Patient Prescribed High-Doses of Controlled Medications Seeking Admission to Psychiatric Unit

[AD04]

The prescribing by mid-level providers are atrocious. I have patients on high dose suboxone and high dose xanax and high dose adderall seeking admission to the psychiatric unit.

I do not want to promote diversion or abuse of their prescription medication. I do not want addicts to treat the inpatient unit as a way for them to get more controlled substances after they have run out.

I have been heavy handed and would not prescribe controlled medications and make them withdraw if they choose to stay. I would watch out for seizure and give the necessary medications if needed for seizure. I was wondering if there is a better way without feeding into the addiction.

How would your prescribe or not prescribe if you had such patients in the inpatient unit?

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[Sushirolls]

Need more details to this clinical history to get a better understanding. At face value, substance abusing and needs detox stabilization they are at the right place. Help us understand how there is abuse with some of these admissions?

 

[AD04]

I'll provide a hypothetical case:

37-yo M seeks admission to the psychiatric unit for hallucinations and suicidal ideation with plan. Home medications include suboxone 24mg-6mg daily, xanax 2mg TID, adderall 30mg BID, risperdal 2mg BID, and zoloft 100mg daily. Reported compliance with medications. UDS shows he has been taking his controlled medications and he hasn't been taking drugs off the street. Vitals are stable. Labs WNL. No medical concerns. Oriented and has capacity to make his own decisions.

No other information provided or available.

How would you treat?

 

[robellis]

No need for the stimulant

 

[Stagg737]

I'll provide a hypothetical case:

37-yo M seeks admission to the psychiatric unit for hallucinations and suicidal ideation with plan. Home medications include suboxone 24mg-6mg daily, xanax 2mg TID, adderall 30mg BID, risperdal 2mg BID, and zoloft 100mg daily. Reported compliance with medications. UDS shows he has been taking his controlled medications and he hasn't been taking drugs off the street. Vitals are stable. Labs WNL. No medical concerns. Oriented and has capacity to make his own decisions.

No other information provided or available.

How would you treat?

Discontine Xanax and treat the withdrawal, hold the Adderall and consider 30 day refill at d/c (would not refill if they are doing this repeatedly), continue the Suboxone (if certified).

No reason to continue a benzo, Adderall would be dependent on history but I'd leave that up to their outpatient doctors to prescribe, suboxone if using appropriately is likely the one providing actual benefit in terms of substance treatment, so as long as they're not abusing it and actually taking it I'd continue it on d/c. Would likely initially hold it though to r/o it possibly playing a role in "hallucinations".

 

[TexasPhysician]

Report to the board.

 

[robellis]

Discontine Xanax and treat the withdrawal, hold the Adderall and consider 30 day refill at d/c (would not refill if they are doing this repeatedly), continue the Suboxone (if certified).

No reason to continue a benzo, Adderall would be dependent on history but I'd leave that up to their outpatient doctors to prescribe, suboxone if using appropriately is likely the one providing actual benefit in terms of substance treatment, so as long as they're not abusing it and actually taking it I'd continue it on d/c. Would likely initially hold it though to r/o it possibly playing a role in "hallucinations".

They don’t want to stop the Xanax hypothetically, you want to force someone into withdrawal even though they will be discharged and get back on it?

 

[Sushirolls]

Report to the board.

Report what?
ASAM and the likes haven't put their foot down to say officially no benzos with bupe.
OP alludes to ARNP prescribing. Doubtful they'll do anything.

 

[hallowmann]

I'll provide a hypothetical case:

37-yo M seeks admission to the psychiatric unit for hallucinations and suicidal ideation with plan. Home medications include suboxone 24mg-6mg daily, xanax 2mg TID, adderall 30mg BID, risperdal 2mg BID, and zoloft 100mg daily. Reported compliance with medications. UDS shows he has been taking his controlled medications and he hasn't been taking drugs off the street. Vitals are stable. Labs WNL. No medical concerns. Oriented and has capacity to make his own decisions.

No other information provided or available.

How would you treat?

This seems like an appropriate admission. Discontinue Xanax and manage withdrawal with symptom triggered or long-acting taper and hold or significantly decrease Adderall.

They likely won't need as much when their focus and impulsivity improves magically after being off Xanax, and then watch their panic attacks and irritability improve on lower stims. If you have the time to truly manage them inpatient, they might love you for making them feel normal again. Maybe it's still idealistic, but I've seen it happen at least more than once.

The buprenorphine should obviously stay, and if their GOC includes reduction, they can do that with their NP.

 

[hebel]

I typically call the outpatient doctor after admission to run my changes by him or her, as well as my reasons for concern before changing a whole lot. I don't like the idea of a rapid taper only to have them immediately restart it after discharge because the outpatient doc is just going to continue the meds.

For situations such as a psychotic person on stimulants, I'll act preemptively.

 

[hallowmann]

I typically call the outpatient doctor after admission to run my changes by him or her, as well as my reasons for concern before changing a whole lot. I don't like the idea of a rapid taper only to have them immediately restart it after discharge because the outpatient doc is just going to continue the meds.

For situations such as a psychotic person on stimulants, I'll act preemptively.

Obviously if you can communicate with the outpatient doc, that is ideal. Chances are that they've wanted to decrease or stop something for a while, but didn't have a great opening. You could do it inpatient and give them the excuse/opportunity.

Most people, even midlevels, don't want people on ridiculous regimens of controlled substances, and it's usually done out of ignorance (treating side effects with more meds) or inertia (continuing controlled substances when the patient "isn't ready").

Most likely they'll end up on some benzo at discharge, but hopefully it'll be a lot less than alprazolam 2 mg TID.

 

[TexasPhysician]

Report what?
ASAM and the likes haven't put their foot down to say officially no benzos with bupe.
OP alludes to ARNP prescribing. Doubtful they'll do anything.

All being high doses is inappropriate. Likely contributed to the inpatient admission in some way which is harm.

 

[AD04]

The hypothetical dose of suboxone is quite high. In conjunction with xanax and adderall, addiction is a very very real possibility. Diversion cannot be ruled out either. So for those that would rather continue suboxone, is abuse of suboxone ok as long as they don't abuse street opioids?

 

[hallowmann]

The hypothetical dose of suboxone is quite high. In conjunction with xanax and adderall, addiction is a very very real possibility. Diversion cannot be ruled out either. So for those that would rather continue suboxone, is abuse of suboxone ok as long as they don't abuse street opioids?

24-6 mg is a high dose, but it's far from unheard of. I've had a couple up to 32-8 mg. Plenty of people live in the 16-4 to 24-6 range. It's bad in conjunction with the benzo and stimulant, but in and of itself, its not a crazy dose.

 

[Sushirolls]

Could convert to injectable bupe.

Depending on age and other comorbidities probably has OSA, and central apnea contribution from bupe could benefit from CPAP, and likely help stopping the stimulant.

If needed, consider Dayrana patch for stimulant? Less diversion potential over oral?

Call Rx ARNP, update on concerns and plan while on unit. Document this. And make sure discharge summary actually gets sent to Rx ARNP.

 

[calvnandhobbs68]

24-6 mg is a high dose, but it's far from unheard of. I've had a handful up to 32-8 mg. Plenty of people live in the 16-4 to 24-6 range. It's bad in conjunction with the benzo and stimulant, but in and of itself, its not a crazy dose.

Yup I have a few people on 20-24. It’s on the high end but justifiable.

60mg total of Adderall is also not unheard of. I certainly try to convert to XR if possible but the dosage range isn’t crazy. Certainly people with a history of OUD are allowed to have real ADHD too. Now when I see people go up to 90 ehhhh. I also try to have people on Vyvanse if possible but I have a few people who came to me on adderall that function well and don’t really want to mess with it. Of course, these people are not showing up to an inpatient psych unit saying they’re hallucinating and have SI.

Like everyone else says, it’s the benzo that stands out. That needs to go and would definitely be a reason to admit for controlled detox.

 

[calvnandhobbs68]

The hypothetical dose of suboxone is quite high. In conjunction with xanax and adderall, addiction is a very very real possibility. Diversion cannot be ruled out either. So for those that would rather continue suboxone, is abuse of suboxone ok as long as they don't abuse street opioids?

It’s very rare that people “abuse” suboxone as in trying to get high from it. From what I hear tell, it’s quite hard because the partial agonist effect caps out. More likely people divert part of their prescribed dose to people who can’t/won’t get into a Suboxone program (ex. People who don’t want to do the SUD counseling/AA) or people trying to stave off heroin withdrawal.

that’s tougher to figure out but that’s why now we typically cap people at 16mg

 

[psychacad]

I'd kill one bird at a time. Call the NP first and figure out why he's on Adderall (and vent a month's worth of pent up anger). Does he also have a psychotic disorder (presumably since he's on risperdal)? Where's the AH coming from? My first go to would be to taper Adderall (even if he's ADHD, hard to justify). Can also convert Xanax to Ativan (or Klonopin if you're ambitious). Don't think you want to make too many changes at a single time and you still want the patient to cooperate somewhat with you.

 

[birchswing]

But what is causing the hallucinations?

The rapid taper is extremely difficult to live with post-discharge. There's the risk of kindling, increased post-acute withdrawal syndrome, and a lot of people end up reinstating.

And then there's still the hallucinations.

I don't know the answer. It sounds like a bad situation.

 

[kopftonmd]

I'd kill one bird at a time. Call the NP first and figure out why he's on Adderall (and vent a month's worth of pent up anger). Does he also have a psychotic disorder (presumably since he's on risperdal)? Where's the AH coming from? My first go to would be to taper Adderall (even if he's ADHD, hard to justify). Can also convert Xanax to Ativan (or Klonopin if you're ambitious). Don't think you want to make too many changes at a single time and you still want the patient to cooperate somewhat with you.

I definitely get calling the outpatient provider, but (hypothetically), what if they don't want to talk turkey and work with you, say if they're committed to the med regimen as described for XYZ reason? I suppose beyond reporting to the board as @TexasPhysician said, what options do you have?

 

[psychacad]

I definitely get calling the outpatient provider, but (hypothetically), what if they don't want to talk turkey and work with you, say if they're committed to the med regimen as described for XYZ reason? I suppose beyond reporting to the board as @TexasPhysician said, what options do you have?

Sorry, editing, I thought first what if the patient is not cooperating.

In that case, you need to do what's best for the patient, which wouldn't really change your treatment plan substantially.

 

[michaelrack]

I rarely give stimulants to adult inpatients... usually just stop abruptly

 

[birchswing]

I usually leave well enough alone . . . but I kept thinking about this.

The person is actively psychotic.

And people are suggesting just stopping the equivalent of 120 mg of Valium (and I know the equivalencies aren't exact, but that's the ballpark).

Hallucinations are one of the symptoms of sudden benzodiazepine withdrawal. I don't advocate benzos at all to anyone. Actively discourage them. I just have a hard time grasping how this could work even in the best of circumstances let alone someone having hallucinations.

 

[Liquid8]

These patients are always tricky.

In the hypothetical case my differentials would include a stimulant induced psychosis and depression with psychotic features..

At first glance the stimulant might be contributing and the dose of Zoloft is probably suboptimal. That psychotic symptoms have persisted despite being on a decent dose of an antipsychotic is also noteworthy.

To clarify things I would first taper/cease the stimulant. If the hallucinations settle, we can assume that’s the cause and look at non-stimulant treatments for ADHD.

If psychotic symptoms persist, then it suggests Riperidone isn’t controlling the psychosis, so I’d look at an increase or switching to an alternative antipsychotic. Similar logic applies with the mood symptoms – there is room to increase Zoloft or switch based on patient preference.

For me the benzo side of things is not the immediate priority as having something on board will likely help with the initial symptoms. However, I’d still want to reduce and convert them to a long acting alternative. This goes hand in hand with pushing for a higher dose of antidepressant as that will be better long term for anxiety management compared with Xanax.

It’s usually much easier to control benzo dosing in the inpatient setting, but I’ve learnt to be very vigilant with PRN charts after having a few who managed to max out all their daily allocations which can happen with alcohol withdrawal regimes (usually happens with the wrong combination of inexperienced nursing staff).

Agree that the diversion risk is elevated with these patients, but this generally shouldn't be an issue as an inpatient. At our private hospital every so often we have patients caught bringing in substances or dealing - once found out they get discharged and banned.

 

[clozareal]

I rarely give stimulants to adult inpatients... usually just stop abruptly

For the case above who is on a stimulant and an antipsychotic, we need to be careful when we stop or start one of them. Either acute dystonia or acute dyskinesia can occur depending on the situation. The stimulant should be tapered off slowly.

When the person is on the combination of a stimulant and an antipsychotic, two things happen:
1. Because stimulants increase dopaminergic neurotransmission, there is downregulation or decreased activity of dopamine receptors.
2. The antipsychotic is blocking a high proportion of the remaining dopamine receptors.

So, the postsynaptic dopamine receptors are reduced plus the antipsychotic is blocking dopamine receptors. Now, when a stimulant is suddenly stopped, a third factor is introduced — dopaminergic neurotransmission falls.

All this leads to a “perfect storm” with an acute drop in dopaminergic activity which may lead to acute dystonia. We may think of it as equivalent to giving a large dose of an antipsychotic all at once.

 

[clausewitz2]

For the case above who is on a stimulant and an antipsychotic, we need to be careful when we stop or start one of them. Either acute dystonia or acute dyskinesia can occur depending on the situation. The stimulant should be tapered off slowly.

When the person is on the combination of a stimulant and an antipsychotic, two things happen:
1. Because stimulants increase dopaminergic neurotransmission, there is downregulation or decreased activity of dopamine receptors.
2. The antipsychotic is blocking a high proportion of the remaining dopamine receptors.

So, the postsynaptic dopamine receptors are reduced plus the antipsychotic is blocking dopamine receptors. Now, when a stimulant is suddenly stopped, a third factor is introduced — dopaminergic neurotransmission falls.

All this leads to a “perfect storm” with an acute drop in dopaminergic activity which may lead to acute dystonia. We may think of it as equivalent to giving a large dose of an antipsychotic all at once.

Citation? There is PET work showing reduction in dopamine receptor density in folks chronically using very large quantities of amphetamines and some animal work but this is very different from anything like a clinical dose.

I can't find a single case report of acute dystonia happening due to w/d of an amphetamine or other psychostimulant.

 

[Celexa]

I'll provide a hypothetical case:

37-yo M seeks admission to the psychiatric unit for hallucinations and suicidal ideation with plan. Home medications include suboxone 24mg-6mg daily, xanax 2mg TID, adderall 30mg BID, risperdal 2mg BID, and zoloft 100mg daily. Reported compliance with medications. UDS shows he has been taking his controlled medications and he hasn't been taking drugs off the street. Vitals are stable. Labs WNL. No medical concerns. Oriented and has capacity to make his own decisions.

No other information provided or available.

How would you treat?

Theres a couple pieces of information missing here--whether or not you actually believe the patient is suicidal and hallucinating, and whether or not they'd meet involuntary admission criteria if they weren't seeking hospitalization (I'm assuming no, but that circumstance can definitely happen).

If they only meet criteria for being a voluntary patient, I would admit them but explain that appropriate inpatient treatment would involve decreasing the doses of medication that could be contributing to their symptoms or that are unsafe. If they understand that, in they go. If they refuse they have the right to do so. Once on the unit my first move would be to hold the Adderall and prn a lower dose of benzo and see what happens.

It sounds like you suspect some of these patients to have been abusing their meds and using the inpatient unit to bridge them to their next refill. In that case I would discharge if I had a good enough hx to make the case, or admit but communicate to the patient that refills for their controlled meds would not be provided upon discharge and that their admission will be discussed with their outpatient provider. If I were not going to be the inpatient provider I would also communicate that the inpatient provider would be making their own decision about the meds and that that might involve tapering.

I would leave the suboxone alone regardless. 24mg is on the high side but as people have said not unreasonable, and although I might suspect it's too high I would not make that kind of adjustment in an acute setting, especially not with all the other meds which should be changed first.

 

[dl2dp2]

This particular regimen is suboptimal, but if you substitute Xanax with Klonopin it would sound vaguely like many of my patients. The classic outpatient problem list looks like the following:
1. MDD severe with or without psychotic features (vs. parapsychosis of BPD)
2. opioid use disorder - in sustained remission
3. GAD
4. r/o BPD with chronic suicidality (typically these people have a trauma history)
5. benzo physical dependence with or without a history of abuse
6. ADHD

If you are the outpatient doc, you inherit someone like this, the order of de-prescribing looks something like this:
1. transition benzo from Xanax to low dose Klonopin ==> this step is not easy. sometimes requires bridge with antipsychotics, sometimes require very long tapers, sometimes patients just refuse taper
2. reduce short-acting stimulants or switch to Adderall XR/Vyvanse etc
3. DC antipsychotics

But for a lot of people, it's hard to either of these things quickly. The underlying diagnosis is usually a personality disorder, but this part takes a lot of work (DBT, etc) to correct. In my experience, long term treatment with sustained-release stimulants cannot be removed if you want the patient to be employed and so on.

If I was the inpatient admission attending, I'd probably write the following admission meds (for your reference):
1. zoloft 100mg
2. suboxone 24mg
3. Klonopin (whatever is the equivalent to Xanax 2 TID)
4. Haldol/Ativan PRN for agitation
5. Vitals/CIWA q4-6h

He's not gonna die or withdrawal for not having stimulants.

Then during the day get in touch with the NP to get more history to figure out if this is BPD or something else. Inpatient is a good place to swap out Xanax and DC antipsychotic for fake psychosis. You keep him for day to assess for SI then send back to outpatient. The outpatient should continue meds/manage withdrawal, etc.

 

[robellis]

This particular regimen is suboptimal, but if you substitute Xanax with Klonopin it would sound vaguely like many of my patients. The outpatient problem list looks like the following:
1. MDD severe with or without psychotic features (vs. parapsychosis of BPD)
2. opioid use disorder - in sustained remission
3. GAD
4. r/o BPD with chronic suicidality
5. benzo dependence
6. ADHD

If you are the outpatient doc, you inherit someone like this, the order of de-prescribing looks something like this:
1. transition benzo from Xanax to low dose Klonopin ==> this step is not easy. sometimes requires bridge with antipsychotics, sometimes require very long tapers, sometimes patients just refuse taper
2. reduce short acting stimulants or switch to Vyvanse
3. DC antipsychotics

But for a lot of people, it's hard to either of these things quickly. The underlying diagnosis is usually a personality disorder, but this part takes a lot of work to correct. In my experience, long term treatment with sustained-release simulants cannot be removed.

If I was the inpatient admission attending, I'd probably write the following admission meds (for your reference):
1. zoloft 100mg
2. suboxone 24mg
3. Klonopin (whatever is the equivalent to Xanax 2 TID)
4. Haldol/Ativan PRN for agitation

He's not gonna die or withdrawal for not having stimulants.

Then during the day get in touch with the NP to get more history to figure out if this is BPD or something else. Inpatient is a good place to swap out Xanax and DC antipsychotic for fake psychosis.

Why antipsychotic bridge for Xanax to klonopin switch?

 

[dl2dp2]

Why antipsychotic bridge for Xanax to klonopin switch?

A number of my patients need an additional Seroquel 400 to sleep transition from Xanax 2 TID to once or twice daily Klonopin dosing. In addition, in long Klonopin taper, I find it hard to get people drop below 1mg Klonopin daily without temporarily using Seroquel 400+ or Zyprexa 2+. Unfortunately one of my patients had a seizure, which may or may not be related to the Seroquel. His neurologist also doesn't call me back, which is very frustrating.

I think this is bread and butter outpatient addiction. These people would benefit from addiction consults to sort out their meds. My experience has been general psychiatrists don't evaluate whether "high dose" is really a use disorder or just tolerance--which is fine, I understand if you don't have time during admits, etc. I have patients who are on very high doses of stimulants (Concerta 200mg+) and suboxone (36mg+) and don't have a use disorder. There are people who are on high benzos w/o a use disorder, but benzos at high doses have bad liability in and of itself so would have to be DCed.

 

[clozareal]

Citation? There is PET work showing reduction in dopamine receptor density in folks chronically using very large quantities of amphetamines and some animal work but this is very different from anything like a clinical dose.

I can't find a single case report of acute dystonia happening due to w/d of an amphetamine or other psychostimulant.

Here are several case reports, mostly in children (who are much more prone to side effects of antipsychotics) since they're more likely to be diagnosed with ADHD and prescribed stimulant medications until more recently.

Aman MG, Binder C, Turgay A. Risperidone effects in the presence/absence of psychostimulant medicine in children with ADHD, other disruptive behavior disorders, and subaverage IQ. J Child Adolesc Psychopharmacol. 2004 Summer;14(2):243-54. PubMed PMID: 15319021.

Benjamin E, Salek S. Stimulant-atypical antipsychotic interaction and acute dystonia. J Am Acad Child Adolesc Psychiatry. 2005 Jun;44(6):510-2. Erratum in: J Am Acad Child Adolesc Psychiatry. 2005 Sep;44(9):960. PubMed PMID: 15908830.

Guler G, Yildirim V, Kutuk MO, Toros F. Dystonia in an adolescent on risperidone following the discontinuation of methylphenidate: a case report. Clin Psychopharmacol Neurosci. 2015 Apr 30;13(1):115-7. PubMed PMID: 25912546; PubMed Central PMCID: PMC4423153.

Keshen A, Carandang C. Acute dystonic reaction in an adolescent on risperidone when a concomitant stimulant medication is discontinued. J Child Adolesc Psychopharmacol. 2007 Dec;17(6):867-70. PubMed PMID: 18315457.

McLaren JL, Cauble S, Barnett RJ. Aripiprazole induced acute dystonia after discontinuation of a stimulant medication. J Clin Psychopharmacol. 2010 Feb;30(1):77-8. PubMed PMID: 20075654.

Millichap JG, Yee MM. Dystonia with MPH/Risperidone Combined Therapy for ADHD. Pediatr Neurol Briefs. 2016 Jan;30(1):7. PubMed PMID: 27004141; PubMed Central PMCID: PMC4798857.

Shen YC. Amphetamine as a risk factor for aripiprazole-induced acute dystonia. Prog Neuropsychopharmacol Biol Psychiatry. 2008 Oct 1;32(7):1756-7. PubMed PMID: 18703111.

Silvestri S, Seeman MV, Negrete JC, Houle S, Shammi CM, Remington GJ, Kapur S, Zipursky RB, Wilson AA, Christensen BK, Seeman P. Increased dopamine D2 receptor binding after long-term treatment with antipsychotics in humans: a clinical PET study. Psychopharmacology (Berl). 2000 Oct;152(2):174-80. PubMed PMID: 11057521.

 

[birchswing]

I

3. Klonopin (whatever is the equivalent to Xanax 2 TID)

That is the equivalent. They are equivalent (at least as far as the estimates go).

Klonopin is very high potency. I don't get the love for it. It's incredibly hard to taper precisely because it's so high potency and so you have to cut fairly large amounts at a time since it's not available in more manageable doses to titrate with.

 

[dl2dp2]

I

That is the equivalent. They are equivalent (at least as far as the estimates go).

Klonopin is very high potency. I don't get the love for it. It's incredibly hard to taper precisely because it's so high potency and so you have to cut fairly large amounts at a time since it's not available in more manageable doses to titrate with.

No what I mean here is Klonopin at the DOSE following the online calculator of Ativan equivalents.

 

[birchswing]

A number of my patients need an additional Seroquel 400 to sleep transition from Xanax 2 TID to once or twice daily Klonopin dosing. In addition, in long Klonopin taper, I find it hard to get people drop below 1mg Klonopin daily without temporarily using Seroquel 400+ or Zyprexa 2+. Unfortunately one of my patients had a seizure, which may or may not be related to the Seroquel. His neurologist also doesn't call me back, which is very frustrating.

I think this is bread and butter outpatient addiction. These people would benefit from addiction consults to sort out their meds. My experience has been general psychiatrists don't evaluate whether "high dose" is really a use disorder or just tolerance--which is fine, I understand if you don't have time during admits, etc. I have patients who are on very high doses of stimulants (Concerta 200mg+) and suboxone (36mg+) and don't have a use disorder. There are people who are on high benzos w/o a use disorder, but benzos at high doses have bad liability in and of itself so would have to be DCed.

Why not a glutamate antagonist or anti-seizure med? Not that there's great evidence for any of them in withdrawal, but antipsychotics don't directly treat the problem.

 

[birchswing]

No what I mean here is Klonopin at the DOSE following the online calculator of Ativan equivalents.

You could convert it to Ativan and back again, but the guidelines say 0.5 mg Xanax is equivalent to 0.5 mg Klonopin.

 

[dl2dp2]

Why not a glutamate antagonist or anti-seizure med? Not that there's great evidence for any of them in withdrawal, but antipsychotics don't directly treat the problem.

Good thought, and they have been tried, but in my experience, gabapentin/pregabalin don't work well for "anxiety" and "insomnia" (typically trauma-related) in benzo taper. One could try ketamine, which may be a one stop shop solution, but I reserve this for people who fail TCA/MAOI.

Benzo dependence is not very well understood as a condition. Both NIDA and industry are also fairly uninterested in funding research in this area at the moment. Sponsors are more interested in crystal meth/other stimulants right now.

 

[birchswing]

Good thought, and they have been tried, but in my experience, gabapentin/pregabalin don't work well for "anxiety" and "insomnia" (typically trauma-related) in benzo taper. One could try ketamine, which may be a one stop shop solution, but I reserve this for people who fail TCA/MAOI.

Benzo dependence is not very well understood as a condition. Both NIDA and industry are also fairly uninterested in funding research in this area at the moment. Sponsors are more interested in crystal meth/other stimulants right now.

Yes—I remember writing to the head of NIDA once many years ago after I saw her on 60 minutes talking about the opiate epidemic, and I wrote to her about the problem with benzodiazepines. She actually wrote back which was nice, but basically said it was not high on their radar.

 

[AD04]

It seems my prescribing patterns are even more conservative compared to those on SDN. For my outpatient side, I don't prescribe two different types of controlled medications in the same patient (e.g. benzodiazepine and stimulant) for long and will make the patient choose 1 and taper the other.

I will reconsider how I tackle suboxone on the inpatient setting. I may be doing too much too quickly but I would hate to continue their addiction or diversion.

I want these type of patients to have skin-in-the-game (withdraw) so I can weed out those that are really looking for help vs those that just want more controlled medications because they diverted them or abused them. Those who are serious will stay and those who are malingering will leave.

FYI, in my area, ALL the patients who presented with mass doses of various controlled medications are low-functioning. No jobs. On disability. Legal history. Addiction history. If they were high functioning, I wouldn't be so heavy-handed.

How do the low-functioning patients get these medications? The local pill mill (mostly run by NPs with 1 absentee physician supervisor) keeps on giving controlled medications out like candy (especially suboxone) because they receive government subsidy for doing so. People have reported them in the past but no one does anything. (I guess it is because the area is severely underserved.)

 

[clausewitz2]

Yes—I remember writing to the head of NIDA once many years ago after I saw her on 60 minutes talking about the opiate epidemic, and I wrote to her about the problem with benzodiazepines. She actually wrote back which was nice, but basically said it was not high on their radar.

If you're talking about Nora Volkow, fun fact, she's Leon Trotsky's great-granddaughter

 

[birchswing]

If you're talking about Nora Hollow, fun fact, she's Leon Trotsky's great-granddaughter

I just looked it up in my e-mail—it was from 2012, and it was Nora Volkow—same person?

 

[clausewitz2]

I just looked it up in my e-mail—it was from 2012, and it was Nora Volkow—same person?

I hate autocorrect

 

[birchswing]

Good thought, and they have been tried, but in my experience, gabapentin/pregabalin don't work well for "anxiety" and "insomnia" (typically trauma-related) in benzo taper. One could try ketamine, which may be a one stop shop solution, but I reserve this for people who fail TCA/MAOI.

Benzo dependence is not very well understood as a condition. Both NIDA and industry are also fairly uninterested in funding research in this area at the moment. Sponsors are more interested in crystal meth/other stimulants right now.

I just remembered an interesting argument I heard once. This was a doctor who made the argument—they often had fanciful, unrealistic ideas, and this very probably falls into that category. They thought that the companies who discovered and marketed benzodiazepines should be sued and compelled to create a medication to treat benzodiazepine dependence/tolerance and that would aid in tapering and withdrawal symptoms.

My initial thought was that it's hard to even know if those entities exist at this point. I'm not sure whom would be sued. I guess like Roche and Wyeth, but those companies buy each other up and get sold under new names. Wyeth I know doesn't exist anymore. Roche still exists in some way I think. And they were first marketed so long ago. But the brand names are sold by completely different companies now (except I think in Roche's case).

I also thought that it's a weird idea that you could force a company to invent something. But as I thought of it again two precedents came to mind: 1) Big tobacco was forced to create quitting assistance programs and 2) When Apple was being sued by the FBI for access to encrypted iPhones, the suit was essentially (if it had been successful which it was not) forcing Apple to write software not yet in existence that would have bypassed their encryption methods.

So at a minimum perhaps they could be sued into doing the research for some sort of solution. But again, I'm not sure who "they" are anymore. Who is responsible at this point when brand names are no longer the big part of the market, and it's been so many years.

 

[calvnandhobbs68]

It seems my prescribing patterns are even more conservative compared to those on SDN. For my outpatient side, I don't prescribe two different types of controlled medications in the same patient (e.g. benzodiazepine and stimulant) for long and will make the patient choose 1 and taper the other.

I will reconsider how I tackle suboxone on the inpatient setting. I may be doing too much too quickly but I would hate to continue their addiction or diversion.

I want these type of patients to have skin-in-the-game (withdraw) so I can weed out those that are really looking for help vs those that just want more controlled medications because they diverted them or abused them. Those who are serious will stay and those who are malingering will leave.

FYI, in my area, ALL the patients who presented with mass doses of various controlled medications are low-functioning. No jobs. On disability. Legal history. Addiction history. If they were high functioning, I wouldn't be so heavy-handed.

How do the low-functioning patients get these medications? The local pill mill (mostly run by NPs with 1 absentee physician supervisor) keeps on giving controlled medications out like candy (especially suboxone) because they receive government subsidy for doing so. People have reported them in the past but no one does anything. (I guess it is because the area is severely underserved.)

Dude. If you’re on suboxone you have an addiction history. If you have an addiction history, probably better than 50/50 chance you have a legal history. If you’re a guy who was in a car accident or suffered some work related injury that then lead to you eating oxycodone your doctor prescribed 10 years ago which lead to your OUD, chances are also good you’re no longer employable and on disability. There are plenty of people who hit those things that don’t show up to the psych ER complaining of psychosis and SI when you suspect they might be trying to use the inpatient unit as a way to get early fills on their meds. I wouldn’t put that in your criteria for “low functioning” 🙄

Again people are allowed to have ADHD and a substance use disorder. In fact the data shows that the comorbidity is pretty high (which may contribute to the development of the SUD in the first place). It just means the outpatient doc should be keeping an eye on things (regular f/u, drug screens, etc). I agree with the people above that nobody is gonna die from holding a stimulant inpatient and good way to r/o stimulant contributing to any of the hallucinatory stuff they’re reporting. But I wouldn’t be so suspicious about that specific combo of suboxone and stimulant. That’s like half my caseload. I’d certainly like the suboxone to be 16mg but I have a person or two in the 24mg range on a stimulant too. The benzo plus suboxone is the actually dangerous combo there. Of course if you’re seeing a bunch of patients coming from this same practice with the exact same combo of suboxone+stimulant+benzo then that’s obviously a bit suspicious too.

 

[AD04]

Dude. If you’re on suboxone you have an addiction history. If you have an addiction history, probably better than 50/50 chance you have a legal history. If you’re a guy who was in a car accident or suffered some work related injury that then lead to you eating oxycodone your doctor prescribed 10 years ago which lead to your OUD, chances are also good you’re no longer employable and on disability. There are plenty of people who hit those things that don’t show up to the psych ER complaining of psychosis and SI when you suspect they might be trying to use the inpatient unit as a way to get early fills on their meds. I wouldn’t put that in your criteria for “low functioning” 🙄

Again people are allowed to have ADHD and a substance use disorder. In fact the data shows that the comorbidity is pretty high (which may contribute to the development of the SUD in the first place). It just means the outpatient doc should be keeping an eye on things (regular f/u, drug screens, etc). I agree with the people above that nobody is gonna die from holding a stimulant inpatient and good way to r/o stimulant contributing to any of the hallucinatory stuff they’re reporting. But I wouldn’t be so suspicious about that specific combo of suboxone and stimulant. That’s like half my caseload. I’d certainly like the suboxone to be 16mg but I have a person or two in the 24mg range on a stimulant too. The benzo plus suboxone is the actually dangerous combo there. Of course if you’re seeing a bunch of patients coming from this same practice with the exact same combo of suboxone+stimulant+benzo then that’s obviously a bit suspicious too.

I appreciate the explanation. I'm not disagreeing with you when you look at specific aspects only (e.g. on suboxone and not working). The patients you have in mind are not likely to abuse their medications because they are unlikely to come to the inpatient unit complaining of psychosis and suicidal ideation. I would consider them moderate-functioning. They are not functioning as well as they were. And abuse / diversion is less likely.

I'm looking at the whole picture. On suboxone, on adderall (not even vyvanse or adderall XR), on xanax (not even klonopin or valium). Not working. In and out of jail. Want admission to the psychiatric unit. Addiction is HIGHLY suspect. Abuse or diversion is a real possibility. Low-functioning.

P.S. Why is half your case load on stimulant and suboxone? Are those patients holding a job or looking for a job at the very least? My partners (which include C&A) rarely have anyone on that combination, if at all.

 

[psychacad]

I appreciate the explanation. I'm not disagreeing with you when you look at specific aspects only (e.g. on suboxone and not working). The patients you have in mind are not likely to abuse their medications because they are unlikely to come to the inpatient unit complaining of psychosis and suicidal ideation. I would consider them moderate-functioning. They are not functioning as well as they were. And abuse / diversion is less likely.

I'm looking at the whole picture. On suboxone, on adderall (not even vyvanse or adderall XR), on xanax (not even klonopin or valium). Not working. In and out of jail. Want admission to the psychiatric unit. Addiction is HIGHLY suspect. Abuse or diversion is a real possibility. Low-functioning.

P.S. Why is half your case load on stimulant and suboxone? Are those patients holding a job or looking for a job at the ve
ry least? My partners (which include C&A) rarely have anyone on that combination, if at all.

I'm also surprised how commonly adult adhd is diagnosed and people put on stimulants.. At least in my residency clinic these cases were few and far in between. Maybe it's underdiagnosed. Would be interesting to see prevalence in comparison to more common psych diagnoses. It's also such a tricky dx to make.

 

[dl2dp2]

On suboxone, on adderall (not even vyvanse or adderall XR), on xanax (not even klonopin or valium). Not working. In and out of jail. Want admission to the psychiatric unit. Addiction is HIGHLY suspect. Abuse or diversion is a real possibility. Low-functioning.

Several points independent of the overall clinical picture:

Suboxone is not really abusable. I would caution you against tapering Suboxone inpatient -- this is strongly associated with overdose at discharge in several datasets looking at inpatient detox-rehab facilities. There are pending lawsuits against detox facilities that DCed suboxone while the patient was hospitalized which resulted in an overdose death, and regulators (SAMHSA, etc) are also coming against this practice.

I understand you are staffing MICA, not detox, but it's still an important point. MOUD cannot be stopped for people with a history of OUD. Stopping it at any time immediately increases relapse and overdose for the majority of people. After a long period of abstinence there may be situations where it may be stopped/tapered, but we don't know the circumstances yet and for who you can do this. NIDA has an ongoing trial (RDD, you can Google it) to figure how when you can discontinue MOUD.

Suboxone may be diverted, which is actually probably a *good* thing from a public health perspective. The current innovation in implementation science in this area is to increase buprenorphine access in the ER--so this is actually leaning in the opposite direction of what you are practicing. Especially because of the rise of high potency opioids, any increase in community exposure to buprenoprhine can be lifesaving. (i.e. there is data showing someone who's on and off suboxone has a lower chance of overdose than someone who's never on suboxone or recently tapered from suboxone).

W.r.t. adderall, it can't harm the patient to DC it during inpatient esp with "hallucinations". With benzos, well, the patient is probably addicted to benzos. But you can't really taper benzos inpatient (quickly) because of w/d. However, if you taper suboxone and the patient uses benzos and heroin, and relapses on heroin when you discharge him and not prescribe him suboxone to take home, he can *easily* die the next day. Ongoing OUD #1 issue right now and the benzo misuse is a covariate that increases overdose risk. The patient is vastly safer on both bup and benzo than detox off both at discharge. I understand this can be non-intuitive for non-addiction people--but in 2021, you must try to think of addictions as chronic conditions like diabetes or lupus--in general when you detox you need to add a maintenance meds after... If you want to discharge off benzo and suboxone, minimally, I would give him a Vivitrol shot. If you think suboxone isn't working and is a cause of his low functioning or many hospitalizations, the next stop is methadone or depot, NOT detox then med free.

 

[calvnandhobbs68]

I appreciate the explanation. I'm not disagreeing with you when you look at specific aspects only (e.g. on suboxone and not working).

I'm looking at the whole picture. On suboxone, on adderall (not even vyvanse or adderall XR), on xanax (not even klonopin or valium). Not working. In and out of jail. Want admission to the psychiatric unit. Addiction is HIGHLY suspect. Abuse or diversion is a real possibility.

P.S. Why is half your case load on stimulant and suboxone? Are those patients holding a job or looking for a job at the very least? My partners (which include C&A) rarely have anyone on that combination, if at all.

Sorry for the eye roll

I do some work at an adult outpatient addictions practice. There's also some other part time people there who aren't psychiatry who essentially refuse to prescribe stimulants when legacy patients got transferred to them and there's some legacy patients who have been stable there for years who basically got transferred to me. These are people that have been functional, stable, have jobs or kids at home they take care of every day (I can't actually think of any of my patients on stimulants who are on disability now that I think of it). Some of them were on IR Adderall BID, I try to convert to convert at least half of it to XR if I can or Vvyanse if insurance will cover it but honestly, if they've been doing alright and nothing I'm worried about in terms of diversion or abuse, it's kind of a dick move to just be like "sorry man, I know you've been doing okay on this for 5+ years now based on your controlled substance report but now we're gonna have to change to something else whether you like it or not".

As others have alluded to, its hard enough on the outpatient side to wean down stuff that you can clearly state to the patient is dangerous, much less try to change things around without a great reason just because it's a personal "policy" or something to not give stimulants and suboxone together. Granted, this is a hotly debated topic even within addictions and you'll definitely find addiction psychiatrists/physicians who are hardcore no other controlled substances with suboxone.

I also get to get all the "ADHD" evals for any new patients/IOP patients, which I'm much more conservative with...for me to start someone on a new stimulant requires a decent threshold for me personally when you're an adult. I treat those like any other adult ADHD eval (so a pan-positive ASRS isn't gonna cut it lol) but there have been a couple SUD patients I have started on Vyvanse/extended release stimulants. So I'm far from a candy-man but I'm also not going to suddenly start changing things around on patients who have been doing okay on something for years unless I have a reason to do it (and yes that includes some people on 24mg equivalent Suboxone/30mg BID Adderall that I inherited).

I also realized my wording initially wasn't very accurate. By "controlled detox" for the benzo, I mean conversion to something more easily tapered long term and a little taper down with a plan to keep that going as an outpatient, you're not gonna detox someone off a years long prescribed benzo in an inpatient stay. But again, this would require coordination with the outpatient NP to make sure they aren't just gonna switch them back to TID Xanax next time they show up.

 

[futuredo32]

I would reach out to the midlevel prescribing her current medications. If the NP plans to go back to her initial medications, there's no point to taper off of Xanax. Usually, we don't give psychotstimulants inpatient.

 

[AD04]

@sluox @calvnandhobbs68

Good job. I'm convinced.

 

[birchswing]

you're not gonna detox someone off a years long prescribed benzo in an inpatient stay

You'd be surprised the things people try.

There's a place near me that uses low dose flumazenil. Reviews on that place are mixed, but the majority are bad. I think that's a fairly esoteric treatment, and I just happen to live near one of the few places that does that.

From what I have heard, I don't think it's uncommon to use short inpatient stays to get people off benzodiazepines without them dying by using some combination of sedating antipsychotic and antiseizure med (or even phenobarbital). But from what I have read, people leave worse than they came in and end up going back on the med.