Patients on benzos and an opiate?

[futuredo32]

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[WisNeuro]

Plenty of my referred patients are still on both. When I was at the VA, they had been doing a good job of tapering people off benzos, but not making much headway on opiates.

 

[st2205]

Plenty of my referred patients are still on both. When I was at the VA, they had been doing a good job of tapering people off benzos, but not making much headway on opiates.

New solution:

Offer all patients opioids who are on benzos, then ask them to choose. When they choose opioids, send them to primary care.

This sounds like a huge headache solver for psychiatrists.

 

[Attending1985]

I have problems with this as well. Unless I have good reason I don’t like to do unilateral benzo tapers. I do random uds and pill count and warn them but don’t insist on taper.

 

[Attending1985]

New solution:

Offer all patients opioids who are on benzos, then ask them to choose. When they choose opioids, send them to primary care.

This sounds like a huge headache solver for psychiatrists.

This is what I do when people are on benzos and stimulants. Choose one or the other.

 

[MacDonaldTriad]

I think it is useful to reframe our duty to get PCPs out of trouble. Tapering Benzos is a good part of our bread and butter and this is what we do. It take time and a good therapeutic relationship to get patients to trust us enough to go through a taper and that is why it is our burden and we should be good at it.

 

[WisNeuro]

Patients CAN have both ( I do but I can't tolerate any of the ADHD meds unfortunately) . I have no problem with this. I used benzos as a LAST resort. I'm not as worried about this as I am about the opiates............... They have TRUE genuine pain and true panic disorder, therapy has helped minimally all other meds have helped minimally.................................. It seems cruel to say pick one, have panic attacks or suffer in pain...............

Benzos won't do anything to limit the number of panic attacks, It can maybe take the edge off the tail end of one after you're already coming down, but they won't do anything about the onset, besides just reinforce it mostly.

 

[WisNeuro]

That has not been the case with the patients I have seen with all due respect if they are taking them scheduled not prn.

I remain skeptical, there is really just no theoretical basis for that. And, way too easily explained by cognitive biases. "Of course the addictive medication I am on is helping me!"

 

[hamstergang]

With the new black box warning on patients being on both benzos and an opiate , what are you doing?

Why would you change your prescriptions over a black box warning?

 

[st2205]

Why would you change your prescriptions over a black box warning?

Nothing strikes fear into the heart of a physician more than an arbitrary bureaucratic decree that wields societal power.

 

[WingedOx]

It just seems cruel to me, stop the one drug that has helped with your panic attacks or stop the only medicine that controls your pain, do you want panic attacks or do you want pain?

What's cruel is when you see those patients hit 70 and start having falls.

 

[VA Hopeful Dr]

I have a patient in her mid 80's stable on 0.5 mg Xanax and a high dose of Fentanyl............................ She was born with a spinal issue and then had severe pain in an MVA several surgeries later her pain only worsened. Never fills early no red flags, never asks to increase her dose.....

Its not the patient on 0.5mg Xanax that's the problem. Its the 2mg TID xanax with the Fentanyl that kills people - or causes a fall, a hip fracture, and death that way.

 

[VA Hopeful Dr]

She is on a HUGE dose of Fentanyl. What if she gets pneumonia and her respiration is suppressed via that? She obviously has a tolerance but she is quite elderly and she is sick often..........................

That's absolutely a discussion that whoever is writing that Fentanyl needs to have with her.

 

[WingedOx]

Its not the patient on 0.5mg Xanax that's the problem. Its the 2mg TID xanax with the Fentanyl that kills people - or causes a fall, a hip fracture, and death that way.

Even ignoring the safety issue, multiple dose/day xanax is a great way to ensure a patient's anxiety never gets better. Better to get them off early before you get to the point where you need to taper off an 80 year old.

 

[WingedOx]

I have a patient in her mid 80's stable on 0.5 mg Xanax and a high dose of Fentanyl............................ She was born with a spinal issue and then had severe pain in an MVA several surgeries later her pain only worsened. Never fills early no red flags, never asks to increase her dose..... And I did tell her she has to taper off or stop the Fentanyl. Felt AWFUL. It obviously isn't impairing balance for her, but due to her age........................... I just don't feel like there's a right answer. Either choice- let her stay on or force her to pick one, both feel wrong.

I just had a patient fire me today for refusing to go back up to his previous clonazepam dose (he's also on morphine), and I've been really slow on my taper with him for years, but for whatever reason he decided this was it.

Unfortunately we've had a couple decades MDs treating a combination of norco/xanax as the "white working-class multivitamin" and it's hard to find a psychiatrist who hasn't been put in your situation. I've had a ton of them in my clinic the last few years, and dealing with them is awful. The patients treat you like you're Satan when you have to do it, but I've also had a number of success cases getting people off, as well as seen the consequences of allowing patients to stay on too long, so I keep at it and do what I need to do, even if it unfortunately is difficult for the patient.

 

[VA Hopeful Dr]

That's always my goal but in my limited experience when all else has failed it DOES help many.

Sure, just like how vodka prevents DT...

 

[clausewitz2]

Sure, just like how vodka prevents DT...

Or how Bayer developed heroin as a treatment for morphine dependence. Turns out to be super effective for that indication.

 

[VA Hopeful Dr]

Or how Bayer developed heroin as a treatment for morphine dependence. Turns out to be super effective for that indication.

I wouldn't mind some of their heroin cough syrup from the 1900s next time I get bronchitis

 

[Attending1985]

Patients CAN have both ( I do but I can't tolerate any of the ADHD meds unfortunately) . I have no problem with this. I used benzos as a LAST resort. I'm not as worried about this as I am about the opiates............... They have TRUE genuine pain and true panic disorder, therapy has helped minimally all other meds have helped minimally.................................. It seems cruel to say pick one, have panic attacks or suffer in pain...............

This has been debated on previous forms but I cannot see the science behind prescribing a cns stimulant and depressant together

 

[wolfvgang22]

I taper everyone off benzos as much as I can. Most patients would rather be enslaved by benzos than do the hard work of therapy, but that is not healthy.

 

[birchswing]

I taper everyone off benzos as much as I can. Most patients would rather be enslaved by benzos than do the hard work of therapy, but that is not healthy.

It would be nice if there were a form upfront describing the enslavement.

I kind of doubt most would go for it then.

If it truly is an enslavement, then it's difficult to assign agency exclusively to the patient and their unwillingness to do therapy. Therapy doesn't re-sensitize GABA receptors or attenuate glutamate hyperactivity. If it did that, I think patients would make a beeline.

The reason you say it's hard work is because benzodiazepine tolerance is a physiological illness. It's hard work because it's not specifically the solution to a very specific physiologic problem, anymore that going to therapy is the answer to going through chemotherapy. And I know therapy theoretically can change a person's physiology, but it's not a finely tuned weapon like a benzo going in and changing the rate of chloride ion channel openings at GABA receptors.

 

[Attending1985]

I have a patient in her mid 80's stable on 0.5 mg Xanax and a high dose of Fentanyl............................ She was born with a spinal issue and then had severe pain in an MVA several surgeries later her pain only worsened. Never fills early no red flags, never asks to increase her dose..... And I did tell her she has to taper off or stop the Fentanyl. Felt AWFUL. It obviously isn't impairing balance for her, but due to her age........................... I just don't feel like there's a right answer. Either choice- let her stay on or force her to pick one, both feel wrong.

Do you have any elder care services in your community? Occupational therapy can do functional assessment and if she’s functioning well it would be some backing to leaving her on it. At age 80 who knows how much longer you’ll live. I understand not wanting to make someone miserable at that age.

 

[futuredo32]

Do you have any elder care services in your community? Occupational therapy can do functional assessment and if she’s functioning well it would be some backing to leaving her on it. At age 80 who knows how much longer you’ll live. I understand not wanting to make someone miserable at that age.

She has a nurse come once a week to help her with running errands. She has a really hard life. She lives with her developmentally disabled son who has bipolar disorder. She had C-Dif for years and the infectious disease doc sent me a letter asking ME to treat her I kid you not. They were giving her oral meds. I called them and they finally gave her IV meds and it resolved. They thought she wasn't taking her meds and was malingering.................... I saw her labs and she WAS positive for C Dif. And all she could talk about was wanting to get better. She has had a crappy life from day one. She barely gets by financially, I don't charge her a copay or a no show fee when she misses an appointment. She has had PT after her hospital stay from C-Diff.

 

[futuredo32]

This has been debated on previous forms but I cannot see the science behind prescribing a cns stimulant and depressant together

I respect that you don't understand the science behind it but patients can and do have both and often treating the ADHD lessens the anxiety.

 

[VA Hopeful Dr]

I respect that you don't understand the science behind it but patients can and do have both and often treating the ADHD lessens the anxiety.

So you wouldn't need benzos for anxiety anyway, especially with all the other great treatment options out there.

 

[futuredo32]

So you wouldn't need benzos for anxiety anyway, especially with all the other great treatment options out there.

Sometimes it's the ONLY med that helps, tried everything else even tiagabine. All the "other great treatment options" including therapy don't always work for panic disorder. Most of my patients are in therapy either with me or someone else. I think I have two patients on benzos not in therapy one is in his 60s and did 30 years of therapy and one works worldwide about 90 hours a week, the rest are in therapy. Thanks to all for your opinion. I am going to make people pick, opiate or benzo. One poor patient switched from methadone to suboxone, sucks to be her, and she was using it for pain....... But that is what my psychiatrist is doing for liability reasons. I'm going to follow suit and do the CYA. I have 3 in my pp and a few at a one day a week independent contractor job.

 

[WingedOx]

So you wouldn't need benzos for anxiety anyway, especially with all the other great treatment options out there.

Yeah, it's one thing to give a stim in a patient with anxiety but if you are, the benzo is just reckless.

 

[futuredo32]

Thanks for the thoughtful replies. I got what I was looking for and then some . Psychiatry is so objective and there really is almost never a wrong answer nor never one right answer.

 

[littlefred]

With the new black box warning on patients being on both benzos and an opiate , what are you doing? I inherited a few. They aren't abusing and have been stable on this regimen for years. One is on Suboxone (prescribed by an addictions specialist). I don't know if this is nationwide or just in Michigan. I DO warn patients about taking them together (although they have been on them for years)...................

They removed this black box warning, they could be on both. In the past they were contraindicated. Now they are not.

 

[Jules A]

I just "inherited" some patients from a well respected local psychiatrist and holey tomoley all of her patients were on tons of benzos and one on benzos Adderall and two doses of Concerta and with that patient I have cut down both slowly.

Well respected or well liked by patients who were receiving egregious regimens?

I'm probably dating myself but justifying an unsafe regimen by saying they aren't abusing a combination that essentially is a speed-ball is a moot point in my opinion.

I wonder if you are struggling with some countertransference. The repeated high charged words/phrases sound more like a patient than physician "cruel", "poor patient", "ONLY med that helps", "They have TRUE genuine pain and true panic disorder", "My shrink is doing exactly what some of you have said, making patients choose.................. It's just a hard place to be in." Just something to consider.

 

[futuredo32]

They removed this black box warning, they could be on both. In the past they were contraindicated. Now they are not.

Not in Michigan

 

[futuredo32]

Well respected or well liked by patients who were receiving egregious regimens?

I'm probably dating myself but justifying an unsafe regimen by saying they aren't abusing a combination that essentially is a speed-ball is a moot point in my opinion.

I wonder if you are struggling with some countertransference. The repeated high charged words/phrases sound more like a patient than physician "cruel", "poor patient", "ONLY med that helps", "They have TRUE genuine pain and true panic disorder", "My shrink is doing exactly what some of you have said, making patients choose.................. It's just a hard place to be in." Just something to consider.

only med that helps- I or another provider tried everything under the sun. And as mentioned one patient is allergic to like everything and I have the allergists report.
Cruel, yeah, either suffer from panic disorder or pick pain? It is cruel, maybe necessary but cruel nonetheless and yeah I do feel bad
Poor patient- some of my patients are the worried well, but these patients are really in hard spots physically and financially and anyone with a heart would feel empathy for them. It IS a hard spot to be in for me. I am doing what my shrink is doing. I don't like it but I am doing it......

 

[WisNeuro]

Cruel, yeah, either suffer from panic disorder or pick pain? It is cruel, maybe necessary but cruel nonetheless and yeah I do feel bad

These are not the only options, especially considering that benzos do not actually do anything for panic disorder, other than make it worse in the long run. This false dichotomy is not helping your patients.

 

[WingedOx]

The problem is the assumption that you feel that you alone are responsible for alleviating the patient's mental suffering. It's an attitude that leads to iatrogenic suffering down the road for the patient.

 

[futuredo32]

The problem is the assumption that you feel that you alone are responsible for alleviating the patient's mental suffering. It's an attitude that leads to iatrogenic suffering down the road for the patient.

Not by a long shot, I inherited some and some have had horrid lives and there's only so much therapy and meds can do for them. I feel that I am one part of the equation. And I get you aren't a fan of benzos but we had very different training in residency . I don't prescribe them like candy but I do prescribe them for patients with panic disorder.

 

[futuredo32]

These are not the only options, especially considering that benzos do not actually do anything for panic disorder, other than make it worse in the long run. This false dichotomy is not helping your patients.

I have mentioned MANY times all other drugs had failed and in my short experience they have helped to limit panic attacks in severity or number of panic attacks overall when taken daily not prn.
Thanks again for those who came up with helpful suggestions,

 

[WisNeuro]

I have mentioned MANY times all other drugs had failed and in my short experience they have helped to limit panic attacks in severity or number of panic attacks overall when taken daily not prn.
Thanks again for those who came up with helpful suggestions,

I can count on no hands the number of patients I've seen over the years who have experienced either a decrease in frequency of panic attacks, or a demonstrable improvement in QOL after going on benzos.

 

[futuredo32]

I can count on no hands the number pf patients I've seen over the years who have experienced either a decrease in frequency of panic attacks, or a demonstrable improvement in QOL after going on benzos.

Interesting, thanks for sharing that and thanks to all who replied with thoughtful responses. I am quite clear on what I will be doing.

 

[birchswing]

I haven't heard about this drug in a long time. It's benzo-like in effect but not supposed to cause tolerance (which has been said and been untrue about many drugs before it):
Emapunil - Wikipedia

Is there something about the nervous system that predisposes drugs that attenuate it to resulting in tachyphylaxis?

Or is it just that the drugs that happened to have been discovered for anxiety happen to have that quality?

I always feel like it's a bit of a cruel joke to have put anxious people on meds they were in many cases anxious to take to begin with and then years down the road put them in a situation where the meds don't work and have put them in the situation of having to withdraw from what many have called the worst type of drug withdrawal there is.

And the agency gets kicked like a can down the road; people don't remember the originator—that someone once told this patient anxious people take anti-anxiety medicine and if you are going to be compliant you will take this. That person is long gone when the person is in a withdrawal, forced or voluntary. I think that's one thing to be mindful about when prescribing benzos—you will not be there forever, and when you die or move or whatever happens, the next treating provider may without warning suddenly force the patient into a withdrawal. And I feel like if you do decide that for whatever reason long-term prescribing is a good idea, you should warn the patient that there may be no one else in your absence who would ever consent to continue it.

But back to the nature of the beast. It just seems so uniquely cruel. No one accuses the hypertensive of mollycoddling their hearts with ACE inhibitors for example. I mean yeah, they accuse people of not doing lifestyle intervention. But the drugs that are prescribed by doctors are not suddenly made out to be something the patient has conjured up as if the patient created this easy-way-out pill, as if there hadn't been decades of research and marketing, as if there hadn't been years of prescribing. If that's who the patient was (someone who would design a fast-acting, don't care about the consequences pill), if that were their inherent nature, they probably would have turned to alcohol instead of a doctor. And it's not the doctors' fault. I mean cardiologists didn't work extra hard to attain meds that work over the longterm to control blood pressure. It's just the nature of these meds, whether it's barbiturates, benzos, z-drugs. Why it's their nature, why the body forces a homeostasis that renders the drugs somewhat useless and the brain in a hyperexcitatory state, when the same isn't true for many other drugs, I would be curious to know.

 

[WisNeuro]

I always feel like it's a bit of a cruel joke to have put anxious people on meds they were in many cases anxious to take to begin with and then years down the road put them in a situation where the meds don't work and have put them in the situation of having to withdraw from what many have called the worst type of drug withdrawal there is.

I can understand the sentiment. There was a time, long ago, when we believed that these specific drugs could help people with anxiety. So, I don't blame those prescribers from long ago. They were going on the best available information. Now, we know how harmful these things are, and that they do not work in most cases of anxiety. At this point we know better because if the preponderance of evidence. At this point the continuation of such practices is just bad medicine. I unfortunately work with a patient population where I see the harmful consequences of such incompetence on a regular basis, unfortunately.

 

[aim-agm]

Is there something about the nervous system that predisposes drugs that attenuate it to resulting in tachyphylaxis?

My hypothesis would be that a core function of the nervous system is adaptation (e.g. to environment, experiences) and broadly speaking it has much greater capacity to change in response to chemical stimuli (attenuators, accentuators, and other modifiers), unlike most other organs and systems which have relatively static functions.

 

[SourceOfDenial]

If you're concerned about respiratory depression it's worthwhile using a validated assessment that can help quantify the risk. RIOSORD is one tool, there are different ones for different populations.

I'm much more on the primary opioid prescribing side but I think psychiatrists have a duty to think of the risk and document it if providing a benzo. Also I'd consider whether it made sense to also write for naloxone.

In general, you're far better off when you aren't written for these in the first place. When that's not possible always having an eye towards using the least amount. While much of the pain world is focused on taking everyone off opioids--I think it's a bit of a fantasy to think that's feasible.

 

[whopper]

I've mentioned this before and I'm doing it again.
About half the psychiatrists I see out there, I see no evidenced-based data to support what they're doing. The only acceptable use of treatment without good evidence is if the patient, by chance, happens to have something outside the norm where this med just happens to work cause they're an outlier.

I mentioned this before. A doctor I worked with in a state-hospital used to medicate patients based on "redness and blueness" she spiritually felt from patients, and when I questioned her she told me she was an artist and the patient was her palette, the medications her paint.

There's good and bad in every field but in surgery if you're off it's so much more apparent cause it's so much more objective. Psychiatry is a great field with good science backing it up but because of the subjectivity in interpreting diagnosis it should if anything make us that much more dilligent and out of a sense of ethics and dignity go the extra mile when diagnosing correctly, and so many people in our field don't do this to any acceptable degree.

 

[birchswing]

There's good and bad in every field but in surgery if you're off it's so much more apparent cause it's so much more objective.

It's not only more objective but the results are more immediate and if there is to be harm it's more obvious. All drugs have side effects, but those deleterious ones that kill and destroy quality of life do so slowly, whether it's benzo dependence or Zyprexa-induced diabetes. You could throw a dart to pick a psych drug and without knowing anything about the patient you're giving it to the likelihood of immediately causing serious or irreversible harm would be low. And if the patient doesn't get better, well, you can't really single out the psychiatrist because human suffering has existed since the dawn of time, so people don't go in with a high expectation of getting better—or at least don't place that expectation as much on the doctor.

I've seen the artist psychiatrists too. I had one who only believed in changing medicines during certain seasons of the year and another who believed you could cure cancer with the power of your mind. There is nothing so queer as folk.

 

[Attending1985]

I saw a 60 year old guy today who had panic disorder with agoraphobia that caused him to quit his job and was placed on Prozac and Xanax 0.5 mg tid twenty years ago with resolution of symptoms and no dose escalations or recurrence for twenty years. His pcp wanted a second opinion on the Xanax. He had no side effects so we discussed risks and he elected to stay on it. I didn’t suggest a unilateral taper because I don’t do that without evidence of abuse or physical harm when someone comes to me dependent on Benzos. Just interesting to see someone who had benefited for so long without issues. Maybe primary care sees this more?

 

[futuredo32]

I saw a 60 year old guy today who had panic disorder with agoraphobia that caused him to quit his job and was placed on Prozac and Xanax 0.5 mg tid twenty years ago with resolution of symptoms and no dose escalations or recurrence for twenty years. His pcp wanted a second opinion on the Xanax. He had no side effects so we discussed risks and he elected to stay on it. I didn’t suggest a unilateral taper because I don’t do that without evidence of abuse or physical harm when someone comes to me dependent on Benzos. Just interesting to see someone who had benefited for so long without issues. Maybe primary care sees this more?

THIS was the typical patient I was talking about.

 

[WisNeuro]

I imagine if you survey the providers on here, they will overwhelmingly report back that this particular anecdote is anything but typical. I imagine it will be more like what most of us in geriatrics see, which is delirium and dangerous falls, usually resulting in multiple hospital admissions. Sorry to keep harping on this, but my department is usually the one that has to clean up the mess that this causes when irresponsible prescribers keep doing this. I'm sure you can find an anecdote here and there where benzos happened to not do damage. But, most of us can give you dozens of examples to the damage it causes, even in just patients we've seen in 2018 alone.

 

[Attending1985]

I imagine if you survey the providers on here, they will overwhelmingly report back that this particular anecdote is anything but typical. I imagine it will be more like what most of us in geriatrics see, which is delirium and dangerous falls, usually resulting in multiple hospital admissions. Sorry to keep harping on this, but my department is usually the one that has to clean up the mess that this causes when irresponsible prescribers keep doing this. I'm sure you can find an anecdote here and there where benzos happened to not do damage. But, most of us can give you dozens of examples to the damage it causes, even in just patients we've seen in 2018 alone.

I imagine it’s alao that we are specialists so we don’t see people that are simple and doing well. They are not referred to us. I’m certainly not endorsing benzos. I use them sparingly, selectively, not long term and use my clinical judgement on appropriate pateints. However I don’t believe the issue is totally black and white.

 

[WisNeuro]

I imagine it’s alao that we are specialists so we don’t see people that are simple and doing well. They are not referred to us. I’m certainly not endorsing benzos. I use them sparingly, selectively, not long term and use my clinical judgement on appropriate pateints. However I don’t believe the issue is totally black and white.

Nothing in healthcare is totally black and white. But, the preponderance of evidence in the clinical and research realm would point to the black side of things for benzos.

 

[WingedOx]

I imagine if you survey the providers on here, they will overwhelmingly report back that this particular anecdote is anything but typical. I imagine it will be more like what most of us in geriatrics see, which is delirium and dangerous falls, usually resulting in multiple hospital admissions. Sorry to keep harping on this, but my department is usually the one that has to clean up the mess that this causes when irresponsible prescribers keep doing this. I'm sure you can find an anecdote here and there where benzos happened to not do damage. But, most of us can give you dozens of examples to the damage it causes, even in just patients we've seen in 2018 alone.

Eh, I think his case is typical enough, actually. The bigger thing I notice here is that the patient is 60... so whatever.

Now what happens when the patient is 70? 75? What about when they start having cognitive or mobility issues? Hell, I inherited a patient a few years ago who's now 93 and still has an bottle of alprazolam, that thankfully he only uses every 6 months or so.

Just because the patient is "doing fine" doesn't mean you've done your job as a clinician. If that patient is well controlled on 0.5 TID, then there's no reason they can't handle taking one of the three doses down to 0.375, then two doses down to 0.375 a few months later.

Your job as a clinician is not to achieve zero distress for your patient. Coming off benzos is uncomfortable. A fall in the shower or an auto accident is worse.