolent.

p.s. clonazepam is not a long-acting benzo, it is a medium acting benzo like lorazepam. valium and librium are the most widely available long-acting benzos, and in general if you are tapering you should switch to one of these (usually diazepam). I will confess to having used clonazepam for benzo tapers but this is NOT what is recommended in the guidelines, in fact Heather Ashton who was the world expert in benzodiazepine dependence/withdrawal explicitly says clonazepam shouldn't but used like this.

 

[shan564]

A lot of people prefer clonazepam because it doesn't have active metabolites like valium and librium. Also, valium seems to have higher abuse potential because of its rapid onset. This is anecdotal, but I feel like patients tend to do better when switched from valium to klonopin, and I always attributed that to the fact that it's a cleaner drug. Also, I didn't say that clonazepam is "long" acting, I said "longer" with respect to lorazepam. The half-life is significantly longer. Valium and librium last longer and accumulate because of their metabolites... I'd rather just have control over how much of the drug the patient is getting.

When I say "PRN for anxiety," I meant situations like refractory panic attacks and the like. My experience is quite limited, but I haven't seen many situations in which the patient is experiencing "acute severe anxiety" that appears to be genuinely acute. The only exceptions I can think of were pregnant women - I had two patients in that situation, both of whom were already on benzos and had this acute anxiety after stopping the benzo upon learning they were pregnant. Unless you count patients who have anxiety from corticosteroids or some other general medical illness/drug - in that case, I'm all for giving scheduled benzos.

 

[Leo Aquarius]

Why is a 1st year resident who has a total of 5 whole months of residency under his belt telling us how to prescribe benzos??????? ???????? (btw, claiming to have clinical "anecdotal" information can only be used after there are years of experience under one's belt.)

This reminds me of school where the kid who always raised his hand in class gave long-winded answers, and everyone else stayed quiet out of politeness.

 

[shan564]

I don't think I ever said "this is what you should do." I mostly said things like "this is what I've seen people do" mixed in with a couple of examples of "this is what I would do." The only two people posting above me were a med student and a "not a doctor"... if a more experienced person had already answered the question, I wouldn't have bothered.

Also, I'm not telling "you" (or rather, the collective "us" to which you referred) anything. My intent was to help provide some frame of reference for a non-psychiatrist by saying "here's what I've seen psychiatrists do, and here was their rationale for doing it." If somebody with more experience has better advice, I'm all for following it.

But in case I didn't make it clear enough earlier, I'll clarify now that I have very little relative experience and everything that I say is based on what I've learned from literature or from people who have a lot more experience. Don't take my advice over that of an attending psychiatrist. And if somebody corrects me, they're probably right.

 

[TexasPhysician]

I think we are getting a little off topic from the OP's question. This may be the case due to the fact that there is probably no single answer to that question. There are MANY ways to determine benzo usage that varies by clinician.
I personally believe benzos have gotten a more negative rap than deserved by many clinicians, likely due to some clinicians being too trigger happy in their prescribing.

Tapering benzo's is another topic that is equally as hotly debated.

 

[SmallBird]

Why is a 1st year resident who has a total of 5 whole months of residency under his belt telling us how to prescribe benzos??????? ???????? (btw, claiming to have clinical "anecdotal" information can only be used after there are years of experience under one's belt.)

This reminds me of school where the kid who always raised his hand in class gave long-winded answers, and everyone else stayed quiet out of politeness.

Probably more fair to look at what his advice is - evidence is more important than eminence after all - and in this case Shan makes an excellent argument.

 

[SuperSoccer19]

Very carefully.

And the most useful and fact based post in this forum goes to TheRiddler...this is not a joke.

 

[Salpingo]

I'm a pain physician and I prescribe opioids carefully. I have inherited many patients on benzos (usually ativan 1mg po TID prn anxiety) sometimes temazepam qhs as well.

My question is how does a psychiatrist evaluate/decide if a patient should be on benzos or not?

Thanks

I'm curious how you evaluate/decide on using opiates for your patients.

The overall evaluation is probably the same. The initial history may include more time on substance abuse, plumbing for details (e.g. when the person says "social drinker", getting a sense of how often, how many and how much). If the person is a recovering addict, most often the patient is educated enough to want to avoid benzos on their own. If they maintained their sobriety through AA/NA, you can ask them about "person, places, or things", with extra concern if they appeared to be using substance to self-medicate distress. For drug-seekers, the universal red flags apply: asking for medication by name, having multiple prescribers, unlikely allergies, splitting behavior ("nobody understands my pain like you... all those other doctors are frauds"), etc. Different states have enacted different means to track overprescription of schedule II substances, but if you have concerns you can also contact the patient's pharmacy.

As mentioned above, Xanax/alprazolam is a major concern, and is probably the benzo equivalent of "the only thing that works for my pain is Dilaudid... IV... with Benadryl..." It has somewhat different receptor activity than the other benzos, with quick onset, short half-life and consequently bad rebound anxiety. Some people may prescribe it for short, anxiety-provoking events, such as a plane taking off, but the pill counts in those cases would be very low.

Once you establish that benzos won't establish more harm than good, Splik pretty much nails the indications. Its mostly a bridge for severe panic attack in the 2-4 weeks it takes more meaningful therapy to kick in (e.g. SSRIs, CBT/exposure-based therapy). Otherwise, its simply a matter of taking a good history to see when the symptoms occur. If the person has ruminative thoughts and anxiety that keeps them up at night, a small dose of clonazepam may be helpful. It can also be useful if the person has an agitated depression (often seen in geriatric patients in the am). Benzos are an essential component of acute mania, which you would hopefully not be seeing in the pain management office.

 

[birchswing]

6. if you are continuing long-term benzodiazepine therapy you should be informing and documenting that the patient is informed there is no evidence of benefit, and their risk of death is significantly greater from all causes.

I have read that there is an increased risk of death from long-term benzodiazepine use, as well (on wikipedia), but it doesn't say specifically what. When you say all causes, does that mean there is an increased risk for every cause of death? Or are there specific systems that are affected?

What upsets me is that I know for a fact there are doctors who don't believe this. In fact, I know of one specifically who believes long-term benzodiazepine therapy is the first answer for anxiety issues. Not seeking medical advice here, but I was put on Ativan as needed when I was 14 up to 2 mg a day. As needed given my problems meant I took 2 mg a day to get through a day of school. I would go off in the summers, which wasn't pleasant. When I went to a pressure cooker college, the psychiatrist I saw there added Klonopin to take not as needed but daily, indefinitely. When I told him I was already concerned about the Ativan use, he said that Klonopin was nothing like Ativan. Klonopin was for long-term use and he had patients on it for over 15 years. He convinced me that it was not addictive. He compared it to an anti-depressant for anxiety. And this was a university's psychiatrist--the only one, in fact. It did not not help, and I ended up dropping out of college, on both Ativan and Klonopin at that point. I still think I was misdiagnosed and probably had ADHD. Anyhow--not seeking medical advice. It's just too difficult with this topic for me not to be vocal. There is still ignorance on this topic and it really can contribute to the ruin of a person's life.

 

[hamstergang]

I have read that there is an increased risk of death from long-term benzodiazepine use, as well (on wikipedia), but it doesn't say specifically what. When you say all causes, does that mean there is an increased risk for every cause of death? Or are there specific systems that are affected?

When we talk about "all cause mortality" we mean death from all causes bundled together. That is, it is NOT the case that long term benzos make it more likely that you die from heart disease and more likely that you die from infection and more likely that you die from brain tumors and ... It is the case that long term benzos make it more likely that you die younger, be it from heart disease or infection or brain tumors or... (at least that's what they're saying, I'm only serving as a translator, not providing my own input).

 

[shan564]

Generally, people with serious psychiatric disease also have significantly higher all-cause mortality. Benzos are associated with higher all-cause mortality, but I don't think we can reliably say how much of that change is caused by the benzo and how much of it is caused by the disease that the benzo is treating.

 

[birchswing]

When we talk about "all cause mortality" we mean death from all causes bundled together. That is, it is NOT the case that long term benzos make it more likely that you die from heart disease and more likely that you die from infection and more likely that you die from brain tumors and ... It is the case that long term benzos make it more likely that you die younger, be it from heart disease or infection or brain tumors or... (at least that's what they're saying, I'm only serving as a translator, not providing my own input).

Generally, people with serious psychiatric disease also have significantly higher all-cause mortality. Benzos are associated with higher all-cause mortality, but I don't think we can reliably say how much of that change is caused by the benzo and how much of it is caused by the disease that the benzo is treating.

Thanks. That's helpful to know. Seems a lot is unknown, but nice to know what is known, nonetheless.

I would love to add more to the conversation based on my experiences with regard to how long-term benzo use relates to physical health, but I have to be mindful of not crossing a line in which by relating my personal experiences I sound to some as if I am seeking advice, when I truly am not.

But it's nice to know that there are doctors thinking about these things.

 

[michaelrack]

I'm a pain physician and I prescribe opioids carefully. I have inherited many patients on benzos (usually ativan 1mg po TID prn anxiety) sometimes temazepam qhs as well.

My question is how does a psychiatrist evaluate/decide if a patient should be on benzos or not?

Thanks

It seems that the question you are trying to ask is "If a patient has been on benzo's for a while, should they be continued?"

I would recommend getting a psychiatrist to evaluate these patients.
The answer depends on how long they have been on benzo's, and their response. According to Kaplan and Sadock's Comprehensive Textbook of Psychiatry (2009, ch 14.8, Anxiety Disorders: Somatic Treatment) "Patients who have been on benzodiazepines for many years and continue to have good therapeutic responses to chronic benzodiazepine use, with no evidence of abuse or misuse, should generally be permitted to stay on the benzodiazepine if that is their preference. Switching stable patients merely for the sake of 'getting them off a benzodiazepine' generally does not make good clinical sense."

 

[vistaril]

I think you'll see that this is an area where standard of care is pretty much all over the place.

It definately seems that the more options a patient has(in terms of their ability to pay), the more likely they are to get benzos(and fairly significant doses). Many cmhc's have a strict no benzo policy. Of course they will still treat these patients, but when you look on their med list it is the cmhc psych who is prescribing the zyprexa and the pt's private internist who has them on xanax and klonopin.

And it definately seems that in the more affluent and higher functioning outpt world, benzos are incredibly common....from both psychs and primary care physicians. As common as statins it seems in many cases.

 

[MLT2MT2DO]

8. gabapentin is sometimes used for anxiety. this drug has abuse potential too, possible street value,

Any idea where I can read more about this? Just thinking, I would think the abuse potential for Nyquil would be higher.

 

[MLT2MT2DO]

a

 

[shan564]

Any idea where I can read more about this? Just thinking, I would think the abuse potential for Nyquil would be higher.

Type "www.pubmed.org" into your browser's URL bar.
Type "gabapentin abuse" into the search bar.

 

[gibits]

I have gotten into arguement a with my residents over benzo on more than one occasion. Most seem to take a draconian approach: no benzodiazepines, ever.
And like most absolutist approaches it has no place in medicine. Anxiety disorders are the most common diagnoses, to deprive yourself of a potent weapon is just mind boogling.

Should we assume all anxious pts are drug seeking rather than actually anxious? I personally assume the pt is telling the truth unless something in the history, collateral info or database (state or insurance) gives me reason to doubt them.

Protecting yourself from a potential abuse case, one that very we'll may not happen is just..... Bad care. I would rather give one drug seeker benzos than let 10 anxious pts go without proper treatment.

From my own experience, most people when told about the possibility of developing a tolerance to benzo are very cautious of using it. They know it works and want it to continue to do so. In fact, just having it as a back up (to some SSRI) gives them some feeling of control over there panic attacks. Even when they don't take a tab. And my preferred rescue benzo of choice? Xanax, mostly because it's fast and provides relief quickly and reinforces the illusion of control better, which is often the underlying cause of the anxiety in the first place.

 

[deleted185747]

Thank you all for your (mostly) thoughtful responses. I saw a patient in pain clinic today who was asking for xanax for anxiety. I obtained a UDS and she was positive for amphetamine. She was surprisingly receptive to my plan which was: no opioids, no benzos and no speed.

Someone asked how I evaluate someone for opioids.
1) must have physical pain from a known source
2) must functionally improve on my medication regimen or it will be stopped
3) agree to the very strict rules of the pain clinic and sign the agreement
4) patient is risk stratified in terms of opioid misuse and seen at an appropriate interval, either 2, 4, or 8 weeks.
5) random UDS (urine drug screen) to make sure patient is taking their meds (and not selling them) and not using street drugs.
6) Review state-wide prescription drug monitoring database to see if they are obtaining from multiple prescribers.

monitor opiophile.org to stay abreast of the latest ways to trick and manipulate the doctor

 

[mahasanti]

I have gotten into arguement a with my residents over benzo on more than one occasion. Most seem to take a draconian approach: no benzodiazepines, ever.
And like most absolutist approaches it has no place in medicine. Anxiety disorders are the most common diagnoses, to deprive yourself of a potent weapon is just mind boogling.

Should we assume all anxious pts are drug seeking rather than actually anxious? I personally assume the pt is telling the truth unless something in the history, collateral info or database (state or insurance) gives me reason to doubt them.

Protecting yourself from a potential abuse case, one that very we'll may not happen is just..... Bad care. I would rather give one drug seeker benzos than let 10 anxious pts go without proper treatment.

From my own experience, most people when told about the possibility of developing a tolerance to benzo are very cautious of using it. They know it works and want it to continue to do so. In fact, just having it as a back up (to some SSRI) gives them some feeling of control over there panic attacks. Even when they don't take a tab. And my preferred rescue benzo of choice? Xanax, mostly because it's fast and provides relief quickly and reinforces the illusion of control better, which is often the underlying cause of the anxiety in the first place.

I'm not against all benzo use, but prn alprazolam for panic disorder seems to be a great way to stay in business (ie keep your patients sick and reliant on you as their prescriber.) Really, prn benzos seem pretty pointless for panic, unless taking it before entering a panic inducing situation, or perhaps if a patient has a prolonged feeling of being "on edge" after an attack. And if they do end up working to curb some of the anxiety in the moment, that's probably worse from a behavioral standpoint.

Prn benzos for panic reinforces an awful lot -- I can't tolerate anxiety, I need to avoid my anxiety at all costs, I need to feel better immediately, I need a pill to feel better, I am not in control of my anxiety, etc. Every study I have read regarding treatment for panic disorder has shown that prn benzo use is a negative predictor for treatment outcome--I have obviously not read every study, so if there is a study showing that prn benzo use is better than scheduled, I would love to see this.

The APA practice guideline for panic disorder states

A regular dosing schedule rather than a p.r.n. ("as needed") schedule is preferred for patients with panic disorder who are taking benzodiazepines [II], where the goal is to prevent panic attacks rather than reduce symptoms once an attack has already occurred.

And I am not sure what patient population you are working in, but where I work, "most people" are not "very cautious" about using benzos.

 

[Merovinge]

Thanks for posting that mahasanti. One of my favorite parts about training in the midwest is the extremely careful use of benzodiazapines by all my mentors. We've had 2 MICU admissions related to Xanax in a year, both of which were minutes to a few hours from death but thankfully had intervention. I do my best to teach every medical student I work with appropriate use of benzodiazapines, so hopefully the next generation of PCP docs aren't prescibing 8mg of Xanax a day.

 

[birchswing]

In my experience personally and talking to other people, in southeast Virginia benzodiazepines are often used by psychiatrists as first-line treatment for anxiety disorders (my experience is from the 1990s, but I see it with people I know still), and the risks of tolerance raised by patients are dismissed with very folksy and somewhat odd non-truths (e.g., "Yeah, Valium was addictive, but the new ones like Xanax aren't" or "Yeah, the ones they use in England are addictive, but these are completely different"). What is more troubling to me are doctors who think it is appropriate to drink alcohol and use benzodiazepines concurrently. I don't think there is a realization that there is a tipping point when it comes to CNS depression is much closer when you combine these things than say attempting to OD on a benzo alone.

It's interesting to hear about the Midwest and how they treat benzos. My opinion of psychiatry was extremely low until finding this forum. If I had based my opinion only on psychiatrists I had met in southeastern Virginia, I would have, as I did, decried the field as full of drug pushers without enough intellectual curiosity to even know or care what harm they are causing. Through this forum, I have seen there are intelligent, thoughtful doctors.

Also, I do agree about benzodiazepines prn reinforcing fears. I think they can be useful prn, but when I was young, no one took the time to explain what was happening to my body during anxiety. I was quite young on benzos and had no therapy, no explanation. So to me, Ativan meant I could breathe again because part of my experience of anxiety was feeling like I was suffocating. Ativan made that go away. Ergo, I felt as if I needed Ativan to breathe when I was at school. It's definitely a bad reinforcement when not given in the right context. I literally thought it was helping me to breathe better, as if it were an asthma medication. I also had a missed diagnosis of POTS, so there was that too.

 

[MLT2MT2DO]

Type "www.pubmed.org" into your browser's URL bar.
Type "gabapentin abuse" into the search bar.

I'm sorry if I came across as snarky. I did search pubmed before posting that, outside of a single study that included 20 patients I'm seeing very little about this. Additionally there seems to have been a single case of a man triggering a seizure during abrupt withdrawal of high doses of gabapentin and not a single death.

It seems to me splik made a lot of "in your face, matter of fact statements" and I was just hoping they were based on more than his clinical opinion. If it's his clinical opinion that is fair, except he didn't present it that way.

 

[splik]

this is an emerging area and the medical literature has not really kept up or reflected this rise of gabapentin abuse, but this is not my opinion but something well known by those working with certain populations - especially in jails, prisons, with substance users. you can look this up on the internet - lots of people are abusing gabapentin, and are reporting withdrawal syndromes. the limited literature reports withdrawal complicated by delirium and seizures suggesting as I said that gabepentin withdrawal can be potentially lifethreatening (and knowing the pharmacology of gabapentin and other gabaergic drugs tells us that withdrawal of these agents can be serious). unfortunately, the problems with gabepentin and pregabalin are not as well appreciated as they should be - and remember for every case in the literature there are usually hundreds more that aren't reported. journals are also not the only place adverse effects are reported - there are clinical databases that try and (imperfectly) capture adverse effects of drugs postmarketing.

 

[SuperSoccer19]

I'm sorry if I came across as snarky. I did search pubmed before posting that, outside of a single study that included 20 patients I'm seeing very little about this. Additionally there seems to have been a single case of a man triggering a seizure during abrupt withdrawal of high doses of gabapentin and not a single death.

It seems to me splik made a lot of "in your face, matter of fact statements" and I was just hoping they were based on more than his clinical opinion. If it's his clinical opinion that is fair, except he didn't present it that way.

SDN is all about snarky comments. Its a good place for giving advice without having to post your credentials or lack there of...

So, now my turn to talk out of my a**:

People who are going to abuse a medication will try to abuse ANY medication, even if you can't get high off of it. I had a patient once claim he snorted Tylenol regularly. I refuse to give them ativan and then run into them at the grocery story buying triple C and whipped cream.

I see where you were coming from being sarcastic yourself since reputable journals, Stahl, etc. continually address Gabapentin's promising effects on alcohol disorders. I'd rather hear my patient is abusing his Gabapentin then abusing his Adderall or Xanax. According to Stahl your gut can only absorb a certain amount at a time anyway.

As far as the Xanax, the only way to get two psychiatrists to have have an identical opinion on this is to shoot one. Personally, I try to avoid using benzos except in the case where we are waiting for the SSRI to kick in. However, I do have a few patients where they have never shown any indication of misuse, other medications don't seem to work and they take it infrequently. I personally feel it is merely a cover up, but if someone has debilitating panic attacks, therapy has failed, I do maintain them on this as a prn.

 

[MLT2MT2DO]

SDN is all about snarky comments. Its a good place for giving advice without having to post your credentials or lack there of...

So, now my turn to talk out of my a**:

People who are going to abuse a medication will try to abuse ANY medication, even if you can't get high off of it. I had a patient once claim he snorted Tylenol regularly. I refuse to give them ativan and then run into them at the grocery story buying triple C and whipped cream.

I see where you were coming from being sarcastic yourself since reputable journals, Stahl, etc. continually address Gabapentin's promising effects on alcohol disorders. I'd rather hear my patient is abusing his Gabapentin then abusing his Adderall or Xanax. According to Stahl your gut can only absorb a certain amount at a time anyway.

As far as the Xanax, the only way to get two psychiatrists to have have an identical opinion on this is to shoot one. Personally, I try to avoid using benzos except in the case where we are waiting for the SSRI to kick in. However, I do have a few patients where they have never shown any indication of misuse, other medications don't seem to work and they take it infrequently. I personally feel it is merely a cover up, but if someone has debilitating panic attacks, therapy has failed, I do maintain them on this as a prn.

Splik's explanation was great. The guy who linked pubmed's link, not so much. I asked the question because I was actually interested in more information and it really isn't out there; though my comment on Nyquil may have been a bit snarky, I felt there was some truth to it.

I'm currently a jaded 3rd year who has had his share of subpar Dr.'s (also had some great ones but that doesn't fit into this rant well) telling me insanely incorrect things stating them as fact. Unless something vastly changes in the next 8 months I'll be going into Psych and enjoy learning why/how people practice. Also this is one place where I can question a physician about the whys/hows and get an honest answer without it affecting my grade/future.

I'll just sleek back into SDN stalker mode again. Thanks for humoring me.

 

[shan564]

Sorry, I was just trying to be funny. I'm only successful at that about 20-25% of the time.

 

[SuperSoccer19]

I'm currently a jaded 3rd year who has had his share of subpar Dr.'s (also had some great ones but that doesn't fit into this rant well) telling me insanely incorrect things stating them as fact. Unless something vastly changes in the next 8 months I'll be going into Psych and enjoy learning why/how people practice. Also this is one place where I can question a physician about the whys/hows and get an honest answer without it affecting my grade/future.

I'll just sleek back into SDN stalker mode again. Thanks for humoring me.

Even as an attending this drives me up the wall and probably always will. At least I don't have to get graded anymore for the most part and can pick which pissing matches I want to get into. You are doing your research and at some point gonna make your own conclusions based on what you see clinically.

Good luck and don't be afraid to post and ask questions. I do. If people think im an annoying idiot, welp, very few people on here know who I am in real life anyway.

 

[shan564]

I'm currently a jaded 3rd year who has had his share of subpar Dr.'s (also had some great ones but that doesn't fit into this rant well) telling me insanely incorrect things stating them as fact. Unless something vastly changes in the next 8 months I'll be going into Psych and enjoy learning why/how people practice. Also this is one place where I can question a physician about the whys/hows and get an honest answer without it affecting my grade/future.

I'll just sleek back into SDN stalker mode again. Thanks for humoring me.

I know that students always worry about their grades when asking questions that might appear to imply "I'm not sure if what you just said is correct," but personally, I tend to give better grades for "knowledge base" to the students who ask those questions. As long as you phrase them in a professional way - i.e. "thanks for the advice... I've actually heard a few conflicting opinions about that point, so I'm a bit unclear on something... what do you think about (insert respectfully-phrased conflicting opinion here)? I know that there's no standard of care and different clinicians will choose different routes, so I was just hoping to see what your experience has shown."

This may not apply to your situation, but as a student, I often learned that my opinion (which I considered was the gold standard because my "opinions" were based solely on level 1 evidence, since I had no experience to taint my opinions with level 5 evidence) was actually wrong because the evidence can be somewhat misleading if not integrated with clinical experience. For example, the evidence might say that Drug X is superior to Drug Y because X leads to symptomatic improvement in 60% of patients, while Y only leads to symptomatic improvement in 45%. But with clinical experience, you might see that X only leads to mild barely-measurable improvement in those 60%, while Y leads to significant improvement in those 45%. Think about TCAs vs. muscle relaxants for functional abdominal pain... TCAs are the standard first-line therapy because most patients get some relief, but I've never seen a patient have substantial relief of pain from a TCA. On the other hand, muscle relaxants only work once in a while, but when they work, they seem to work really well. The reason is probably because "functional abdominal pain" is a nonspecific diagnosis that probably includes some patients who are actually having un-diagnosable muscle spasms... but the point is that if you don't have that clinical experience, it might seem silly to give tizanidine to a patient whose chief complaint is pain (or at least it would have until a couple of years ago when some of the data started coming out to support it).