PCP changing medication dosage

[nrmp]

Patient was referred by PCP and was seen once. Patient was on Xanax and changed to klonopin for panic attacks with an agreement to stop cannabis, advised to obtain complete sobriety from cannabis otherwise no benzo will be prescribed while monitoring drug screen. Patient was seen by PCP who increased dosage of benzo and provided one refill on top of it while knowing my plan on initial consult and patient admitting to continuous use of cannabis as before. I have strictly warned patient on 2nd visit about obtaining complete sobriety from cannabis before further f/u in next few weeks. How would you deal with PCP and further management? Send them back to PCP for med management, discharge or give more chances and time to obtain sobriety?

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[Sushirolls]

Wide range of options really.

Could consider to continue to see patient, and let them know you won't be prescribing them any controlled substance. And already determined by the PCP, they will be prescribing all future benzos - not you. Treat them for depression/anxiety whatever it is you are working towards and remind them ongoing cannabis use to lower their expectations for symptom recovery. PCP wants to prescribe benzos, let them. Ultimately they are primary and more their patient than your patient.

I avoid this by making clear my patients I won't ever prescribe benzos unless I'm doing their taper off them. Currently I have 0 patients on benzos.

 

[adiradirim]

If it were me, I would refer the patient back to the PCP and allow him to manage it going forward. I would allow the patient to see me again but I would not prescribe any benzos but I would offer SSRI/anxiety treatment and potentially addiction therapy referral if desired.

 

[VA Hopeful Dr]

Patient was referred by PCP and was seen once. Patient was on Xanax and changed to klonopin for panic attacks with an agreement to stop cannabis, advised to obtain complete sobriety from cannabis otherwise no benzo will be prescribed while monitoring drug screen. Patient was seen by PCP who increased dosage of benzo and provided one refill on top of it while knowing my plan on initial consult and patient admitting to continuous use of cannabis as before. I have strictly warned patient on 2nd visit about obtaining complete sobriety from cannabis before further f/u in next few weeks. How would you deal with PCP and further management? Send them back to PCP for med management, discharge or give more chances and time to obtain sobriety?

There's a decent chance the PCP has no idea what's going on from your end, I know I never receive notes from psychiatry in the area. So its up to the patient to tell me what the plan is from their psychiatrist.

I'd call the PCP to see what happened on their end.

 

[Psychresy]

Wide range of options really.

Could consider to continue to see patient, and let them know you won't be prescribing them any controlled substance. And already determined by the PCP, they will be prescribing all future benzos - not you. Treat them for depression/anxiety whatever it is you are working towards and remind them ongoing cannabis use to lower their expectations for symptom recovery. PCP wants to prescribe benzos, let them. Ultimately they are primary and more their patient than your patient.

I avoid this by making clear my patients I won't ever prescribe benzos unless I'm doing their taper off them. Currently I have 0 patients on benzos.

Do you see utility in using benzo's as a bridge in a highly anxious person? Or perhaps someone with panic and agoraphobia in particular may benefit from a short course. My program is pretty conservative but these are certainly instances where most of our attendings are OK with benzos.

 

[Sushirolls]

No.
Gabapentin PRN; Hydroxyzine PRN; PHP/IOP
Too often after people try a benzo 'nothing is as good' and 'doc just give me more'
Prevention is worth a pound of cure.

 

[birchswing]

Does the marijuana help the anxiety?

It seems like the less dangerous of the two drugs, especially if he can find a way to take it without smoking it.

 

[hamstergang]

I'd call the PCP to see what happened on their end.

This is clearly the only correct answer. You can't judge the situation without a conversation to find out what really went on.

 

[Sushirolls]

This is clearly the only correct answer. You can't judge the situation without a conversation to find out what really went on.

No, it's not "the only correct answer." Adult patients are fully capable of listening to and following instructions. This patient chose to not follow the instructions and plan.
*Yes there is a minority of patients who are questionable in the capacity to function.

 

[hamstergang]

No, it's not "the only correct answer." Adult patients are fully capable of listening to and following instructions. This patient chose to not follow the instructions and plan.

You don't know what the PCP (another doctor whom the patient has known for longer) said or why. You're making a judgment with only half the information. I'd say that that's wrong.

 

[Sushirolls]

States have controlled substance databases to monitor for controlled substance prescribing.

Let's assume the PCP checked the database, and saw the Psychiatrist's name with a Klonopin Rx on the chart. Why would they further prescribe any controlled substance at that point without reaching out to the Psychiatrist first? Some states require the database checks with each controlled Rx. Two prescribing docs for the same class of controlled substance? The onus was on the PCP to reach out... Especially after the PCP placed a referral to a specialist, and that specialist name shows up, and then they still continue to intercede.

So still, nope. The judgement stands, even with potentially half the information.

*Further assumptions in this case was that the referral was for complete evaluation and management which is 95%+ of referrals to routine Psychiatry and not just Consultation for recommendations. So, this patient was truly referred to Psychiatry to Treat and Manage the psychotropics.
*If this was consultation only for recs, we wouldn't have heard about it or seen the topic of follow ups.

 

[nrmp]

There's a decent chance the PCP has no idea what's going on from your end, I know I never receive notes from psychiatry in the area. So its up to the patient to tell me what the plan is from their psychiatrist.

I'd call the PCP to see what happened on their end.

Like I said after knowing my plan as I sent my initial consult note assessment/plan.

 

[nrmp]

States have controlled substance databases to monitor for controlled substance prescribing.

Let's assume the PCP checked the database, and saw the Psychiatrist's name with a Klonopin Rx on the chart. Why would they further prescribe any controlled substance at that point without reaching out to the Psychiatrist first? Some states require the database checks with each controlled Rx. Two prescribing docs for the same class of controlled substance? The onus was on the PCP to reach out... Especially after the PCP placed a referral to a specialist, and that specialist name shows up, and then they still continue to intercede.

So still, nope. The judgement stands, even with potentially half the information.

I agree as once they have already referred patient to us why would they interfere with psychotropic medication changes (yes it's easy to look up on state database without even having any coordination) particularly controlled substance knowing patient was already hospitalized a year ago for alcohol/drug abuse in above patient. I like your clear boundary about prescribing benzo but the market I am in I can't apply it otherwise I would probably be jobless (I am sure many of us are in the same boat) unless I consider changing job/moving.

 

[Sushirolls]

Let's flip this around. I have a patient with cardiac symptoms suspicious of A-fib or SVT. I refer to cardiology. They do their amazing work up. Patient has SVT, isn't or doesn't want to do ablation, and gets a Beta blocker prescribed.

I see the patient again in follow up - now as NRMP as pointed out - with consult notes and recs in hand, tell the patient, no Beta Blockers are bad... because you know the dinosaur Board Certification question and that still on the PRITE is around, where beta Blockers cause depression, and I tell the patient no, stop that beta blocker, and only use a low dose PRN propranolol 5mg BID. (I would never do any of this....)

Should the cardiologist be calling me up and asking why I changed their beta blocker? No. They should wipe their hands of the issue and say fine, let psychiatry continue with their [insert choice words here] management plan.

Feel free to even substitue out Psychiatry with FM/IM/PCP in this example if it is more revealing.

 

[Sushirolls]

I agree as once they have already referred patient to us why would they interfere with psychotropic medication changes (yes it's easy to look up on state database without even having any coordination) particularly controlled substance knowing patient was already hospitalized a year ago for alcohol/drug abuse in above patient. I like your clear boundary about prescribing benzo but the market I am in I can't apply it otherwise I would probably be jobless (I am sure many of us are in the same boat) unless I consider changing job/moving.

Sorry NRMP. But conversely, don't be surprised how man PCP pockets might be in your market who are just waiting for a more vocal anti-benzo Psych to pop up on their radar to refer to. They do exist.

 

[VA Hopeful Dr]

Like I said after knowing my plan as I sent my initial consult note assessment/plan.

Doesn't mean they read it.

You can, of course, do whatever you want but the best advice is to call the PCP and find out why they did what they did.

 

[VA Hopeful Dr]

States have controlled substance databases to monitor for controlled substance prescribing.

Let's assume the PCP checked the database, and saw the Psychiatrist's name with a Klonopin Rx on the chart. Why would they further prescribe any controlled substance at that point without reaching out to the Psychiatrist first? Some states require the database checks with each controlled Rx. Two prescribing docs for the same class of controlled substance? The onus was on the PCP to reach out... Especially after the PCP placed a referral to a specialist, and that specialist name shows up, and then they still continue to intercede.

So still, nope. The judgement stands, even with potentially half the information.

*Further assumptions in this case was that the referral was for complete evaluation and management which is 95%+ of referrals to routine Psychiatry and not just Consultation for recommendations. So, this patient was truly referred to Psychiatry to Treat and Manage the psychotropics.
*If this was consultation only for recs, we wouldn't have heard about it or seen the topic of follow ups.

You're assuming a lot of things that could very easily not be true.

My state doesn't require checking the database for schedule 4 drugs.

The patient could have easily said "the psychiatrist wants you to keep writing for the klonopin". One of the psychiatrists here in town is notorious for doing just that. I got a consult note literally today that said "pt received ativan from PCP in the past, will leave decisions about that medication to PCP" while the psychiatrist in question was managing and prescribing the patient's trintellix and seroquel.

 

[nrmp]

Sorry NRMP. But conversely, don't be surprised how man PCP pockets might be in your market who are just waiting for a more vocal anti-benzo Psych to pop up on their radar to refer to. They do exist.

Interesting, that's really good to know!

 

[Crayola227]

Let's flip this around. I have a patient with cardiac symptoms suspicious of A-fib or SVT. I refer to cardiology. They do their amazing work up. Patient has SVT, isn't or doesn't want to do ablation, and gets a Beta blocker prescribed.

I see the patient again in follow up - now as NRMP as pointed out - with consult notes and recs in hand, tell the patient, no Beta Blockers are bad... because you know the dinosaur Board Certification question and that still on the PRITE is around, where beta Blockers cause depression, and I tell the patient no, stop that beta blocker, and only use a low dose PRN propranolol 5mg BID. (I would never do any of this....)

Should the cardiologist be calling me up and asking why I changed their beta blocker? No. They should wipe their hands of the issue and say fine, let psychiatry continue with their [insert choice words here] management plan.

Feel free to even substitue out Psychiatry with FM/IM/PCP in this example if it is more revealing.

I'm sorry, but my knee jerk reaction when I got to the bolded part, was "Yeah, if they don't give a damn about the patient and just their own CYA." Doesn't seem like the way to get the patient the best treatment plan.

Seems to me they should call and find out why another doctor messed with the plan.

 

[thepoopologist]

Patient was referred by PCP and was seen once. Patient was on Xanax and changed to klonopin for panic attacks with an agreement to stop cannabis, advised to obtain complete sobriety from cannabis otherwise no benzo will be prescribed while monitoring drug screen. Patient was seen by PCP who increased dosage of benzo and provided one refill on top of it while knowing my plan on initial consult and patient admitting to continuous use of cannabis as before. I have strictly warned patient on 2nd visit about obtaining complete sobriety from cannabis before further f/u in next few weeks. How would you deal with PCP and further management? Send them back to PCP for med management, discharge or give more chances and time to obtain sobriety?

I'd send them back to the PCP and they can own whatever consequences come from treating the patient.

You have two big variables to deal with, the PCP and the patient who decided not to take your advice. You're not a miracle worker.

 

[thepoopologist]

I should add that my own experiences with polysubstance users has been really poor.

I think bargaining and playing dumb is a pre-contemplative state and there's no reason to spend your time on that.

 

[Crayola227]

You can't control the patient; you can however influence how other providers prescribe to the patient, by blowing a patient's story out of the water, or educating/making a provider aware of their actions or treatment from the specialist's perspective.

We are 100% responsible for making reasonable attempts to communicate with other professionals in the coordination of care. We all know things fall through the cracks and just sending over a note does not always do the job, sometimes it takes a phone call.

 

[NickNaylor]

If it were me, I would refer the patient back to the PCP and allow him to manage it going forward. I would allow the patient to see me again but I would not prescribe any benzos but I would offer SSRI/anxiety treatment and potentially addiction therapy referral if desired.

For the OP: I had this issue a few times when I was in our outpatient clinic in residency... had a few issues with patients that were on stupid regimens of controlled substances initially started/managed by a PCP that the patient was now requesting that I manage. I had a frank discussion with the patient about the fact that I would not continue to prescribe these medications if there was no plan to taper, try alternatives, etc. Almost invariably, something would happen and the patient would magically get a refill on their 2 mg QID Xanax that had been tapered over the preceding months. I would give them the benefit of the doubt one time, but if it happened again, the quote above is what I would do, and I was very direct with the patient about this being the plan.

 

[Celexa]

For the OP: I had this issue a few times when I was in our outpatient clinic in residency... had a few issues with patients that were on stupid regimens of controlled substances initially started/managed by a PCP that the patient was now requesting that I manage. I had a frank discussion with the patient about the fact that I would not continue to prescribe these medications if there was no plan to taper, try alternatives, etc. Almost invariably, something would happen and the patient would magically get a refill on their 2 mg QID Xanax that had been tapered over the preceding months. I would give them the benefit of the doubt one time, but if it happened again, the quote above is what I would do, and I was very direct with the patient about this being the plan.

I haven't had to deal with any of the most egregious examples of these patients but I work similarly, if a patient shows up on a controlled substance by anothet provider I explain my proposed treatment plan and also explain that for safety only one provider should be prescribing the controlled substance. The focus on safety helps the conversation go down a little easier. I also explain the existence of the pdmp if the patient is unaware of it. If the patient wants continue care with me and I am taking over the med I call the person currently prescribing it and have a conversation with them (and document it!) so that there is no ambiguity about what is going to happen. If the patient then get the med filled somewhere else? at most one second chance. otherwise they can transfer care.

I am fortunate to have attendings who will back this all up and work in a place that does not have a reputation for being free and easy with benzos.

 

[Candidate2017]

You can't control the patient; you can however influence how other providers prescribe to the patient, by blowing a patient's story out of the water, or educating/making a provider aware of their actions or treatment from the specialist's perspective.

We are 100% responsible for making reasonable attempts to communicate with other professionals in the coordination of care. We all know things fall through the cracks and just sending over a note does not always do the job, sometimes it takes a phone call.

At the end of the day, there's really no right or wrong. I lean toward the autonomy of the patient and PCP.

Patient (with capacity) doesn't want to take my professional opinion? Cool, 'Murica, free country.

PCP wants a BZD consult from me but doesn't want to read my note? Cool, no one reads my lengthy, lovingly crafted notes either. But at least skip to the A&P like everyone else. English, do you read it mofo? I assume, yes. And appropriate use of BZDs isn't some mysterious concept mastered only by psychiatrists. If I was concerned, I'd leave a message to the PCP, "Saw your referred patient, recommended BZD taper, see my note."

What's right, best, and practical are debatable anyway. If I chase down every PCP benzo rebel or referred BZD patient who tells me to shove my plan where the sun don't shine, then I have less time for patients who actually want help and will see less patients. Who's to say the best answer isn't slapping the PCP and locking up the patient for a quick inpatient BZD taper? Arguably, society would benefit and more lives would be saved if we radio-tagged every non-compliant psychotic patient or severe opioid user and blow-darted meds at them q1 month.