Patients with pre-existing dx and wacky meds

[beezley]

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What do you do with the patients that come to you with suspect diagnosis and even more suspect med regimens and are invested/addicted to the meds they are on?

Can you ever get someone off benzos? Not feeling too lucky there if it has been years.

 

[Ceke2002]

Can you ever get someone off benzos? Not feeling too lucky there if it has been years.

I know I can't give you a medical point of view, but as a former benzo patient, sure you can get someone off benzos, even if it has been years. I was bought off an 8 year regimen of Xanax (prescribed upwards of 16 mgs a day, with an average daily dose of 12 mgs). My treating Doctor used the Ashton Protocol. I was also in treatment at the time for other (poly) drug issues, had an underlying anxiety disorder, chronic anorexia nervosa, and was experiencing as then undiagnosed episodes of major depression with psychotic features, so it wasn't exactly like I was an easy case to work with either.

Here's the manual for the Ashton Protocol, developed by Professor C Heather Ashton DM, FRCP. I'm sure one of your fellow Physicians on here will be able to give you more details on it from a medical point of view. Good luck helping your patient off benzos. 🙂

http://www.benzo.org.uk/manual/

 

[vistaril]

What do you do with the patients that come to you with suspect diagnosis and even more suspect med regimens and are invested/addicted to the meds they are on?

Can you ever get someone off benzos? Not feeling too lucky there if it has been years.

if a pt comes to me on some jacked up benzo dose(like xanax 2mg qid or something), I wont see that pt.......in a lot of cases the pt is very open about "wanting" to work with a psychiatrist or physician to slowly taper down on their benzos, but you never know what their real intentions are.......

I think psychiatrists often fall in the trap of taking pts from other providers on high doses of benzos, and then tapering them down over a long period of time, thinking that they got a pt addicted to benzos off benzos. For example, a guy told me recently that he had a pt come in on a total of 8mg xanax a day and switched him to klonopin 2mg BID and eventually got it down to 0,5bid(now) after 5 months or whatever.....

I told him "well we really don't know what in the hell that pt was taking before they cae to you. We DO KNOW, however, that you have given the pt prescriptions for about 350mg of Klonopin over the last 5 months".......

again, people are going to take whatever stance on benzos they won't. I'll occasionally give pts benzos, and Im honest about it. What I wont do is accept pts on high dose benzos from other physicians and accept them under that guise......

 

[splik]

Can you ever get someone off benzos? Not feeling too lucky there if it has been years.

yes you can if they are willing or you can convince them the benzos are contributing to their depression and anxiety (good evidence for this) and switch them on to a long acting benzo (i.e. diazepam) and taper off whilst teaching various skills for managing anxiety etc I know there are some patients who have been on benzos for 40 years and I suspect it would be v. hard, if not potentially life-threatening to withdraw benzos from, but 5-10 years worth it's deffo worth giving it a shot if they are willing.

 

[Ceke2002]

in a lot of cases the pt is very open about "wanting" to work with a psychiatrist or physician to slowly taper down on their benzos, but you never know what their real intentions are.......

Yes, yes patients just live to scam you at every turn, clearly we have nothing better to do

 

[F0nzie]

Regarding clinical situations that have been carefully reviewed that call for tapering benzo's, my starting point has been to develop a good rapport with the patient and provide them with psychoeducation regarding tolerance and long term use of benzodiazepines. The issue of tolerance is generally well understood and received. Withdrawl seems to be one of their biggest fears. In my experience I've found that providing a lot of reassurance has been a very effective strategy. I tell my patients that I will assist them by switching them to an equivalent dose of Valium and I emphasize that it works by a similar mechanism of action but that it is long acting. I tell them that I will titrate them down over several months such that they will not experience any symptoms of withdrawl. After adjusting the new long acting benzo to an adequate dose and see that they are not feeling overly anxious, I start the gradual taper. The fact that some of these patients have been on multiple ineffectual med regimens and sketchy diagnoses may help you facilitate the discussion of alternatives such as more sensible med regimens and psychotherapy. Providing empathic statements highlighting their struggle to find "the right medication" may help them feel more understood. Expressing to the patient that your clinical decisions are in keeping the patient's best interests in mind may also help them feel more reassured and IMO, more likely to stick with you.

 

[vistaril]

Yes, yes patients just live to scam you at every turn, clearly we have nothing better to do

certainly not all. depending on the setting, perhaps not even most.

But anytime someone of fairly normal cognition comes in to see you in 2012 and the previous person/people had them on 8mg xanax or more a day, the pt *knew* what was going on to some degree and was complicit with it.

This is 2012. pts google or go to webmd to find out exactly what ppi they are on. Almost no patients are just floating around out there on 8+mg of xanax per day and are complstely unaware that it is not the best or safest thing for them. Please......

Now that's not to say those pts are bad; Or that they dont ever deserve help. but Im not going to see pts who come from other providers on those doses of benzos. Simple as that. If someone else wants to treat them and write them a ton of benzos on a slow taper, feel free......

 

[Ceke2002]

Regarding clinical situations that have been carefully reviewed that call for tapering benzo's, my starting point has been to develop a good rapport with the patient and provide them with psychoeducation regarding tolerance and long term use of benzodiazepines. The issue of tolerance is generally well understood and received. Withdrawl seems to be one of their biggest fears. In my experience I've found that providing a lot of reassurance has been a very effective strategy. I tell my patients that I will assist them by switching them to an equivalent dose of Valium and I emphasize that it works by a similar mechanism of action but that it is long acting. I tell them that I will titrate them down over several months such that they will not experience any symptoms of withdrawl. After adjusting the new long acting benzo to an adequate dose and see that they are not feeling overly anxious, I start the gradual taper. The fact that some of these patients have been on multiple ineffectual med regimens and sketchy diagnoses may help you facilitate the discussion of alternatives such as more sensible med regimens and psychotherapy. Providing empathic statements highlighting their struggle to find "the right medication" may help them feel more understood. Expressing to the patient that your clinical decisions are in keeping the patient's best interests in mind may also help them feel more reassured and IMO, more likely to stick with you.

Yes, definitely lots of reassurance helps, a lot, especially if the patient has had a previous bad experience with trying to do withdraw off benzos. Silly me made the mistake of trying to just jump off Xanax cold turkey. I knew I was going to go through withdrawals, but I figured I could just suck it up, and get through it. I spent the first night hallucinating, and babbling at our fish tank, because I thought I was transmitting messages from our fish to their brothers and sisters in the ocean, by the second night I had a seizure. The experience was frightening, and painful enough that I became genuinely scared of withdrawing off the meds. Even with slow tapering, at the start every twinge I felt would send me into a complete panic that I was going to have another seizure. Having a psychiatrist take the time to reassure me throughout the process, and help me to feel safe, went a long way towards my eventual success.

 

[Ceke2002]

But anytime someone of fairly normal cognition comes in to see you in 2012 and the previous person/people had them on 8mg xanax or more a day, the pt *knew* what was going on to some degree and was complicit with it.

This is 2012. pts google or go to webmd to find out exactly what ppi they are on. Almost no patients are just floating around out there on 8+mg of xanax per day and are complstely unaware that it is not the best or safest thing for them. Please......

Even if they are complicit, and I will admit I certainly was in my own Xanax use, why can't they be allowed to admit they've made a mistake by seeking treatment to come off the meds, without facing suspicion or discouragement. Sure back in the 90s when I was first prescribed Xanax I wasn't really aware of what the dangers were, but by the time I was completely dependent on it, and being prescribed doses of 16 mgs a day, I knew what was up, I knew the risks, but 1) I was an addict, and 2) every time I broached the idea of coming off Xanax with my prescribing Doctor I got the 'it's just like a diabetic needs insulin' speech.

I realise I made a mistake with Xanax, I realise I was complicit in continuing its use, but if I'd gotten the attitude from Doctors that I wasn't going to be treated, because I should have known better (especially when I was genuinely reaching out for help), I'd still be messed up on the stuff today.

 

[whopper]

I wont see that pt

Then how will they ever get off the benzo? If they're clearly still wanting it for the wrong reasons, I see, but from personal experience, in private practice, when I explained to most patients that benzos are bad for long-term treatment, they wanted off of it and were fully cooperative with my efforts to wean them off.

Now, unfortunately, that was not the case in other practice settings, but in PP it was.

I told him "well we really don't know what in the hell that pt was taking before they cae to you. We DO KNOW, however, that you have given the pt prescriptions for about 350mg of Klonopin over the last 5 months".......

You could get prior medical records and in some states you can get a hold of reports showing every single controlled substance they've gotten from pharmacies in a matter of moments.

I see your point about weaning someone off of benzo may in fact be giving them one they shouldn't have, and may have misinterpreted your meaning, but it appears you have a "if they're on a benzo, I won't see them" mentality.

Patients on large doses of benzos, I tell them if they want to continue seeing me, I will have to get them off of it, the question then becomes how much time will I give them. This depends on the specific patient but in general I usually have them completely off in 1-4 months in an outpatient setting. I have given some other patients much longer than that but these were exceptions to the rule and on the order of less than 10% of my patients on chronic benzo usage.

 

[vistaril]

Even if they are complicit, and I will admit I certainly was in my own Xanax use, why can't they be allowed to admit they've made a mistake by seeking treatment to come off the meds, without facing suspicion or discouragement. Sure back in the 90s when I was first prescribed Xanax I wasn't really aware of what the dangers were, but by the time I was completely dependent on it, and being prescribed doses of 16 mgs a day, I knew what was up, I knew the risks, but 1) I was an addict.

i think that's the core of it.....I don't use my outpt med mgt slots as an addiction med clinic. Im sure some people dont mind serving in that capacity, and that's why they can go to those providers for that.

 

[vistaril]

Then how will they ever get off the benzo? If they're clearly still wanting it for the wrong reasons, I see, but from personal experience, in private practice, when I explained to most patients that benzos are bad for long-term treatment, they wanted off of it and were fully cooperative with my efforts to wean them off.

Now, unfortunately, that was not the case in other practice settings, but in PP it was.



You could get prior medical records and in some states you can get a hold of reports showing every single controlled substance they've gotten from pharmacies in a matter of moments.

I see your point about weaning someone off of benzo may in fact be giving them one they shouldn't have, and may have misinterpreted your meaning, but it appears you have a "if they're on a benzo, I won't see them" mentality.

Patients on large doses of benzos, I tell them if they want to continue seeing me, I will have to get them off of it, the question then becomes how much time will I give them. This depends on the specific patient but in general I usually have them completely off in 1-4 months in an outpatient setting. I have given some other patients much longer than that but these were exceptions to the rule and on the order of less than 10% of my patients on chronic benzo usage.

yeah I know I can run them on the controlled rx report, but so many people just get their benzos from their aunt, the bf, etc.......naybe the pt has been getting 2mg xanax BID from their sister in law for the last year, and now that isnt taking the edge off like it used to. Now they figure they can come to my office, claim to be using twice that amt for 3 years, and hope I'll give them a long taper on another benzo.....they're just using me to supplement their usual use,

and yeah I could try to obtain records or call the provider who was supposedly giving them 8+ mg of xanax per day, but that's of limited utility as well. For one, I really dont care to talk to someone who is so useless as a physician. Secondly, that doesnt tell me all I need to know......it doesnt give me any reassurance(even if hey were getting rxs) that they arent still going to do polypharmacy from another prescriber....

it's just impossible to police these pts. Even with a lot of work.

And like I said, them becoming addicted to benzos in 99% of cases in 2012 isnt a case of unfortunate iatrogenic addiction the pt had nothing to do with. If someone is on 8mg of xanax a day in 2012 they know darn well what they are doing and they are drug seeking. pt's dont wind up at those sorts of doctors by chance. Maybe in 1987 that was a possibility, but not in 2012. So you're already dealing with a drug seeking addict, so I've got that in the back of my mind.....

Im not saying those people dont deserve treatment. Im just saying my outpt med mgt clinic is not the right place for them.

 

[Pershing]

it's just impossible to police these pts. Even with a lot of work.

The outpatient detox clinic that I worked in put everyone with benzodiazepine dependence on a phenobarbital taper, so they could monitor urines for relapse on benzodiazepines. I imagine this strategy is uncommon and that it has its own pitfalls.

 

[whopper]

Im not saying those people dont deserve treatment. Im just saying my outpt med mgt clinic is not the right place for them.

Well I can see that point to some degree. I've turned away patients that I did not feel I could handle, e.g. a very bad borderline pt that needed DBT, and I don't provide that.

Patients should not be turned away merely out of convenience. Getting records from pharmacies IMHO isn't a big deal, getting one of those state reports (though it's not in every state) takes less than a minute, and you can get staff members to do it.

it's just impossible to police these pts. Even with a lot of work.

No system is 100%, but you don't necessarily have to "police them." You could give hard guidelines such as you'll only provide it for about a limited duration while they are tapered down and if they don't follow the rules they will be terminated.

I find it interesting that you were defending benzo prescribing a few weeks ago and now you appear to have a 180-turnaround in your opinion.

 

[vistaril]

No system is 100%, but you don't necessarily have to "police them." You could give hard guidelines such as you'll only provide it for about a limited duration while they are tapered down and if they don't follow the rules they will be terminated.

I find it interesting that you were defending benzo prescribing a few weeks ago and now you appear to have a 180-turnaround in your opinion.

1) Im not so much worried about them breaking rules I could catch them breaking. In a scenario where they are using their sister in law's xanax and just want a little extra to top it off, I dont doubt for a second they would "comply by my rules".....in fact, a suspect that they would very much appreciate the klonopin I am giving them in a supposed taper which they are using to top off the klonopin or xanax they get from their sister in law......Im not interested in playing that game, or even wondering which of my pts are doing that and which arent.

2) the situations are different.....I have a small number of pts on low dose benzos. In those cases, Im giving them benzos because I believe it is clinically indicated to treat their mental illness. In a case of a transfer pt on massive benzo doses, if I gave them benzos I would be treating their benzo dependence(not something I really care to do) as well as giving them larger doses of benzos(again not something I care to do)......

 

[notdeadyet]

I'm having a tough time reconciling this:

2) the situations are different.....I have a small number of pts on low dose benzos. In those cases, Im giving them benzos because I believe it is clinically indicated to treat their mental illness.

With this:

I've noticed that the tendency for salaried psychiatrists is to condemn these people when benzos and schedule2 stimulants are prescribed without very clear indications. ...

That's just the business realities imo. If you're a mostly med mgt outpt psychiatrist that isn't salaried through a CMHC type place, you *need* paying patients. Either self-pay cash or the insured pts with the highest reimbursing insurance. And let's be honest, if someone with GAD, depression, whatever is coming to see you, most are going to expect a benzo. Or take that money to another psych who will give it to them. ....

I don't think it is unreasonable for the typical med mgt outpt psychiatrist in private practice to say: "yeah, I know this pt has run of the mill GAD and is drug seeking on some level. And maybe ideal standard of care is to not have them on Klonopin forever. But you know what.....they aren't a bad guy and seem somewhat reliable, and at least this way I can monitor them. And I'll try to set reasonable limits in terms of refusing to keep increasing it over time"........

that's what happens in the real world. I don't think it's fair for a salaried CMHC person or a C-L psych to judge these people, because they aren't in there shoes......

 

[vistaril]

I'm having a tough time reconciling this:


With this:

the difference is obvious: in one case you are treating benzo dependence. In another case you are treating anxiety(or at least the psychician thinks he is.....we could argue about standard of care). Also, in one case low doses of benzos are being used. Whereas in other cases larger doses are, at least initially, being used. Furthermore, in one case you are treating someone who isn't known to have drug problems, whereas in the other case you are treating someone who does.

three significant differences.