Old People With Unipolar Depression on Seroquel 800mg

[clement]

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I inherited a dump of a case in the outpatient setting. 74 yo on Seroquel 800 (14 years), Trazodone 200, Prazosin 1mg AM, 2mg HS, Ativan 0.5 bid prn. Has an obviously high tolerance to the sedating effects of her regimen. Unipolar depression per the last treating psychiatrist of years, oh and a and a touch of ptsd. How slowly would you shave off Seroquel? It’s 90% being used as a sleep aid only.

Formerly w/ an iatrogenic sedative hypnotic use d/o in full remission until it was decided to re start Ativan at 0.25 bid prn last March and bump up to 0.5 bid prn a few months ago, then transfer the case out to a new doctor (me). Reports sparing use of Ativan. I’m tempted to get rid of the prn Ativan bold turkey and offer gabapentin prn. If wanted to be kind/prudent I might shave off 0.25mg/week. I don’t favor offering clonazepam.

 

[clausewitz2]

I inherited a dump of a case in the outpatient setting. 74 yo on Seroquel 800 (14 years), Trazodone 200, Prazosin 1mg AM, 2mg HS, Ativan 0.5 bid prn. Has an obviously high tolerance to the sedating effects of her regimen. Unipolar depression per the last treating psychiatrist of years, oh and a and a touch of ptsd. How slowly would you shave off Seroquel? It’s 90% being used as a sleep aid only.

Formerly w/ an iatrogenic sedative hypnotic use d/o in full remission until it was decided to re start Ativan at 0.25 bid prn last March and bump up to 0.5 bid prn a few months ago, then transfer the case out to a new doctor (me). Reports sparing use of Ativan. I’m tempted to get rid of the prn Ativan bold turkey and offer gabapentin prn. If wanted to be kind/prudent I might shave off 0.25mg/week. I don’t favor offering clonazepam.

So how many times has she fallen in the last year? I can't imagine the answer is 0.

 

[clement]

So how many times has she fallen in the last year? I can't

So how many times has she fallen in the last year? I can't imagine the answer is 0.

None. She’s built tolerance to the sedating effects of these meds like a champ. Daily passive SI prevented her previous doctor from adjusting prescribing practices to current standards/guidelines I guess.

 

[clausewitz2]

None. She’s built tolerance to the sedating effects of these meds like a champ. Daily passive SI prevented her previous doctor from adjusting prescribing practices to current standards/guidelines I guess.

I think you'll have to pick Ativan or Seroquel to taper initially, not both, at least if you want her to maintain any buy-in. My inclination would be 50-100 mg a month of the later, maybe leaning towards the first to start so she can have the experience of getting used to sleeping on a lower dose and transient disturbances resolving. You may need to be prepared to do a lot of CBT-I type interventions, sleep is clearly a major preoccupation for this person.

EDIT: agree with the below about benzo first if at all possible

 

[Sushirolls]

Benzo first
Always strive for benzo first

Then do 50mg seroquel every month once you clear the benzo hurdle.
May need a sleep consult along the way for OSA, assuming snores or is obese...

 

[comp1]

Definitely concur with benzo first. That looks the worst for the elderly. And go slow. I wouldn't recommend 14 years, but you are looking at years here, not weeks, to fix this. Your goal is to get her well into her 80's without a fall (or self harm, obviously). Daily passive SI sounds like someone who should be in therapy or possibly an IOP or PHP while shaving off these meds. Always have a darn low threshold for PHP/IOP... And of course she should have seen a sleep specialist at some point. Hopefully you have those records. If not, she needs to see one right away.

 

[Celexa]

Benzo first including getting a handle on how often it's being used. It's prescribed prn, patient may say they aren't taking it often, but how often are they filling? I see so many 'prn' prescriptions that are still filled every month.... Either their taking it standing or they have enough bottles of Ativan lying around to start their own pharmacy. Either situation is not good.

If very attached to the idea of prn, then seroquel could become prn as the standing dose is weaned down.

 

[Celexa]

Diagnostically, would also clarify that PTSD piece. It's possible that is the dominant diagnosis. If so, and if the tranquilizer doses were a misaimed attempt to sedate someone suffering from nightmares, that prazosin is inadequately dosed to be a real trial and is worth increasing after Ativan is out of the picture, but in a 74 yo you're gonna have to be real careful watching for hypotension. I hope she has a blood pressure cuff at home.

 

[clozareal]

If the Ativan is PRN, how often is she using it? If they bumped up the benzo, perhaps she is still anxious or having symptoms and would benefit from a standing agent for anxiety first. This would be a strange regimen for unipolar depression for this age unless she's tried everything else.

Benzo first, then Seroquel, then trazodone, then prazosin, then nothing!

 

[annoyedpsychiatrist]

one at a time, gradual taper each visit with strong documentaiton explaining you didn't start the medication but abrupt cessation of medicaiton poses higher risk of withdrawl sx and worsening psychiatric sx, and you will perform gradual dose reduction when indicated at each visit. If something happens with that, you're hard to blame, as you didnt put her on 800mg and any reasonable physician wouldn't abruptly go from 800 to 0.

 

[Stagg737]

The puzzle pieces aren’t fitting. That’s not a med list for unipolar depression or even really PTSD (though closer there). How severe is anxiety and insomnia? Did she ever have depression with psychotic features?

I agree with tapering one med at a time and starting with the Ativan. Could probably go a bit quicker with the Seroquel initially, like 100 mg per month until you hit 300 or 400 mg. What is her actual status? May be a bit different if she’s been “stable” on these meds vs just hanging on.

 

[clement]

If the Ativan is PRN, how often is she using it? If they bumped up the benzo, perhaps she is still anxious or having symptoms and would benefit from a standing agent for anxiety first. This would be a strange regimen for unipolar depression for this age unless she's tried everything else.

Benzo first, then Seroquel, then trazodone, then prazosin, then nothing!

Says she’s taking 0.5mg of the Ativan daily. Got very defensive about it. Added that she was administratively kicked out of another clinic in her fifties when they first starting beefing up Seroquel and Ativan to the point she was medically admitted for benzo withdrawal. Grey sunami here we come. The last generation or two of psychiatrists has left us some parting gifts. Oh, let me add she disclosed (for the first time) getting into a car accident last year and no longer driving.

 

[clement]

The puzzle pieces aren’t fitting. That’s not a med list for unipolar depression or even really PTSD (though closer there). How severe is anxiety and insomnia? Did she ever have depression with psychotic features?

I agree with tapering one med at a time and starting with the Ativan. Could probably go a bit quicker with the Seroquel initially, like 100 mg per month until you hit 300 or 400 mg. What is her actual status? May be a bit different if she’s been “stable” on these meds vs just hanging on.

I considered depression w/ psychosis but even then, 800 of Seroquel? The insomnia and anxiety have been chronically bad likely due to trauma and sleep architecture destruction. Trauma is likely her primary issue. PD is nowhere in the chart other than her weaponizing SI as an elderly woman every time she’s been faced w/ the prospect of decreasing Seroquel or removing Ativan over the years.

PD is definitely in there though, which makes sense as nothing else makes sense about this.

I get that she was middle aged when the “this one psychiatrist who was giving everyone a lot meds” shut her up with Seroquel. Panacea for trauma and unspecified PD, right?

She’s been stable on her regimen with Seroquel 800 as the base of this “soup” +/- Ativan and bunches of antidepressants she won’t hold on to for long (often won’t expand on her distaste for all meds except Seroquel, benzos, though seemingly embraces Sertraline 100 at least).

Update: I got confirmation from the dumping doctor who transferred her and kept her on this regimen for 4 years (minus the variable antidepressants), that he was “hoping” I’d be the one to change the Seroquel at least.

Sure enough, she got incensed today at the idea of touching her Seroquel or Ativan “ever” at any point in the future…Even at a very gradual rate. She threatened, “I’d rather not exist than to ever have my medications changed.” Followed by a future oriented threat to “file a complaint,” began verifying my “credentials,” asking how long I’ve been practice, and getting her self a f/u visit with the clinic’s supervising psychiatrist to advocate for her return to her former doctor.

The kicker is, this supervising psychiatrist tries reaally hard to not have dumps go back to their former psychiatrist (in this case a guy still in clinic)….because she also dumped some of her own on the new doctor (me). I’m fine with getting this pt back if so, but I will walk if she tries to tell me I have to keep filling this pts bs regimen at 74.

 

[annoyedpsychiatrist]

I considered depression w/ psychosis but even then, 800 of Seroquel? The insomnia and anxiety have been chronically bad likely due to trauma and sleep architecture destruction. Trauma is likely her primary issue. PD is nowhere in the chart other than her weaponizing SI as an elderly woman every time she’s been faced w/ the prospect of decreasing Seroquel or removing Ativan over the years.

PD is definitely in there though, which makes sense as nothing else makes sense about this.

I get that she was middle aged when the “this one psychiatrist who was giving everyone a lot meds” shut her up with Seroquel. Panacea for trauma and unspecified PD, right?

She’s been stable on her regimen with Seroquel 800 as the base of this “soup” +/- Ativan and bunches of antidepressants she won’t hold on to for long (often won’t expand on her distaste for all meds except Seroquel, benzos, though seemingly embraces Sertraline 100 at least).

Update: I got confirmation from the dumping doctor who transferred her and kept her on this regimen for 4 years (minus the variable antidepressants), that he was “hoping” I’d be the one to change the Seroquel at least.

Sure enough, she got incensed today at the idea of touching her Seroquel or Ativan “ever” at any point in the future…Even at a very gradual rate. She threatened, “I’d rather not exist than to ever have my medications changed.” Followed by a future oriented threat to “file a complaint,” began verifying my “credentials,” asking how long I’ve been practice, and getting her self a f/u visit with the clinic’s supervising psychiatrist to advocate for her return to her former doctor.

The kicker is, this supervising psychiatrist tries reaally hard to not have dumps go back to their former psychiatrist (in this case a guy still in clinic)….because she also dumped some of her own on the new doctor (me). I’m fine with getting this pt back if so, but I will walk if she tries to tell me I have to keep filling this pts bs regimen at 74.

this screams misuse to me. I strongly suspect addiction component/misuse. People abuse the hell out of seroquel tbh with you. At my last job, there were a few times we found bottles of it in the waiting room with the label removed.

Strong documentation. You have a treatment plan for her. She does not want to along with it. Apologize you werent able to find common ground, give her a list of community resources and three month supply of meds and wave goodbye. When patients start doing this, its impossible to have a therapeutic relationship when they start trying to force you into fear based prescribing. Id document all this.

 

[Celexa]

this screams misuse to me. I strongly suspect addiction component/misuse. People abuse the hell out of seroquel tbh with you. At my last job, there were a few times we found bottles of it in the waiting room with the label removed.

Strong documentation. You have a treatment plan for her. She does not want to along with it. Apologize you werent able to find common ground, give her a list of community resources and three month supply of meds and wave goodbye. When patients start doing this, its impossible to have a therapeutic relationship when they start trying to force you into fear based prescribing. Id document all this.

Yeah this reeks of use disorder.

I've had patients be very anxious and psychologically attached to other antipsychotics and not want to decrease. Seroquel is the only one people have screamed at me about or left abusive voicemails if they didn't have a refill or melted down if it wasn't ordered during a medical admission.

 

[clement]

this screams misuse to me. I strongly suspect addiction component/misuse. People abuse the hell out of seroquel tbh with you. At my last job, there were a few times we found bottles of it in the waiting room with the label removed.

Strong documentation. You have a treatment plan for her. She does not want to along with it. Apologize you werent able to find common ground, give her a list of community resources and three month supply of meds and wave goodbye. When patients start doing this, its impossible to have a therapeutic relationship when they start trying to force you into fear based prescribing. Id document all this.

You are 100% accurate re screams misuse. This is a county clinic that is catering to patients. So she’s being treated like a disgruntled client/patient who gets to grieve with the psychiatry supervisor within a week of our visit. Said director already has a chip on their shoulder because I complained that such cases were permitted to be dumped on me as the new guy in clinic (including her cases).

 

[calvnandhobbs68]

Says she’s taking 0.5mg of the Ativan daily. Got very defensive about it. Added that she was administratively kicked out of another clinic in her fifties when they first starting beefing up Seroquel and Ativan to the point she was medically admitted for benzo withdrawal. Grey sunami here we come. The last generation or two of psychiatrists has left us some parting gifts. Oh, let me add she disclosed (for the first time) getting into a car accident last year and no longer driving.

Old lady on seroquel and ativan for unclear reasons who's had issues with benzo withdrawal before and recently got into a car accident? Absolutely theres a personality component or misuse/abuse if she's already starting to vaguely threaten SI at the first sign of you wanting to adjust things.

Yeah no thanks I'd get out of that place if they're doing liability dumps like that, what a D-bag "hope you'd change the Seroquel young gun, I was too chicken to do it for the last 4 years".

 

[whopper]

So how many times has she fallen in the last year? I can't imagine the answer is 0.

I had a similar dump case. Elderly woman, on mega dosages of benzos and Seroquel. While in my office she fell down a flight of stairs and it was likely from the medication. She broke a bone in her foot and was then wheelchair bound for months. Wasn't my fault as we were in the process of weaning her off of it. I suggested it was likely cause her medication regimen.

Took about 4 months but we were able to wean her off of all of her bad meds. Replaced with Lamotrigine and Silexan (the Silexan worked wonders for her. In many patients it does nothing but if it does work its about as good as a benzo).

 

[annoyedpsychiatrist]

You are 100% accurate re screams misuse. This is a county clinic that is catering to patients. So she’s being treated like a disgruntled client/patient who gets to grieve with the psychiatry supervisor within a week of our visit. Said director already has a chip on their shoulder because I complained that such cases were permitted to be dumped on me as the new guy in clinic (including her cases).

for what its worth, most hospital systems are not for profit and PSLF eligible. Im working for a hospital system and its significantly better than my last job in the community health setting

 

[Candidate2017]

for what its worth, most hospital systems are not for profit and PSLF eligible. Im working for a hospital system and its significantly better than my last job in the community health setting

This is a county clinic that is catering to patients. So she’s being treated like a disgruntled client/patient who gets to grieve with the psychiatry supervisor

Physicians, in their traditional role, directly generate income for themselves. And today, for The Man as well. The impact of this is not fully appreciated by residents and new attendings.

An organization for which a phsyician directly generates income will treat the physician better. The more income generated, the better you are treated. For example, ortho bro can demand the hospital provide more money, more staff, more equipment, etc. and usually get it.

So OP, how does your org, a CMHC in this case, print money? Do they make money from trivial stuff like you tapering Seroquel 2000 mg and Xanax 2 mg qid (hint: inpatient Medicaid/care utilization rates would probably dramatically decrease if all their "clients" were on that regimen)?

Once you figure out how they make money (hint: not from your labor), you'll appreciate why they "cater to clients" and why they do or do not treat you well. In fact, who are the real clients of a CMHC (hint: lobbying is involved)?

 

[sloh]

Physicians, in their traditional role, directly generate income for themselves. And today, for The Man as well. The impact of this is not fully appreciated by residents and new attendings.

An organization for which a phsyician directly generates income will treat the physician better. The more income generated, the better you are treated. For example, ortho bro can demand the hospital provide more money, more staff, more equipment, etc. and usually get it.

So OP, how does your org, a CMHC in this case, print money? Do they make money from trivial stuff like you tapering Seroquel 2000 mg and Xanax 2 mg qid (hint: inpatient Medicaid/care utilization rates would probably dramatically decrease if all their "clients" were on that regimen)?

Once you figure out how they make money (hint: not from your labor), you'll appreciate why they "cater to clients" and why they do or do not treat you well. In fact, who are the real clients of a CMHC (hint: lobbying is involved)?

Please expand on this!!!

 

[calvnandhobbs68]

Please expand on this!!!

I'd suspect what's being alluded to here is that the way CMHCs stay afloat and make money is through significant block grants through federal and state governments. for example:

Community Mental Health Services Block Grant

The Community Mental Health Services Block Grant (MHBG) program makes funds available to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 6 Pacific jurisdictions to provide community mental health services.

www.samhsa.gov

What these agencies care about is how much "access" the centers are providing to care. That is, how many warm bodies do you have contact with every day. They don't care very much about what KIND of care you're providing. If you look under "performance requirements" it mostly alludes to "providing services" and the way you prove you're "providing services" is having a list of birthdays/SSNs who are "accessing care".

 

[clement]

I'd suspect what's being alluded to here is that the way CMHCs stay afloat and make money is through significant block grants through federal and state governments. for example:

Community Mental Health Services Block Grant

The Community Mental Health Services Block Grant (MHBG) program makes funds available to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 6 Pacific jurisdictions to provide community mental health services.

www.samhsa.gov

What these agencies care about is how much "access" the centers are providing to care. That is, how many warm bodies do you have contact with every day. They don't care very much about what KIND of care you're providing. If you look under "performance requirements" it mostly alludes to "providing services" and the way you prove you're "providing services" is having a list of birthdays/SSNs who are "accessing care".

Meanwhile, liability.

 

[Candidate2017]

Please expand on this!!!

CMHCs control payment for indigent inpatient psych hospitalization. They act as payor and get government money by lobbying based on the premise they can save money by improving outcomes and decreasing hospitalizations. That's a huge conflict of interest because each patient they keep out of the hospital is profit. Like any third party payor, taking in money but declining to pay out and provide services is the business model.

On consults, during training, there were many times we recommended hospitalization, but the patient was discharged home by the time we talked to the psych ward because the CMHC deemed them no longer suicidal after their suicide attempt.

I'd suspect what's being alluded to here is that the way CMHCs stay afloat and make money is through significant block grants through federal and state governments. for example:

CMHCs are more than staying afloat. Their annual budget is more than that of the average public school system. I was quite shocked the first time I saw a CMHC facility. It was a lot nicer than the average PP office.

 

[clement]

I'd suspect what's being alluded to here is that the way CMHCs stay afloat and make money is through significant block grants through federal and state governments. for example:

Community Mental Health Services Block Grant

The Community Mental Health Services Block Grant (MHBG) program makes funds available to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 6 Pacific jurisdictions to provide community mental health services.

www.samhsa.gov

What these agencies care about is how much "access" the centers are providing to care. That is, how many warm bodies do you have contact with every day. They don't care very much about what KIND of care you're providing. If you look under "performance requirements" it mostly alludes to "providing services" and the way you prove you're "providing services" is having a list of birthdays/SSNs who are "accessing care".

Are county clinics and community mental health centers the same in this regard? I imagine so. Mine is county.

 

[clement]

Old lady on seroquel and ativan for unclear reasons who's had issues with benzo withdrawal before and recently got into a car accident? Absolutely theres a personality component or misuse/abuse if she's already starting to vaguely threaten SI at the first sign of you wanting to adjust things.

Yeah no thanks I'd get out of that place if they're doing liability dumps like that, what a D-bag "hope you'd change the Seroquel young gun, I was too chicken to do it for the last 4 years".

liability dumping

for what its worth, most hospital systems are not for profit and PSLF eligible. Im working for a hospital system and its significantly better than my last job in the community health setting

Eh but CA has been behind. Like working for a group that services hospitals and PSLF (one cannot work directly for many hospitals). The rules about this re PSLF have changed. If anyone knows of ER telepsych gigs in the meantime that qualify…

 

[clement]

Old lady on seroquel and ativan for unclear reasons who's had issues with benzo withdrawal before and recently got into a car accident? Absolutely theres a personality component or misuse/abuse if she's already starting to vaguely threaten SI at the first sign of you wanting to adjust things.

Yeah no thanks I'd get out of that place if they're doing liability dumps like that, what a D-bag "hope you'd change the Seroquel young gun, I was too chicken to do it for the last 4 years".

He didn’t have the spine to change it because his grandmotherly pt has been weaponizing SI. That said, why should it fall on the next guy to pony up? Other than doing the right thing, of course. I’m comfortable calling her bluff because I’ve managed plenty of grandmothers weaponizing SI in psych ER settings when faced w/ the threat of benzo or other CNS depressant depletion. I’d rather not give them or their litigious adult children the bad news as their outpatient doctor…With no proper medical or ancillary services accessible to safely do the deed(s). My dream for her is to be thriving on nortryp or something in some hero’s geropsych unit. 💪

 

[Mad Jack]

This is the problem with CMHC work. In private practice one could simply say, "our first two visits are so I can appreciate the nature of your case and develop a treatment plan," with the understanding that if they aren't in agreement with that plan they will have to look elsewhere. CMHCs don't want anyone looking elsewhere and generally have agreements that every patient must be seen, which puts you in the impossible scenario of having to treat a patient that does not agree with your proposed treatment plan. I trained in this sort of setting and it created frequent problems of the exact sort you're encountering now, and put me off of ever working in such a place ever again.

CMHCs control payment for indigent inpatient psych hospitalization. They act as payor and get government money by lobbying based on the premise they can save money by improving outcomes and decreasing hospitalizations. That's a huge conflict of interest because each patient they keep out of the hospital is profit. Like any third party payor, taking in money but declining to pay out and provide services is the business model.

On consults, during training, there were many times we recommended hospitalization, but the patient was discharged home by the time we talked to the psych ward because the CMHC deemed them no longer suicidal after their suicide attempt.



CMHCs are more than staying afloat. Their annual budget is more than that of the average public school system. I was quite shocked the first time I saw a CMHC facility. It was a lot nicer than the average PP office.

One of the FQHCs I worked at had comprehensive psychiatric services and grants that would make a fiscally conservative voter's eyes bleed. They would get $282 per visit, regardless of service provided or billing level, and could bill for multiple services per day, unlike most multispecialty clinics. You could run a patient through everything like a factory, addiction services, then psych, then medicine, then dental and bill over $1,000 per patient per day. The local CMHCs didn't have it that good but still had it *pretty good*

 

[clement]

This is the problem with CMHC work. In private practice one could simply say, "our first two visits are so I can appreciate the nature of your case and develop a treatment plan," with the understanding that if they aren't in agreement with that plan they will have to look elsewhere. CMHCs don't want anyone looking elsewhere and generally have agreements that every patient must be seen, which puts you in the impossible scenario of having to treat a patient that does not agree with your proposed treatment plan. I trained in this sort of setting and it created frequent problems of the exact sort you're encountering now, and put me off of ever working in such a place ever again.

One of the FQHCs I worked at had comprehensive psychiatric services and grants that would make a fiscally conservative voter's eyes bleed. They would get $282 per visit, regardless of service provided or billing level, and could bill for multiple services per day, unlike most multispecialty clinics. You could run a patient through everything like a factory, addiction services, then psych, then medicine, then dental and bill over $1,000 per patient per day. The local CMHCs didn't have it that good but still had it *pretty good*

With recent reforms, those billing for multiple services per day in this setting are going extinct. Or so that’s what I’ve understood. Being forced to treat someone who disagrees with the plan in this context is also unethical.

I’m going to threaten leaving. I needed reaffirmation and I’ve gotten it. With a 30% vacancy rate and psychiatrists who were clearly starving for a mass dumping opportunity on the new guy, I suspect they’ll cave in…And transfer pts like this back to the dumper rather than “consider it on a case by case basis.”

 

[Stagg737]

The kicker is, this supervising psychiatrist tries reaally hard to not have dumps go back to their former psychiatrist (in this case a guy still in clinic)….because she also dumped some of her own on the new doctor (me). I’m fine with getting this pt back if so, but I will walk if she tries to tell me I have to keep filling this pts bs regimen at 74.

Ridiculous. If they don't have the gonads to do it themselves then they shouldn't expect someone else to do it for them. I've put a hard stop in my consult clinic that I will offer recommendations on how to taper benzos, but I will not do it myself other than 1 or 2 special cases for a PCP who inherited a previous PCP's benzo list where the patients were requesting the taper themselves.

Imo, you're fully justified in threatening to walk from that position. Treat the clinic like the patients they're trying to dump on you, strong boundaries with consequences for breaking the rules (Ie, you leaving).

 

[clement]

Ridiculous. If they don't have the gonads to do it themselves then they shouldn't expect someone else to do it for them. I've put a hard stop in my consult clinic that I will offer recommendations on how to taper benzos, but I will not do it myself other than 1 or 2 special cases for a PCP who inherited a previous PCP's benzo list where the patients were requesting the taper themselves.

Imo, you're fully justified in threatening to walk from that position. Treat the clinic like the patients they're trying to dump on you, strong boundaries with consequences for breaking the rules (Ie, you leaving).

Ridiculous. If they don't have the gonads to do it themselves then they shouldn't expect someone else to do it for them. I've put a hard stop in my consult clinic that I will offer recommendations on how to taper benzos, but I will not do it myself other than 1 or 2 special cases for a PCP who inherited a previous PCP's benzo list where the patients were requesting the taper themselves.

Imo, you're fully justified in threatening to walk from that position. Treat the clinic like the patients they're trying to dump on you, strong boundaries with consequences for breaking the rules (Ie, you leaving).

I can already picture them shuddering at the words, “Sorry, this isn’t going to be sustainable…”