Patients on benzos and an opiate?

[Merely]

This is something you should do instead of perpetuating - and basing your practice on - an outdated and not well supported hypothesis. Our current understanding of mental illness is well past the simplistic model of chemical imbalance.

Are you actually a med student arguing with an attending or are you an attending too?

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[Amygdarya]

Amen, and yet, in an effort to mechanize a patient's understanding of the pathophysiology of mental illness, the whole "chemical imbalance" thing often does get patient's buy in about as deep as their understanding needs to be to see their need for treatment as not a failing.

True, but OP is not talking to patients here. Conceptualizing mental illness as a chemical imbalance can be actually harmful in practice, especially when dealing with potentially addictive substances. Conceptualizing anxiety as a chemical imbalance in need of benzos is not just wrong but harmful.

I would say half-assed psychiatry is probably the least intellectually demanding of all medical specialties actually.

I’ve heard it somewhere, and it sounds very true to me, that psychiatry is an easy specialty to practice poorly and a hard one to practice well.

Are you actually a med student arguing with an attending or are you an attending too?

None of the above I’m a resident, which is irrelevant because this is not a question of seniority or experience but basic/general knowledge/understanding of our current conceptualization of mental illness. To be sure, we’re nowhere near putting a finger on what exactly mental illnesses are and how they’re caused, but chemical imbalances they ain’t.

And just as an aside, pointing out someone’s gaps in knowledge/mistakes in understanding may or may not have a goal of getting into an argument with that person, but considering that this is a public forum it also serves as a correction for anyone who reads it. (Eg. at some point I spent some time dispelling vaccine myths on a public forum. I don’t think I ever managed to convince any anti-vaxxers posting these myths, but I know for a fact there were people who found the information I posted useful.)

 

[futuredo32]

I can't speak to you personally, but a lot of psychiatrists ARE bad. Same with every field in medicine.

I'm not seeking an evaluation of my skills. The question was what I posted initially.

 

[VA Hopeful Dr]

I'm not seeking an evaluation of my skills. The question was what I posted initially.

I didn't post one, and as a general rule would not based on online postings only.

Now if you said you gave all of your depressed patients stimulants because they all said they had no energy, I might be able to assume you're a bad doctor but that's quite the outlier and thankfully seems somewhat rare.

 

[Shufflin]

Just had a patient arrive with benzos and opiates. First step? Verify in CURES. My next step is to wean them down and off if possible.

 

[tr]

Are you actually a med student arguing with an attending or are you an attending too?

Are you actually trying to pull medical hierarchy rank on an anonymous message board? You know appeal-to-authority is a logical fallacy right?

 

[WisNeuro]

Are you actually trying to pull medical hierarchy rank on an anonymous message board? You know appeal-to-authority is a logical fallacy right?

How dare you bring logic into a discussion about benzos!?!

 

[Liquid8]

I normally leave the opiate prescribing and direct any requests for increases to the pain specialists, but I do take people off them from time to time.

Recently had a patient admitted under me on a range of pain meds including a couple of NSAIDs, oxycondone, oxycontin, targin and palexia – all of which was initiated by a surgeon in relatively rapid succession following a minor surgical procedure. Somewhere along the line the surgeon decided that this had to be a "pain disorder" and left me to clean up their mess. Fortunately I’d had success with this patient in the past with reducing their benzos, so the process wasn’t too difficult. What irked me most was that this one was actually iatrogenic, as it seemed that the prescriber had just charted analgesia without actually discussing it beforehand.

 

[birchswing]

What's amazing to me is how fast there has been a sea change with the opiates and then drugs associated with their overdose and how reptilian people's responses are rather than trusting their own judgment. It used to be just years ago that I could not have a dental procedure without having an opiate pushed on me (I always declined and found I never even needed ibuprofen). Now it seems like people are aware of the risks and I see signs in medical offices that three days is the max a pain medicine will be prescribed and they'll use the prescription monitoring, etc. That's fine.

But what is interesting furthermore is that the reaction to benzos has been so mindless. I will argue that long-term prescribing of benzos is deleterious as most here would. And that short-term prescribing is also probably not helpful in most cases. But the reason that practitioners are now against benzo-prescribing often seems to be misinformed. It seems some even have trouble making a distinction between benzos and opiates and I even had one doctor think that suboxone was used to treat benzodiazepine withdrawal. It seems some just have a general awareness there is a crackdown and "these drugs" are bad, and in the same way they were sort of mindless about prescribing opiates they are unaware of why they're cracking down on other drugs associated with opiate overdoses, not understanding the nuances of benzodiazepines—believing things like benzodiazepines in isolation are a large overdose risk. It's the same with gabapentin. I'm not going to argue the virtues of gabapentin as I've heard stories of people having a difficult time coming off of it as well. But I had a doctor who wanted me to go on it a year ago. I didn't want to because I didn't want another gaba-ergic drug to have to withdraw from. Well, it turns out I was right in her case: I would have had to come off of it, as she wants what she calls a "clean panel" and is taking people off all drugs where she'll get "black Xs" as she calls it from the DEA (all benzos and all ADHD drugs). She says gabapentin is now in that class and has taken patients off of it (so I did save myself going on and off as I predicted might happen). So I looked up the info on gabapentin and I found that it is associated with opiate overdoses in the same way benzos are (not a huge surprise), but in isolation it's not really a recreational drug of abuse. But that has nothing to do with me or many other people who don't take opiates. There might be very valid reasons to not prescribe gabapentin, but someone else's polypharmacy with an opiate is not one of them. There has been a huge prescribing practice change in benzos—psychiatrists doing rapid tapers, not accepting patients who are on benzos, etc. It wasn't long ago I had trouble convincing a doctor that benzos were deleterious. It didn't take very long for a doctor to not want to touch a patient on a benzo. Whether it's good or bad, the change has not been informed by decades of information on the nature of benzos but by an unrelated phenomenon: people who use opiates and benzos concurrently (and really mainly just the use of opiates and the knowledge that the synergistic effect of taking another sedative with them puts people over the edge with OD risk and a seeming assumption by some that benzos are the same or similar to opiates). And now I'm seeing it go further down the line to drugs like gabapentin. I'm not arguing for the prescription of any of those drugs but instead for mindfulness and courage to prescribe according to your knowledge instead of what seems sort of like a school of fish moving in one direction or another without really knowing why.

 

[tr]

I'm not going to argue the virtues of gabapentin as I've heard stories of people having a difficult time coming off of it as well. But I had a doctor who wanted me to go on it a year ago. I didn't want to because I didn't want another gaba-ergic drug to have to withdraw from. Well, it turns out I was right in her case: I would have had to come off of it, as she wants what she calls a "clean panel" and is taking people off all drugs where she'll get "black Xs" as she calls it from the DEA (all benzos and all ADHD drugs). She says gabapentin is now in that class and has taken patients off of it (so I did save myself going on and off as I predicted might happen). So I looked up the info on gabapentin and I found that it is associated with opiate overdoses in the same way benzos are (not a huge surprise), but in isolation it's not really a recreational drug of abuse.

Gabapentin is not directly GABAergic, despite its misleading name. It acts at the alpha-2-delta subunit of the calcium channel. One downstream effect of this is modulation of the GABA-synthetic enzyme GAD, increasing endogenous synthesis of GABA. It's actually quite helpful in easing alcohol withdrawal and has some observational support in facilitating benzo tapers.

Mechanisms of action of gabapentin. - PubMed - NCBI
NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals
Gabapentin (Neurontin): An Adjunct for Benzodiazepine Withdrawal

 

[birchswing]

Gabapentin is not directly GABAergic, despite its misleading name. It acts at the alpha-2-delta subunit of the calcium channel. One downstream effect of this is modulation of the GABA-synthetic enzyme GAD, increasing endogenous synthesis of GABA. It's actually quite helpful in easing alcohol withdrawal and has some observational support in facilitating benzo tapers.

Mechanisms of action of gabapentin. - PubMed - NCBI
NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals
Gabapentin (Neurontin): An Adjunct for Benzodiazepine Withdrawal

Ahh, gotcha, thank you.

Yes, I actually about 10 years ago was seeing a different psychiatrist and asked about taking it for benzo withdrawal and he was rather quizzical about its value and didn't want to prescribe it for benzo tapering. I stayed on the benzos. Then this current psychiatrist was for gabapentin before she was against it, based strictly on regulatory issues. She is instead giving me Lamictal to ease the second half of my taper. I know you can't comment on that. And I can't either since I haven't tried it yet, but there's certainly not as much research around it for benzo tapering. But the pertinent part is that it was motivated by her not wanting to prescribe a "drug of concern," one that she previously thought made sense for the same situation I was in a year ago, the only change being a state board of medicine announcement. Anecdotally I've seen people complain about getting off both gabapentin and Lamictal. Personally I'd rather go with the drug that doesn't have the rare but possibly fatal SJS along with some other long-named fatal disease I saw the FDA recently warned about. But if I can't keep making cuts with my taper, I'll try it. She's said it's impossible for me to get SJS based on the GeneSight test she did, which sounded BS-y to me. I looked it up and it turns out it's just less likely I'd develop it based on my genotype. But it's a low dose and I know what to look out for.