Patient with worsening anxiety and abusing xanax from their PCP.

[annoyedpsychiatrist]

Long story short, woman with anxiety sees me for follow up. She had been getting xanax 1mg TID from her PCP but last visit she had told me she weaned herself down to half a tablet a day. This is a telehealth visit (which i generally prefer in person but oh well) and I ask her how many she has left and apparently she only has 9 tablets left, despite filling the medication 30 days prior for 90 tablets. I call her out that it would be impossible to have 9 tablets left if she was only using half a tablet a day and she admits she is "using more than she realizes". And she just casually admits "im also not entirely sober, and using a few sips of vodka a night to go to sleep". Great. She still has one refill left of xanax through her PCP. I told her to come in person for a visit and bring her bottle of xanax in with her as well. With the comorbid alcohol use and xanax use, this is a bit challenging to deal with in the outpatient setting. There arent many voluntary detox facilities here, which is really what I would like her to do, and they can be hard to get into.

So im thinking of getting a more clear history of the alcohol use, and converting her to klonopin or valium taper with the agreement documented that if she fills any benzo prescriptions from outside providers my plan changes to her doing inpatient detox or going to the ER for further management because obviously at that point theres not much I can do. I would do 7 day prescriptions at a time and periodic testing for alcohol.

If she fills the next thing of 90 tabs of xanax I dont think she could follow taper instructions with it and would likely do the same crap.

I generally dont like doing detox on the outpatient setting and the comorbid alcohol use gives me a little pause. She does seem motivated to get better, I think she is ashamed of her issues with misusing alcohol/benzos.

Also we have addiction in the same building (they do more vivitrol/suboxone than benzo tapering though) and im going to have her see him about addressing the alcohol use disorder and keep her as accountable as possible.

But im open to other ideas. I feel like this case im stuck between a rock and a hard place.

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[Candidate2017]

But im open to other ideas. I feel like this case im stuck between a rock and a hard place.

We are not responsible for other people's poor choices. PCP got her hooked on Xanax 1 mg TID, and she has chosen to take more than prescribed. She and PCP need to work it out.

Alternatively, you can offer to take over and wean her off her Xanax once her PCP scripts are done. I use Klonopin and taper weekly, with a new script each week, over 4-6 weeks.

 

[Merovinge]

Any access to PHP/IOP? I bet the issues with GABA receptors is even worse than she is detailing to you here. A few sips of Vodka is not a typical pattern of use as I'm sure you are aware. If she can take time away from any daytime commitments this would be a great next step. They can do the regular alcohol and benzo testing there.

 

[Sushirolls]

Don't even waste your time trying to do any outpatient management.
RED FLAG one, is not being truthful with current xanax count/usage from the start.
RED FLAG two, is use of alcohol with the benzos.
RED FLAG three, is not being entirely truthful from start alcohol intake. Few sips? Really?

Person needs inpatient level care to manage and odds are very low for you to pull this off, even with weekly visits, and weekly scripts.
Possibly, if patient started out saying, I use X amount of xanax. I'm running short. I drink Y amount of alcohol. I'm not doing well, and need help. How can we do this doc? Perhaps then you have someone appropriate for your weekly benzo taper with low threshold for inpatient. But without the responsible, truthful relationship from start, this won't go well.

 

[Old&InTheWay]

Don't even waste your time trying to do any outpatient management.
RED FLAG one, is not being truthful with current xanax count/usage from the start.
RED FLAG two, is use of alcohol with the benzos.
RED FLAG three, is not being entirely truthful from start alcohol intake. Few sips? Really?

Person needs inpatient level care to manage and odds are very low for you to pull this off, even with weekly visits, and weekly scripts.
Possibly, if patient started out saying, I use X amount of xanax. I'm running short. I drink Y amount of alcohol. I'm not doing well, and need help. How can we do this doc? Perhaps then you have someone appropriate for your weekly benzo taper with low threshold for inpatient. But without the responsible, truthful relationship from start, this won't go well.

What would your plan be if she refused inpatient detox?

 

[J ROD]

The way I see it is the PCP wrote for the Xanax. I would document my recommendations to taper Xanax and counseled on alcohol and CC the PCP.

I often refuse to "take over" benzodiazepines that PCP foolishly started and tried to managed. Get over their heads and want me to be the "bad" guy and break the bad news.

 

[forchinet121]

plan is you don’t prescribe any benzos and if she has any withdrawal symptoms she goes to the ER. Period end of discussion. You will never prescribe this person benzos absolutely not under any circumstances. Why am I strict? Because she’ll take 9 mg Xanax, drink alcohol and die and it’ll be your fault

 

[PikminOC]

Long story short, woman with anxiety sees me for follow up. She had been getting xanax 1mg TID from her PCP but last visit she had told me she weaned herself down to half a tablet a day. This is a telehealth visit (which i generally prefer in person but oh well) and I ask her how many she has left and apparently she only has 9 tablets left, despite filling the medication 30 days prior for 90 tablets. I call her out that it would be impossible to have 9 tablets left if she was only using half a tablet a day and she admits she is "using more than she realizes". And she just casually admits "im also not entirely sober, and using a few sips of vodka a night to go to sleep". Great. She still has one refill left of xanax through her PCP. I told her to come in person for a visit and bring her bottle of xanax in with her as well. With the comorbid alcohol use and xanax use, this is a bit challenging to deal with in the outpatient setting. There arent many voluntary detox facilities here, which is really what I would like her to do, and they can be hard to get into.

So im thinking of getting a more clear history of the alcohol use, and converting her to klonopin or valium taper with the agreement documented that if she fills any benzo prescriptions from outside providers my plan changes to her doing inpatient detox or going to the ER for further management because obviously at that point theres not much I can do. I would do 7 day prescriptions at a time and periodic testing for alcohol.

If she fills the next thing of 90 tabs of xanax I dont think she could follow taper instructions with it and would likely do the same crap.

I generally dont like doing detox on the outpatient setting and the comorbid alcohol use gives me a little pause. She does seem motivated to get better, I think she is ashamed of her issues with misusing alcohol/benzos.

Also we have addiction in the same building (they do more vivitrol/suboxone than benzo tapering though) and im going to have her see him about addressing the alcohol use disorder and keep her as accountable as possible.

But im open to other ideas. I feel like this case im stuck between a rock and a hard place.

Do not want.

 

[jbomba]

We are not responsible for other people's poor choices. PCP got her hooked on Xanax 1 mg TID, and she has chosen to take more than prescribed. She and PCP need to work it out.

Alternatively, you can offer to take over and wean her off her Xanax once her PCP scripts are done. I use Klonopin and taper weekly, with a new script each week, over 4-6 weeks.

I've got someone who is trying to get off Klonopin. She's on a low dose at bed but getting off this last bit has proved very difficult. Her sleep is immediately impaired if she goes below 0.75. tried switching to a long acting benzo but she didn't tolerate going down on that either. Any suggestions?

 

[annoyedpsychiatrist]

Yeah ultimately I think you guys are right. Perhaps my weakness in this situation was my desire to fix the patient when in reality i would just be trying to clean up a huge mess caused by irresponsible prescribing. I get a lot of referrals for patient on long term benzos that are dumped on psych by PCPs, and if they're honest and actually do want to get off then I taper them off generally and eventually get them to no use or very limited PRN use. But this situation is a lot more complex then that. The dishonesty from the start and the "few sips of vodka" which who takes a few sips of vodka before bed? Wtf? makes this not an ideal situation for outpatient.

She has a refill for xanax from her PCP. Im going to recommend that she tapers off the xanax and then stops using it after, and strongly recommend treatment for alcohol addiction. We have vivitrol in clinic, though im skeptical in hindsight if she is even ready for treatment because someone that says a few sips is likely in denial of the issue.

The old me would have said "hell no", i think im getting softer as the years progress.

 

[starri]

What would your plan be if she refused inpatient detox?

Tell her to find a different psychiatrist.

 

[randomdoc1]

and this is why I like having control over intakes. I review the case and medication history prior to visit and decide if we are even going to schedule anything. The interesting thing is that, once the boundary is set early on, it almost sounds like word gets around town. And these types of calls disappear completely and you get essentially a funnel of non-train wrecks. You are probably in a situation where you don't have control over intakes though. But I second what has already been said!

Yeah ultimately I think you guys are right. Perhaps my weakness in this situation was my desire to fix the patient when in reality i would just be trying to clean up a huge mess caused by irresponsible prescribing.

You sure you're not still early in your career? This issue is just as much caused by the patient, if not more. Considering that she's decided to drink on it and over use and decides to be dishonest. Red flags all around. This behavior tends to die hard. And keeping her on board...she'll likely be a very involved case who for quite some time will not be fully invested in the evidence based route. If you can, get out of this case, asap.

 

[annoyedpsychiatrist]

I agree that the patient made the wrong decisions and has a role in this, but ultimately if you prescribe someone with an alcohol addiction 90 tablets of xanax and tell them "use responsibly" then ultimately that person is being setup to fail. So I do have some empathy for the patient. While it isnt our job necessarily to clean up messes, if we dont do it from time to time, its doubtful that anyone else will. That said, i agree with the overall sentiment in this thread and that this is a mess that should be cleaned up in a higher level of care setting, and if she refuses such then she has a new rx of xanax from pcp, she should taper off it through the PCPs rx and if she doesnt do a higher level of care or taper off from other rx then i cant anything to ultimately help her.

 

[Evidence Based]

Perhaps my practice setting is different than folks on this thread, as this is a really common scenario for referral to me in an integrated community health/community mental health system and I can't just "turn down" a referral like this, nor do I think "tough **** no benzos for you, go to the ED once you're in withdrawal" would go over well with my clinic either.
One can certainly recommend detox in this setting (I have a patient on higher doses of Xanax than this that I've firmly recommended detox to but declined 2/2 work concerns), but I wouldn't just cut them loose. I document carefully, describe the taper schedule, and stick to it. If the patient chooses to overuse and there's an adverse event, I'm not super worried about this if we've described risks and benefit and they've declined inpatient detox? Would be happy to hear other folk's perspective though, and of course it's different in private practice.

 

[smalltownpsych]

If her exact words were that she is not entirely sober, it makes me think that she has a solid hx of addiction and perhaps some sobriety and relapses. She is probably ashamed and embarassed by the failures and is at high risk of fatality. Having a frank discussion with her about this and making recommendations for necessary life saving treatment is all you can do. If she follows through, then great, she has a chance, if not then you offered the help she needed.

 

[Sushirolls]

What would your plan be if she refused inpatient detox?

Nothing. Free country and people can wreck themselves if they wish.

But if you give recommendations for detox you also need to document discuss withdrawals, what those look like and consequences (i.e. death of untreated withdrawals, and that ED and/or inpatient treats withdrawals.

 

[Sushirolls]

Perhaps my practice setting is different than folks on this thread, as this is a really common scenario for referral to me in an integrated community health/community mental health system and I can't just "turn down" a referral like this, nor do I think "tough **** no benzos for you, go to the ED once you're in withdrawal" would go over well with my clinic either.
One can certainly recommend detox in this setting (I have a patient on higher doses of Xanax than this that I've firmly recommended detox to but declined 2/2 work concerns), but I wouldn't just cut them loose. I document carefully, describe the taper schedule, and stick to it. If the patient chooses to overuse and there's an adverse event, I'm not super worried about this if we've described risks and benefit and they've declined inpatient detox? Would be happy to hear other folk's perspective though, and of course it's different in private practice.

I'm addiction / Psych.

I let PCPs in my area know I'm willing to be the bad guy, but they have to prep patient first that they are done and cutting them off and I will be the one doing the taper. I review they have outs, and there are multiple ARNPs or other random people around who will hit refill. Review the whole bad of benzos and why we are tapering. Outline the taper, make clear there are no deviations. Any deviations will be a 'failure' and warrant inpatient level detox for "failed outpatient." Gets tricky though for documenting on inpatient side to get insurance to cover. But to your point, I won't completely avoid these patients just like you, and I'm in PP. My assistant though up front lets anyone know who is on benzos we won't continue or we will taper off - and that effectively weeds out the folks just wanting a refill.

 

[Sushirolls]

I've got someone who is trying to get off Klonopin. She's on a low dose at bed but getting off this last bit has proved very difficult. Her sleep is immediately impaired if she goes below 0.75. tried switching to a long acting benzo but she didn't tolerate going down on that either. Any suggestions?

Expectations. Need to let people its going to suck. Its going to get worse before it gets better. Outline the taper, give like 1 or 2 weeks worth at time to reduce impact of "doc I took more." See in close follow up like every 1 week if needed, and use trazodone, doxepin, seroquel, gabapentin, whatever to short term assist with sleep disruption. I usually gravitate to gabapentin or doxepin for tapers.

This is why benzo tapers suck. They are rife with so many patient subject negative experiences that it's difficult to see that light at the end of the tunnel.

I got a patient right now who I've spent extra time with and still hasn't formally committed to enact the plan or me taking over prescribing. I suspect, as patient did sign the ROI, that once PCP reads my notes, they'll cut patient off and say you are doing what Sushi says. So much 'what ifs' I get anxious? I don't sleep? etc. etc. etc.

 

[Sushirolls]

Because I weed at the entry point of those who want off benzos or being strongly referred by PCP cutting them off, I have a person I can possibly work with. I give the PCPs the benefit of the doubt, because, well they are PCPs and they didn't even have a psychiatry rotation of any kind in their residency. More and more so, they believe a Psychologist or MSW in their outpatient clinic is good enough to osmotically absorb psychiatry. Knowing this, I know they don't have a clue to do opioid tapers, or benzo tapers and they are at the right place (at minimum) to inform them of their clinical options even if they walk out the door saying "Super Nice things to You Sushi!!"

 

[Merovinge]

I agree that the patient made the wrong decisions and has a role in this, but ultimately if you prescribe someone with an alcohol addiction 90 tablets of xanax and tell them "use responsibly" then ultimately that person is being setup to fail. So I do have some empathy for the patient. While it isnt our job necessarily to clean up messes, if we dont do it from time to time, its doubtful that anyone else will. That said, i agree with the overall sentiment in this thread and that this is a mess that should be cleaned up in a higher level of care setting, and if she refuses such then she has a new rx of xanax from pcp, she should taper off it through the PCPs rx and if she doesnt do a higher level of care or taper off from other rx then i cant anything to ultimately help her.

I completely agree. This is really not different than giving 90 10mg oxy's to someone in recovery from fentenyl/heroin addiction and telling them to use them prn when their back starts hurting. It's really honest and hard work to make a huge change in someone's life, even more so when it's iatrogenic and caused by the system we all work in.

I think the message is: A) I want to be your psychiatrist B) In order to do that you must accomplish xyz at a higher level of care and following that I will talk to your treatment team and as best I can smoothly transition you back to the life you want to live. The points need to come in that order. If patient's get a sense that you see them as a headache or a problem, you've already lost your shot. In this case it sounds like you're a great doc and have a real chance to help these patients.

 

[Candidate2017]

What would your plan be if she refused inpatient detox?

Detox is a fine plan, and you are not required to make multiple plans. A patient has the right to decline your plan and do as they choose. You are not required to be sucked into the patient's terrible decisions.

You can decline to write scripts, fire the patient, or refuse to enter a relationship and wave goodbye as you walk them out the door with a list of NP referrals. Autonomy applies to you as well (unless you work for The Man as an employee at a large organization (hospital system, VA, CMHC, pill mill PP, etc.), or you are a resident, in which case long term exposure to difficult cases is good for your training).

Your duty is to make recommendations and educate. Like any diagnosis/med condition, you educate on the risks of their disorder (i.e., death with benzo abuse and alcohol), what serious symptoms/side effects to watch out for (i.e., withdrawal), and what to do if such symptoms arise (i.e., go to ER).

 

[Candidate2017]

I've got someone who is trying to get off Klonopin. She's on a low dose at bed but getting off this last bit has proved very difficult. Her sleep is immediately impaired if she goes below 0.75. tried switching to a long acting benzo but she didn't tolerate going down on that either. Any suggestions?

In residency, I had a benzo taper patient always punctually come in at 7:45 am for 8 am appointments. They'd always complain about getting zero sleep and how bad things were going with the taper. Meanwhile, I could barely keep my eyes open and was frazzled from rushing in at 8:10 am and trying to boot up my computer. Objectively, based on optics, an impartial observer would guess I was the one struggling with anxiety, ADHD, insomnia, benzo taper.

My point is: if you ignore the objective part of SOAP and only give creedence to the patient's subjective complaints, you are left with SAP. Don't be a SAP.

So, you have all the behavioral, therapeutic, and non-benzo tools/knowledge to help this patient with her sleep, benzo taper, as well as her other comorbidities masquerading as insomnia and anxiety. And Klonopin 0.75 mg can be tapered off very fast. You don't need any technical suggestions.

 

[Stagg737]

Perhaps my practice setting is different than folks on this thread, as this is a really common scenario for referral to me in an integrated community health/community mental health system and I can't just "turn down" a referral like this, nor do I think "tough **** no benzos for you, go to the ED once you're in withdrawal" would go over well with my clinic either.
One can certainly recommend detox in this setting (I have a patient on higher doses of Xanax than this that I've firmly recommended detox to but declined 2/2 work concerns), but I wouldn't just cut them loose. I document carefully, describe the taper schedule, and stick to it. If the patient chooses to overuse and there's an adverse event, I'm not super worried about this if we've described risks and benefit and they've declined inpatient detox? Would be happy to hear other folk's perspective though, and of course it's different in private practice.

A small part of my job has been taking over outpatient consults/follow-ups in a clinic that I can basically run as I please, and I'm running it as an integrated system as that's what it was originally meant to be. I make it clear that I will not be prescribing or managing controlled substances (outside of the rare instances where I start them) but will help them develop a tapering plan for their PCP to enact, and schedule 1-2 f/up appointments to help track their progress and adjust the plan as needed. So far this has gone fairly well, but I have had 1 or 2 patients who were clearly abusing and not ready for a taper. I told the PCP my recommendations and left it up to them as to whether they wanted to continue prescribing the benzos.

In an integrated MH system where you're a consultant, there's plenty of room to make recommendations and guide treatment without being the one taking responsibility for prescribing the controlled substances. I think it's actually the ideal setup to help those patients without taking on the excess liability. Obviously, this requires the PCP to be on board with your plan and cooperate, but if they're in a system like this it's likely because they don't have many other options outside of just managing the benzos themselves.

 

[tr]

I've got someone who is trying to get off Klonopin. She's on a low dose at bed but getting off this last bit has proved very difficult. Her sleep is immediately impaired if she goes below 0.75. tried switching to a long acting benzo but she didn't tolerate going down on that either. Any suggestions?

Assuming the patient is actually motivated, I'm all about the super gentle taper, especially at the end.

0.5 mg every third night, with two nights at 0.75 to recover and reassure her that she still has the capacity to sleep. After 2 -4 weeks or once sleep on the lower dose night is stabilized, go to 0.5 alternating qod with 0.75. Then to 0.5 every night. Then step to 0.25 every third night. Then 0.25/0.5 qod. Etc

 

[hallowmann]

What would your plan be if she refused inpatient detox?

Most people on this thread seem to suggest that they would do nothing or discharge or never see the patient in the first place. While that's every physician's right (doing only what they are comfortable or willing to do), it might not be the solution you're looking for. I personally think OP's plan in the first post is reasonable and probably what I would do in that situation.

I've got someone who is trying to get off Klonopin. She's on a low dose at bed but getting off this last bit has proved very difficult. Her sleep is immediately impaired if she goes below 0.75. tried switching to a long acting benzo but she didn't tolerate going down on that either. Any suggestions?

I have often reduced by 1-2 tabs a month in this kind of situation (e.g. if they have #45 of 0.5 mg tabs, next month they'll get #43 and distribute how they want). They get used to reducing to 0.5 once or twice a week, and eventually there is a hump that they get over. Virtually everyone I've seen that has stayed with me has done this successfully. Did it all the time in residency continuity clinic. Had one guy that would cut the 0.5's into quarters. It kind of makes me wish we had the liquid droppers to reduce by even smaller increments that a lot of places in Europe have.

Yeah ultimately I think you guys are right. Perhaps my weakness in this situation was my desire to fix the patient when in reality i would just be trying to clean up a huge mess caused by irresponsible prescribing. I get a lot of referrals for patient on long term benzos that are dumped on psych by PCPs, and if they're honest and actually do want to get off then I taper them off generally and eventually get them to no use or very limited PRN use. But this situation is a lot more complex then that. The dishonesty from the start and the "few sips of vodka" which who takes a few sips of vodka before bed? Wtf? makes this not an ideal situation for outpatient.

She has a refill for xanax from her PCP. Im going to recommend that she tapers off the xanax and then stops using it after, and strongly recommend treatment for alcohol addiction. We have vivitrol in clinic, though im skeptical in hindsight if she is even ready for treatment because someone that says a few sips is likely in denial of the issue.

I would document appropriately, have the discussion, and make the decision whether you'd rather implement your plan or recommend for the PCP to do so. Its possible the PCP has no idea about any of what the patient told you, because they had 15 min to see the patient for their anxiety, DM2, HLD, and chronic pain, send orders, send referrals, and document.

Perhaps my practice setting is different than folks on this thread, as this is a really common scenario for referral to me in an integrated community health/community mental health system and I can't just "turn down" a referral like this, nor do I think "tough **** no benzos for you, go to the ED once you're in withdrawal" would go over well with my clinic either.
One can certainly recommend detox in this setting (I have a patient on higher doses of Xanax than this that I've firmly recommended detox to but declined 2/2 work concerns), but I wouldn't just cut them loose. I document carefully, describe the taper schedule, and stick to it. If the patient chooses to overuse and there's an adverse event, I'm not super worried about this if we've described risks and benefit and they've declined inpatient detox? Would be happy to hear other folk's perspective though, and of course it's different in private practice.

Yeah, I came here to say the same thing as you, because my practice settings are similar to yours.

Assuming the patient is actually motivated, I'm all about the super gentle taper, especially at the end.

0.5 mg every third night, with two nights at 0.75 to recover and reassure her that she still has the capacity to sleep. After 2 -4 weeks or once sleep on the lower dose night is stabilized, go to 0.5 alternating qod with 0.75. Then to 0.5 every night. Then step to 0.25 every third night. Then 0.25/0.5 qod. Etc

This is a great way of doing it as well for someone more motivated.

 

[forchinet121]

Most people on this thread seem to suggest that they would do nothing or discharge or never see the patient in the first place. While that's every physician's right (doing only what they are comfortable or willing to do), it might not be the solution you're looking for. I personally think OP's plan in the first post is reasonable and probably what I would do in that situation.

I have often reduced by 1-2 tabs a month in this kind of situation (e.g. if they have #45 of 0.5 mg tabs, next month they'll get #43 and distribute how they want). They get used to reducing to 0.5 once or twice a week, and eventually there is a hump that they get over. Virtually everyone I've seen that has stayed with me has done this successfully. Did it all the time in residency continuity clinic. Had one guy that would cut the 0.5's into quarters. It kind of makes me wish we had the liquid droppers to reduce by even smaller increments that a lot of places in Europe have.

I would document appropriately, have the discussion, and make the decision whether you'd rather implement your plan or recommend for the PCP to do so. Its possible the PCP has no idea about any of what the patient told you, because they had 15 min to see the patient for their anxiety, DM2, HLD, and chronic pain, send orders, send referrals, and document.


Yeah, I came here to say the same thing as you, because my practice settings are similar to yours.

This is a great way of doing it as well for someone more motivated.

Patient admits to using benzo and alcohol daily and is lying about extent of her use (clear sign of addiction), you, instead of stopping her benzo supply prescribe her a different benzo (longer acting) and then she goes home and overdoses on a combination of benzos and alcohol. I can see a lawyer having a field day with that one but I might be too conservative..anxiety is not deadly..people don’t NEED benzos but overdose is

 

[hallowmann]

Patient admits to using benzo and alcohol daily and is lying about extent of her use (clear sign of addiction), you, instead of stopping her benzo supply prescribe her a different benzo (longer acting) and then she goes home and overdoses on a combination of benzos and alcohol. I can see a lawyer having a field day with that one but I might be too conservative..anxiety is not deadly..people don’t NEED benzos but overdose is

Counsel the patient, discuss risk, contact the PCP to discontinue script. There's plenty of ways to do this appropriately without truly increased liability. The same case can be said of a patient that you prescribe any substance to based on what they tell you but lie about.

We prescribe dangerous stuff all the time. If you're never going to prescribe a medication that could be potentially deadly when combined with substances a patient might lie about, you're never going to prescribe anything.

Also, lets be realistic about how common malpractice is, how many of these cases end up materializing? We all can see how inappropriately meds are prescribed sometimes, and only a tiny fraction actually results in a case. You're telling me a well documented plan with a single script and a clear indication of discussion of risks to the patient is going to be the death knell for this psychiatrist. I don't think so.

Also, I've absolutely seen people almost die from sedative hypnotic withdrawal, so there's that too.

 

[Ceke2002]

Long story short, woman with anxiety sees me for follow up. She had been getting xanax 1mg TID from her PCP but last visit she had told me she weaned herself down to half a tablet a day. This is a telehealth visit (which i generally prefer in person but oh well) and I ask her how many she has left and apparently she only has 9 tablets left, despite filling the medication 30 days prior for 90 tablets. I call her out that it would be impossible to have 9 tablets left if she was only using half a tablet a day and she admits she is "using more than she realizes". And she just casually admits "im also not entirely sober, and using a few sips of vodka a night to go to sleep". Great. She still has one refill left of xanax through her PCP. I told her to come in person for a visit and bring her bottle of xanax in with her as well. With the comorbid alcohol use and xanax use, this is a bit challenging to deal with in the outpatient setting. There arent many voluntary detox facilities here, which is really what I would like her to do, and they can be hard to get into.

So im thinking of getting a more clear history of the alcohol use, and converting her to klonopin or valium taper with the agreement documented that if she fills any benzo prescriptions from outside providers my plan changes to her doing inpatient detox or going to the ER for further management because obviously at that point theres not much I can do. I would do 7 day prescriptions at a time and periodic testing for alcohol.

If she fills the next thing of 90 tabs of xanax I dont think she could follow taper instructions with it and would likely do the same crap.

I generally dont like doing detox on the outpatient setting and the comorbid alcohol use gives me a little pause. She does seem motivated to get better, I think she is ashamed of her issues with misusing alcohol/benzos.

Also we have addiction in the same building (they do more vivitrol/suboxone than benzo tapering though) and im going to have her see him about addressing the alcohol use disorder and keep her as accountable as possible.

But im open to other ideas. I feel like this case im stuck between a rock and a hard place.

Are you able to write the script in such a way that she has to pick up a limited amount from the chemist every few days? Having said that though I don't like her chances unless she can start being honest with her treating physicians.

When I was first detoxing off of Xanax (tapered over to Valium and detoxed from there) I was only allowed 5 days worth of medication at a time. Obviously this meant I had to see the GP who was overseeing the taper (initially set up by a Psychiatrist) every 5 days as well. Those appointments included me potentially having to be spot checked in terms of pill count, the possibility of random UDS, and a chance for my GP to observe me and make sure I didn't appear 'high'. I also had to sign off on a treatment plan/contract, that essentially said if I messed up and ran out of pills early, because I chose to abuse my script, then I was on my own. I seriously wanted off of the Xanax so the conditions imposed were acceptable to me.

 

[Ceke2002]

Also, I've absolutely seen people almost die from sedative hypnotic withdrawal, so there's that too.

Gotta say this was a big motivator for me during taper in terms of not wanting to mess up, or test whether I could get away with sneaking some extra doses. Experienced sudden withdrawal from Xanax once, and that was enough to know I never wanted to experience it again (the withdrawal symptoms were horrific, far, far worse than opiate withdrawals). The idea that if I did the wrong thing during taper it might very well result in me being thrown back into sudden withdrawal was a pretty huge incentive for me to do the right thing.

 

[annoyedpsychiatrist]

Gotta say this was a big motivator for me during taper in terms of not wanting to mess up, or test whether I could get away with sneaking some extra doses. Experienced sudden withdrawal from Xanax once, and that was enough to know I never wanted to experience it again (the withdrawal symptoms were horrific, far, far worse than opiate withdrawals). The idea that if I did the wrong thing during taper it might very well result in me being thrown back into sudden withdrawal was a pretty huge incentive for me to do the right thing.

Ultimately the patient refilled the xanax after our visit and is not ready to go off the xanax yet. She has had a lot of stressful life situations recently, so while I am very empathetic to that, all I could do is ultimately give her information about symptoms and how xanax influences her anxiety but she is not ready to stop using it. Perhaps at future visits it will sink in more, but we will see. She at least acknowledged what I said and admitted that xanax in itself worsens anxiety in the long run.