New patients evals/transfers with adderall prescription.

[littlefred]

For those getting patients for evaluation that have chronic prescriptions for benzodiazepines, stimulants etc. How do you handle it?

I've started working at a location where most referrals are prescribes Klonopin and Adderall (which I believe is basically malpractice).

Also, most of these patients are not gainfully employed or going to school, what would the purpose of the stimulant be?

Added bonus is that they have multiple different providers in prescription monitoring review. Maybe the prescribers don't feel comfortable prescribing, then the patient hops to the next provider?

---

Members don't see this ad.

 

[robellis]

For those getting patients for evaluation that have chronic prescriptions for benzodiazepines, stimulants etc. How do you handle it?

I've started working at a location where most referrals are prescribes Klonopin and Adderall (which I believe is basically malpractice).

Also, most of these patients are not gainfully employed or going to school, what would the purpose of the stimulant be?

Added bonus is that they have multiple different providers in prescription monitoring review. Maybe the prescribers don't feel comfortable prescribing, then the patient hops to the next provider?

You believe every combination of klonopin and adderall is malpractice? That’s a bit much.. also you don’t have to be employed or go to school in order to need a stimulant, I have patients that are so hyperactive they can’t keep any friends without a stimulant, can’t read a book, can’t form meaningful relationships, etc. you should understand the clinical situation then you use your judgment to decide what’s best for the patient, sometimes you continue what’s working, other times you start discussing tapering or switching to something that might work better

 

[littlefred]

You believe every combination of klonopin and adderall is malpractice? That’s a bit much.. also you don’t have to be employed or go to school in order to need a stimulant, I have patients that are so hyperactive they can’t keep any friends without a stimulant, can’t read a book, can’t form meaningful relationships, etc. you should understand the clinical situation then you use your judgment to decide what’s best for the patient, sometimes you continue what’s working, other times you start discussing tapering or switching to something that might work better

Adderall is a stimulant, if they have anxiety then you should stop it or change to something else. Adding Klonopin or any other benzo to fend off that side effect is bad medicine.

Do tell me good cases where a benzo and a stimulant are good?

 

[VA Hopeful Dr]

Adderall is a stimulant, if they have anxiety then you should stop it or change to something else. Adding Klonopin or any other benzo to fend off that side effect is bad medicine.

Do tell me good cases where a benzo and a stimulant are good?

Except what if the anxiety isn't a side effect of the stimulant? People can have anxiety and ADHD at the same time.

Beyond that, non-stimulant ADHD medications don't work well for everyone.

 

[littlefred]

Except what if the anxiety isn't a side effect of the stimulant? People can have anxiety and ADHD at the same time.

Beyond that, non-stimulant ADHD medications don't work well for everyone.

Curious, do you have patients on Adderall/Concerta and a benzodiazepine as well?

 

[littlefred]

It would be analogous for let's say a patient that has bipolar disorder, you give them an antidepressant and they become manic. Then you give them an antipsychotic to help with the mania, and then you keep them on both (Symbyax, lol).

Don't see the scientific backing for having people on benzodiazepines and stimulants at the same time, just anecdotal evidence which as we know is the lowest level of evidence.

 

[robellis]

Adderall is a stimulant, if they have anxiety then you should stop it or change to something else. Adding Klonopin or any other benzo to fend off that side effect is bad medicine.

Do tell me good cases where a benzo and a stimulant are good?

How long have you been practicing? There are numerous cases where this is appropriate…anxiety is not only a side effect it is often comorbid in these patients..if you have adhd and panic disorder like several of my patients this could be a rational regimen..especially when they have tried many other medications and are finally somewhat stable on this regimen, also stimulants are used not just for adhd..narcolepsy, depression, cognitive enhancement, it’s much too complicated to simply say one regimen is malpractice unless of course it’s clearly black and white which it rarely is

 

[littlefred]

How long have you been practicing? There are numerous cases where this is appropriate…anxiety is not only a side effect it is often comorbid in these patients..if you have adhd and panic disorder like several of my patients this could be a rational regimen..especially when they have tried many other medications and are finally somewhat stable on this regimen, also stimulants are used not just for adhd..narcolepsy, depression, cognitive enhancement, it’s much too complicated to simply say one regimen is malpractice unless of course it’s clearly black and white which it rarely is

I've been an attending for 4 years, and am also addiction trained.
How about you?

 

[robellis]

I've been an attending for 4 years, and am also addiction trained.
How about you?

And during that time every case of benzo/stimulant has been malpractice? You’ve reported how many providers to the board?

 

[Ironspy]

I took over a bunch of patients on inappropriate chronic benzos with many of them also on a stimulant and/or z drug. I’ve never met a patient who is thriving on this combo and don’t think the evidence supports it either. I tell patients that daily benzos are neither safe nor effective for anxiety and that my long term plan is to taper over the coming months/year+. I tell them that chronic benzos put them at increased risk of falls/dementia/death and have a dot phrase to document this discussion. I don’t force the taper but all eventually agree and a few left as I tell them that there are plenty of prescribers who will continue the combo just not I. I don’t mind continuing a stimulant if there is clear benefit and/or history of childhood sx as stimulants have better evidence than chronic benzos. Any acute concerns (falls, polysubstance use, recent ODs) and they get a rapid benzo taper.

 

[littlefred]

And during that time every case of benzo/stimulant has been malpractice? You’ve reported how many providers to the board?

I've reported a total of 0.

What are your credentials?

It seems as if my post was a personal attack to you. I'm here to discuss the evidence and to learn what people are doing in their practice.

If you want to justify what you do based off of anecdotes and your clinical experience, that's fine. That speaks more about the field of psychiatry rather than you personally.

A lot of providers out there practice psychiatry with good intentions but with little to no scientific backing to what they do.

 

[tr]

Multiple prescribers is a huge red flag. Based on the OP's description I'd just tell the patients you don't co-prescribe benzos and stimulants ever and if they choose to continue care with you they will be tapering off the benzo. +/- discussion of the multiple prescribers depending on your stomach for confrontation. This will get them off your caseload. Good riddance. If you want to be a good citizen you could also alert the other prescribers to the issue in case they are not aware.

 

[littlefred]

I took over a bunch of patients on inappropriate chronic benzos with many of them also on a stimulant and/or z drug. I’ve never met a patient who is thriving on this combo and don’t think the evidence supports it either. I tell patients that benzos are neither safe nor effective for anxiety and that my long term plan is to taper over the coming months/year+. I tell them that chronic benzos put them at increased risk of falls/dementia/death and have a dot phrase to document this discussion. I don’t force the taper but all eventually agree and a few left as I tell them that there are plenty of prescribers who will continue the combo just not I. I don’t mind continuing a stimulant if there is clear benefit and/or history of childhood sx as stimulants have better evidence than chronic benzos. Any acute concerns (falls, polysubstance use, recent ODs) and they get a rapid benzo taper.

Thanks for your input. Do you ask for employment/school status to continue stimulants?

 

[littlefred]

Multiple prescribers is a huge red flag. Based on the OP's description I'd just tell the patients you don't co-prescribe benzos and stimulants ever and if they choose to continue care with you they will be tapering off the benzo. +/- discussion of the multiple prescribers depending on your stomach for confrontation. This will get them off your caseload. Good riddance. If you want to be a good citizen you could also alert the other prescribers to the issue in case they are not aware.

I wish it was that easy, we can't communicate with other prescribers due to HIPAA.

I've discussed with patients about tapering off of benzo's but met with obvious discontent. The other alarming fact about most of these patients is that they are higher doses of stimulants than what the FDA recommends e.g. IR Adderall 30 mg TID.

 

[michaelrack]

I have been an attending for 19 years, and while not addiction trained, do have some experience including running a methadone clinic in the past. I do have some patients on stimulants and either a benzodiazepine or z drug, mainly with narcolepsy. And technically under HIPAA u don't need patient permission to talk to their other health care providers

 

[littlefred]

I have been an attending for 19 years, and while not addiction trained, do have some experience including running a methadone clinic in the past. I do have some patients on stimulants and either a benzodiazepine or z drug, mainly with narcolepsy. And technically under HIPAA u don't need patient permission to talk to their other health care providers

Past providers? I would believe so.

 

[robellis]

I've reported a total of 0.

What are your credentials?

It seems as if my post was a personal attack to you. I'm here to discuss the evidence and to learn what people are doing in their practice.

If you want to justify what you do based off of anecdotes and your clinical experience, that's fine. That speaks more about the field of psychiatry rather than you personally.

A lot of providers out there practice psychiatry with good intentions but with little to no scientific backing to what they do.

I’m a recently graduated psych attending..it’s not about it being an attack it’s that people make broad statements without thinking like saying every combination is malpractice..if it’s malpractice you should be reporting to the board, no? But you don’t..because it’s not that straightforward and you’d be laughed out the room if everyone reported every case of this..if you don’t “feel comfortable” then just tell the patient that and let them go somewhere else it’s not too complicated

 

[psycharmed]

How to Come Off a Psych Med Part 2: Antidepressants, Stimulants, and Benzos

What do you do when a patient comes to you on a high dose of Adderall and Klonopin without any clear reason to be on them? Swapnil Gupta tackles this in part II of our interview on deprescribing, and describes how to fine-tune and microdose antidepressants and benzodiazepines to manage...

www.thecarlatreport.com

I thought this was a good article / review on this matter. The author emphasises building rapport / trust through the therapeutic alliance before attempting to taper medications.

 

[littlefred]

I’m a recently graduated psych attending..it’s not about it being an attack it’s that people make broad statements without thinking like saying every combination is malpractice..if it’s malpractice you should be reporting to the board, no? But you don’t..because it’s not that straightforward and you’d be laughed out the room if everyone reported every case of this..if you don’t “feel comfortable” then just tell the patient that and let them go somewhere else it’s not too complicated

I used the malpractice word there as a lay person, you and I both know that malpractice is more than that. Thanks for your input.

If you have any scientific backing to the co-prescription of these meds, let me know!

 

[littlefred]

How to Come Off a Psych Med Part 2: Antidepressants, Stimulants, and Benzos

What do you do when a patient comes to you on a high dose of Adderall and Klonopin without any clear reason to be on them? Swapnil Gupta tackles this in part II of our interview on deprescribing, and describes how to fine-tune and microdose antidepressants and benzodiazepines to manage...

www.thecarlatreport.com

I thought this was a good article / review on this matter. The author emphasises building rapport / trust through the therapeutic alliance before attempting to taper medications.

Then when you develop the rapport and discuss the taper, then they go to another provider 🙂

I think it's a knee-jerk reaction that most of us have to continue medications for new patients to not "rattle the cage" or out of some imaginary respect we may have for the prior psychiatrist (which at times we don't even know who they are).

Sometimes patients have horrible medication regimens that make no sense at all (e.g. of a patient off the top of my head on paxil, zoloft, lithium,vraylar,xanax and ambien who presented manic) should we keep them if the patient tells you they work? Food for thought.

 

[littlefred]

How to Come Off a Psych Med Part 2: Antidepressants, Stimulants, and Benzos

What do you do when a patient comes to you on a high dose of Adderall and Klonopin without any clear reason to be on them? Swapnil Gupta tackles this in part II of our interview on deprescribing, and describes how to fine-tune and microdose antidepressants and benzodiazepines to manage...

www.thecarlatreport.com

I thought this was a good article / review on this matter. The author emphasises building rapport / trust through the therapeutic alliance before attempting to taper medications.

I don't have access to the report, is there anyway you can send it to me?

 

[Liquid8]

Have a couple of colleagues who occasionally refer patients like this to me. One of them is shifting to a psychotherapy focused practice, but it often feels like I’m being dumped these patients especially when the referral just gets sent to me without any prior discussion. Unfortunately, human nature dictates that they aren’t going to pass on “easy” patients preferring to keep them for themselves, so as such my default tendency is to decline which is less of an issue as my waiting list is getting quite long. One example is a patient in his late 60s on 2mg alprazolam/day. It looks like he’s been on it for a very long time, but it’s unclear whether there’s been any effort to reduce this and on further databse checks there’s been instances of early script dispensations. It looks like they’re taking at least 2 a day but of course none of this has been mentioned in the referral letter.

With ADHD patients and stimulants, it depends on the dose that they’re being prescribed. If I consider it too high I usually decline as well, unless there is corroborative evidence that it was used in childhood. Unfortunately there’s a few psychiatrists in my area who seem to like starting patients on very high doses and after a few negative experiences I’m much less inclined to take on their messes. Yesterday I received a referral for a guy on about 50mg of dexamphetamine. To me, this is quite a high dose, and I could see that he already sees someone that I consider to be a very competent psychiatrist who has been prescribing for him. So that begs the question – why is there a desire to change now? Has the patient been sacked for inappropriate use or not paying his fees? If that's the case it will be probably be more trouble that I don't need to get involved in.

On combining stimulants and benzodiazepines, I don’t encourage it but there are cases where it may be appropriate. Eg. stimulants can be used to augment treatment resistant depression who might already be taking a PRN benzo or z-drug. For ADHD patients usually what I do notice is that if ADHD is managed adequately the amount of anxiolytic use tends to go down so it’s rare for any of my patients to be taking both regularly. If there is clear stimulant induced anxiety, it’s usually something encountered early on during the dose titration process so it generally makes sense to switch treatments rather than add something else.

 

[tr]

I wish it was that easy, we can't communicate with other prescribers due to HIPAA.

I've discussed with patients about tapering off of benzo's but met with obvious discontent. The other alarming fact about most of these patients is that they are higher doses of stimulants than what the FDA recommends e.g. IR Adderall 30 mg TID.

I think the discontent is a given, I agree with post by @psycharmed above about using rapport building/MI skills to manage if you have the time/energy/motivation to do so, vs confront and deal with the fallout if you don't particularly want them to stay in your practice/are not concerned about accumulating angry internet reviews.

I'm sure you must have had lots of exposure to this type of scenario in your addiction training.

Then when you develop the rapport and discuss the taper, then they go to another provider 🙂

Right, isn't that what you want? Or do you have a specific reason to want to hang on to problematic patients who won't follow your medical advice?

 

[Ironspy]

Thanks for your input. Do you ask for employment/school status to continue stimulants?

I do. I prefer them to be in school or work and most are. If they are not then I discuss how the stimulant is helpful, what sx they are having etc. I don’t absolutely require school or work but need to see some benefit to continue them.

edited to add: I have a few who are full time parents as well and have seen notable improvements in function with treatment

 

[littlefred]

I think the discontent is a given, I agree with post by @psycharmed above about using rapport building/MI skills to manage if you have the time/energy/motivation to do so, vs confront and deal with the fallout if you don't particularly want them to stay in your practice/are not concerned about accumulating angry internet reviews.

I'm sure you must have had lots of exposure to this type of scenario in your addiction training.



Right, isn't that what you want? Or do you have a specific reason to want to hang on to problematic patients who won't follow your medical advice?

I think the issue is that you have pressure when you work for a big company/hospital setting. They want you to retain patients and for them to be "happy" with the treatment they are receiving. Practicing good science/evidence-based medicine and keeping your employer content can be a hard balancing act.

I also always joke, if I get raving reviews as a psychiatrist I have to ponder if I'm doing good medicine. The one's getting the good reviews are prescribing 2 mg Xanax TID if you get my drift.

 

[tr]

I think the issue is that you have pressure when you work for a big company/hospital setting. They want you to retain patients and for them to be "happy" with the treatment they are receiving. Practicing good science/evidence-based medicine and keeping your employer content can be a hard balancing act.

Demand for psychiatrists is too high for you to take nonsense like that from the admins. There's always another job out there if the management at this one is unreasonable.

 

[Bartelby]

In terms of talking with other providers, HIPAA allows you to speak with current treaters. I do not believe it would let you talk to past treaters without a release. With that said, though, if a patient refuses to let me speak with their other providers I would refer them elsewhere in most cases. That seems to be a major red flag, especially if they have controlled substance prescriptions from multiple providers.

 

[Merovinge]

The one's getting the good reviews are prescribing 2 mg Xanax TID if you get my drift.

6mg daily is for sissy's. I loved admitting patients prescribed Xanny's at 4mg TID along with Adderall 40mg TID with a principal diagnosis of BPD and who were actually taking twice that much Xanax and go into withdrawal after admission as a PGY-1...

But honestly Adderall IR TID at high dose is near 100% for terrible prescriber with the medication being diverted or abused. There are almost no situations in which that is the right formulation of the stimulant even if the need is there. Chronic benzos are also rubish in the majority of cases. I actually think one of the highest value adds of the psychiatrist in these cases is getting some subset to understand the issues with the medication and get onto a reasonable treatment plan. Even if the work feels terrible you can be making a huge difference, particularly with your addictions training.

 

[hamstergang]

Also, most of these patients are not gainfully employed or going to school, what would the purpose of the stimulant be?

By definition, ADHD presents with symptoms in multiple settings, so it's not just work or school that would be impacted. Those tend to be places where the symptoms are most obviously noted to be problematic, but impairments can be seen everywhere. You should assess each patient for what symptoms and problems the medication is addressing.

 

[VA Hopeful Dr]

Curious, do you have patients on Adderall/Concerta and a benzodiazepine as well?

Probably. I can't recall what every patient of mine is on (I'm FM and have over 2000 patients at the moment).

 

[VA Hopeful Dr]

Thanks for your input. Do you ask for employment/school status to continue stimulants?

Why would that matter?

 

[Ironspy]

Why would that matter?

It helps to show improvement in function. If someone watches tv all day on and off a stimulant then it’s hard for me to see how the stimulant is helping.

 

[robellis]

It helps to show improvement in function. If someone watches tv all day on and off a stimulant then it’s hard for me to see how the stimulant is helping.

Do you ask for employment status and evidence of efficacy for ssri to show the depression is improving?

 

[Ironspy]

Do you ask for employment status and evidence of efficacy for ssri to show the depression is improving?

Yes. isn’t it standard of care to assess functional improvement?

Ssri also has lower risk of abuse and diversion compared to stimulants

 

[robellis]

Yes. isn’t it standard of care to assess functional improvement?

Ssri also has lower risk of abuse and diversion compared to stimulants

You ask for evidence of employment to continue prescribing an ssri??? I didn’t know that was standard of care I usually just take the patients word for it when they say they are employed/it’s helping

 

[NITRAS]

You ask for evidence of employment to continue prescribing an ssri??? I didn’t know that was standard of care I usually just take the patients word for it when they say they are employed/it’s helping

It improves the payor mix and will improve his/her outcomes.

🙂

 

[WisNeuro]

You ask for evidence of employment to continue prescribing an ssri??? I didn’t know that was standard of care I usually just take the patients word for it when they say they are employed/it’s helping

That seems to be taking the comment of of context, as the quoted comment also included the phrase "and evidence of efficacy." Which, isn't that standard of care? If you are prescribing an SSRI and the patient reports no change in mood and/or social/occupational/etc status over an adequate length of time, wouldn't you look at other treatments?

 

[Ironspy]

You ask for evidence of employment to continue prescribing an ssri??? I didn’t know that was standard of care I usually just take the patients word for it when they say they are employed/it’s helping

Do you ask for employment status and evidence of efficacy for ssri to show the depression is improving?

I ask for employment status not evidence of employment. It’s part of the social history

 

[robellis]

I ask for employment status not evidence of employment. It’s part of the social history

Oh ok I absolutely agree I interpreted the original comment as like asking for the patient to bring in academic reports or proof of employment

 

[hallowmann]

Asking about employment/social situation is standard of care in medicine. Requiring current employment or school to treat a diagnosis with the first line treatment especially when said diagnosis has clear social and societal implications is not what I would call "standard of care". How exactly is someone with untreated ADHD meant to get a job when they struggle to even make it to interviews ontime and when they do show up they constantly interrupt the interviewer? As for school, it actually takes quite a bit of effort, paperwork coordination, let alone payment to initiate that process, which again would be difficult for some of the individuals I see with ADHD, especially if there is limited social supports to assist in that. I'm not talking the high functioning mild - I'm not doing as well as I should on a test in a course I'm not interested in - "ADHD" that half of my patients claim to have.

I get the apprehension about someone being on a stimulant and benzos/sedative hypnotics, and I would say I have exactly 2 patients on such a combination. One with a TBI, ADHD (on long-acting stimulant) and panic disorder who takes a PRN 0.5 mg lorazepam maybe 1-2 times a month. The other with ADHD and PTSD who takes a long acting stimulant and a low-dose PRN Z-drug for sleep that someone else put her on, and I have not had the best luck weaning.

In most cases this prescribing is inappropriate, but I'd hesitate to call it malpractice. I would also say cases should be looked at individually not based on an algorithm. We aren't midlevels, and Psychiatry is unfortunately not as straightforward.

OP even in how you described things, I'm kind of put off by your approach, but maybe that's a "me" problem. Even your description of the bipolar patient being on an antipsychotic and antidepressant, shows a little lack of imagination, because even just in training I've seen some patients that needed such a regimen to maintain stability and avoid notable side effects.

 

[VA Hopeful Dr]

It helps to show improvement in function. If someone watches tv all day on and off a stimulant then it’s hard for me to see how the stimulant is helping.

Obviously, what about the retired woman who wants to be able to focus on her gardening, sewing, housework, or books?

None of that is employment or school.

 

[deleted1100659]

Lets not get too snarky guys, lol.

In all seriousness, I would say i am always extremely hesitant to prescribe benzos. However, someone that's been on it for 10 years or something else ridiculous..it is insanely hard getting them off the benzo. So if I continue them on it, i make an agreement that the dose will not be raised. Many I still try to do a very slow titration off it, if I feel its not really benefiting them.

Stimulants, on the other hand, ive seen work wonders. Unlikely benzos, they demonstrate clear long term efficacy. If someone isnt abusing a stimulant, and their life is drastically improved by it, who am I to snub my nose at it? After all, our goal is to improve the patient's quality of life is it not?

The combination of the two is a little wonky, not exactly ideal though.

 

[nexus73]

It feels easier to vilify stimulants and benzos in a black and white fashion. In my experience it’s really shades of gray.

 

[Ironspy]

Obviously, what about the retired woman who wants to be able to focus on her gardening, sewing, housework, or books?

None of that is employment or school.

Yes. I should have been more inclusive said any productive day time activity.

 

[AD04]

I don't understand the attacks against OP. It is admirable to prescribe the minimal amount of controlled substances. He's an addiction specialist and wants to prevent further addiction.

Most of the benzodiazepine / stimulant combination comes from PCP and and mid-levels. And then they refer those patient to psychiatrist after starting that combination. If they're so confident about that combination, why refer? I remember a private practice PCP who was so prolific with that combination, he had to refer those patients out because the DEA was on his case about all the controlled substances he was prescribing.

When I see these referrals, I start the appointment by saying if we continue, there is a very very good chance I'm not going to continue that combination just because someone else started it in the past. It isn't fair for me to continue them just because someone started it, especially if I disagree. Set the expectations from the start.

Most patients stay and are able to function well without stimulants and benzodiazepines. If they are resistant to me changing anything, that is a very very strong indicator of addiction. Most of my discharges from outpatient practice were because they agreed in the beginning but then started acting up when I followed through and did not continue the controlled substances.

I wouldn't be surprised if the people hostile to OP has a financial incentive for that atrocious combination, especially if they own their own practice and have to fight for market share. It's easy to have patients come back if they're addicted and they need refills. I see a lot of patients and I have only two on that combination. Those patients stuck with me in finding the best regimen without demanding for controlled substances. And I specifically document that benzodiazepine / stimulant combination is substandard practice but I am prescribing them because <insert reason>. Those 2 patients are working and are productive members to society.

None of my current partners prescribe that combination regularly. Patients on those are the exception and for good reason.

If an employer is more concerned about losing revenue instead of preventing poor medical practice, that isn't an employer a psychiatrist will want to work for. There are too many work options for psychiatrists and they don't have to stoop to catering to the patients' every wish. This isn't Burger King and patients don't always get things their way.

 

[nexus73]

I've seen patients who are doing well on something like Ativan 1 mg BID, for years. They never run out early and never have dirty UDS...hardly addicted IMO. They're working and lives are going well. I think there is a place for lower dose scheduled benzos in specific patients. I'm not advocating xanax/klonopin/ativan 6mg or more per day, but on the lower end to me it doesn't seem so unreasonable.

I've heard many psychiatrists proclaim they don't need to use benzos to treat patients effectively. And I've always wondered if that's because those patients just leave and find someone to prescribe a modest dose for them.

So if you have someone with severe GAD or panic d/o, plus they have ADHD and are doing well on Vyvanse. And the SSRIs/SNRIs/Buspar etc aren't really touching the anxiety, but a low dose scheduled benzo finally makes them functional. Is it the end of the world?

 

[d2305]

I've seen patients who are doing well on something like Ativan 1 mg BID, for years. They never run out early and never have dirty UDS...hardly addicted IMO. They're working and lives are going well. I think there is a place for lower dose scheduled benzos in specific patients. I'm not advocating xanax/klonopin/ativan 6mg or more per day, but on the lower end to me it doesn't seem so unreasonable.

I've heard many psychiatrists proclaim they don't need to use benzos to treat patients effectively. And I've always wondered if that's because those patients just leave and find someone to prescribe a modest dose for them.

So if you have someone with severe GAD or panic d/o, plus they have ADHD and are doing well on Vyvanse. And the SSRIs/SNRIs/Buspar etc aren't really touching the anxiety, but a low dose scheduled benzo finally makes them functional. Is it the end of the world?

Let them run out and they will be in trouble.

 

[nexus73]

Let them run out and they will be in trouble.

Could say the same about someone on lithium or zyprexa or cymbalta.

 

[robellis]

Let them run out and they will be in trouble.

Let the diabetic run out of insulin…

 

[calvnandhobbs68]

Let the diabetic run out of insulin…

That’s what I came here to say.

Let the asthmatic run out of their Flovent and they’ll be in trouble….

for an even more apt analogy, let someone with OUD run out of suboxone and they’ll be in trouble…

wtf does that prove. Physiologic dependence doesnt = addiction, pretty basic concept.