I have a patient who appeared guarded about substance use. I did drug screen and positive for cannabis. How comfortable are you to continue stimulant and benzo?
Speeding is only illegal on federal property, so 99% of speeding isn't a federal violation.So is speeding. Do you prescribe controls to people who speed?
THC isn't that relevant, what is the rational for mixing Benzos and stimulants? Stimulants cause anxiety and insomnia, Benzos cause poor concentration.
Do you not prescribe controlled substances for casual drinkers?
What about heavy coffee drinkers?
What about people who use psychedelics for spiritual purposes?
I absolutely agree, and I even think some times you can mix things. However, for those who are already mentally ill, all psychoactives, especially potpurris, especially potpurris with recreational substances, is a potential recipe for worsened mental health. I believe all patients should be warned away from all recreational substances, including caffeine or guarana or any of that hippy stuff, and then re-evaluate what adding minor to moderate amounts of the stuff, what that does to their mental health and whether or not that's acceptable to their goals of therapy.Do you not prescribe controlled substances for casual drinkers? What about heavy coffee drinkers? What about people who use psychedelics for spiritual purposes? Not all drug use is abuse or bad or wrong or harmful.
The point is that, say you have a depressed patient. They drink moderate amounts of alcohol, say a 1 drink 3 times a week. Do you think it's best for their depression to consider a trial of no alcohol at all, for mood improvement? (Evidence says if nothing else, the effect on sleep would warrant trying no alcohol whatsoever, and sleep is an important aspect of managing mood). I'm assuming we agree, zero booze would be best, at least as a trial, especially if we're not getting as much improvement as we would like from other strategies. Do you withhold an SSRI in this case? Presumably, we agree that there is likely some interaction between the patient's mood, alcohol, and SSRI.The COPD meds in current smoker is not a comparable metaphor. Controlled substance should not be given to people who are currently using addictive potential substances. My ADD patients I let know, I will stop/hold stimulants until UDS clears. Have monthly follow up for 1-2 months before getting back out to 90 day follow ups.
The solution for benzos is just don't use benzos.
I agree with others questioning simultaneous prescription of stimulants and benzos. I suppose it is possible that for some patients this could be justified but almost every time I have seen this it has simply been some pretty sloppy prescribing.
With regard to the question of whether I would stop prescribing a helpful controlled substance for someone using marijuana: No I wouldn't.
My personal opinion is that it's not helpful for me to be moralistic about marijuana use. I certainly tell my patients not to use it—especially those with psychotic or affective illnesses, but they have the right to ignore my advice on that. I don't consider it appropriate to manipulate my patients into not smoking weed by threatening to withhold medications that are helping them.
Many people are on stimulant since childhood or so. Later in their life when they have anxiety and panic attacks, they are not going to agree if you tell them that it's due to stimulant and let's just take that away and anxiety will go away
If the medication wasn’t helping them, then you should probably be stopping it either way. The fact that they’re using marijuana in that case is irrelevant.Agree but with caveats. First is that we don't really know if these were benefiting the above patient. All OP said was they'd been on benzos and stimulants for years. Also, a lot of the psych patients I've seen that regularly use pot do so because they say it helps with their depression or anxiety. So if they're self-medicating my first question is what is the problem with the prescribed meds? Are they not working? Is the patient non-compliant? Do they feel they just get extra benefit from the pot?
Second point is with the trust in the relationship. If I know my patient is lying to me about their substance use (saying they aren't using/haven't used but have positive UDS, sitting in front of me obviously impaired, recent admissions for substance detox, etc) how can I trust them with their controlled substances (or even any meds at all)? How do I know they're not abusing their stimulants or benzos? Obviously clinical judgment has to be used, but the dishonestly adds another layer to the relationship that is not conducive to me wanting to give them any medications with potential for abuse/diversion.
Am I going to stop prescribing for everyone who comes in and says they use marijuana? No, and I'd probably keep them on those meds most of the time. However, if I feel like the med isn't benefiting them or I feel like I can't trust them then I'm not going to keep giving them a potentially dangerous medication, especially if it's a controlled substance.
A positive UDS doesn’t tell you anything—doesn’t indicate frequency or severity, doesn’t indicate if it’s recreational, for therapeutic purposes, or indicates problematic use.
No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.I'll just go ahead and leave these here......
Lembke, A. (2012). "Time to abandon the self-medication hypothesis in patients with psychiatric disorders." Am J Drug Alcohol Abuse 38(6): 524-529.
Wilkinson, S. T., et al. (2015). "Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder." J Clin Psychiatry 76(9): 1174-1180.
Mammen, G., et al. (2018). "Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies." J Clin Psychiatry 79(4).
yes people do drugs in an attempt to "feel good."
I'm not saying it's the only reason, or saying how effective it is.Do they?
^^^My personal opinion is that it's not helpful for me to be moralistic about marijuana use. I certainly tell my patients not to use it—especially those with psychotic or affective illnesses, but they have the right to ignore my advice on that. I don't consider it appropriate to manipulate my patients into not smoking weed by threatening to withhold medications that are helping them.
No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.
I didn't even check out the first paper, just going off the title, yes people do drugs in an attempt to "feel good." That's why they're drugs.
A doctor giving out controlled substances to a person that repeatedly uses illegal substances documented via UDS calls into question the credibility of such doctor. Have fun in court when the lawyer puts you up there and points out you are so negligent and give so little ****s about this patient that you continually give out potentially dangerous drugs ( benzos, stimulants, etc) to someone already “addicted” to an illegal drug. You’re gonna look very bad, but that’s the beauty of medicine everyone can do as they feel comfortable.
I absolutely agree.
But that’s not the self medication hypothesis which is a very specific thing. Which was disproven. And then one of the authors changed the hypothesis. And then it was disproven again. And then one of the creators went to prison for child porn.
There’s a problem when the prevailing idea for substance abuse in the USA isn’t scientific. Which is why the other countries use different models.
When you are in a position of power (doctor-patient, parent-child, etc.) you can only be upset about someone lying to you when you as the person who holds the power sets up the conditions that encourage truth telling. If you give your patients a hard time, make them feel guilty or shameful or judged about using substances, they're understandably not going to want to reveal this info.
What @Crayola227 is saying, though, is what most people I have ever worked with have meant be self medicating, not the specific hypothesis discussed in the papers you provided.
I agree the terminological overlap is not helping. Would "maladaptive coping strategy" go down easier?
This is probably going to look ignorant or offensive, but I happen to read Ann Coulter. And I think I've mentioned here before I'm progressive leaning. I feel I shouldn't have to disclaim that. I know she's a provocateur, but I like to dabble in a bit of everything. She just happened to write a book review recently of a book on the dangers of marijuana in developing mental illness. I am sure there is a better review that people would take more seriously of it elsewhere, but this is the one I happened to read. If it's true (the risk of increased psychosis), it's one I did not know about. And interestingly, I went through drug education (the DARE program) in school. They talked about lack of motivation, falling in with the wrong crowd, using harder drugs, etc. But I don't recall anything about increased risk of psychosis:
Media Pot Reporting: Just Don’t Call Us Uncool! - Ann Coulter
I think I'll direct a series of low-budget movies with names like "Tobacco Madness," "Gun Madness" and "White Male Madness." The plots will be exactly the same with, alternately, cigarettes…www.anncoulter.com
Of course, if all that information is true, it doesn't really have any bearing on whether you should stop prescribing to someone for marijuana use. Maybe the drugs you're prescribing are neuroprotective. I don't know. But good information is the best in my opinion. Sometimes facts can be very inconvenient but they are obstinate. And so if these facts are true, I don't think it would change whether or not you drop a client but instead the case you make for why a substance might be problematic. In this case, however, I have no idea if the assertions are true. They did perk my ears.
If the medication wasn’t helping them, then you should probably be stopping it either way. The fact that they’re using marijuana in that case is irrelevant.
With regard to trust, sure I guess. I tend to think that people have all sorts of reasons to lie and that it’s sort of pointless for me to speculate. That said, we all have different levels of comfort with this kind of thing and I won’t argue with people about it.
The only consideration should be: is the treatment I am prescribing more dangerous given a person's substance use and is that risk acceptable?
Someone getting 1 mg Klonopin daily who smokes weed a few times a day ain't it.
Absolutely. I get that people are not technical with their terms. And that I am, by merit of personality and work in forensics.
I do believe that the data seems to indicate that substance abuse is largely a trait vulnerability. Which is something that can be treated. I would assume we've all seen it in our personal and professional lives, with people who cannot handle having one drink or cigarette, or whatever.
The reason I bring this up is that the entire idea of "let's find out the hidden reasons someone abuses substances, and treat that." would miss the problem, if it's a trait vulnerability. The obvious exmaple is nicotine. Mental health, in general, doesn't try to treat nicotine addiction by finding what the hidden affective ailment is. It uses behavioral techniques, chantix, buproprion, nicotine replacement, etc.
A doctor giving out controlled substances to a person that repeatedly uses illegal substances documented via UDS calls into question the credibility of such doctor. Have fun in court when the lawyer puts you up there and points out you are so negligent and give so little ****s about this patient that you continually give out potentially dangerous drugs ( benzos, stimulants, etc) to someone already “addicted” to an illegal drug. You’re gonna look very bad, but that’s the beauty of medicine everyone can do as they feel comfortable.
Most people who also show up at the psychiatrist you mean? Aka not most people who habitually smoke marijuana?No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.
I think this is more variable than you're implying. Yes, there are going to be those who largely have a pre-disposition to substance abuse which we treat directly. However, there are also people who use those substances as a means of coping with trauma or psychosocial stressors and whose best treatment courses are to address those factors. I think the best way to address this (at least initially) is with a strong social history which is unfortunately a highly variable practice from what I've seen thus far.
While a common clinical theory, the data does not support this idea.
What is supported is that there are people who are trait vulnerable to substance abuse, with some variations in substances. In those specific individuals who are already abusing substances, state anxiety can increase some forms of substance abuse. Which in most substances increase anxiety in the long run. This is very different that the anxiety causing substance abuse, which had never existed prior. The data does not support that treatment of the psychiatric disorder alone results in significant changes in substances abuse.
This may sound very technical, but there are significant treatment and social implications.
Except the substance use is relevant if it's causing dysphoria and interfering with the prescribed medication's effectiveness. These are not always independent of one another and it is certainly. If the medication is ineffective independent of pot use, then it obviously shouldn't be used anyway, but that's not really the point of this thread.
When it becomes apparent that my patients are lying to me, I confront them about it and ask why. On the other hand, how can I expect patients to trust me if I’m just going to assume things about their motives?To the second bolded: it's not really pointless at all, and I'd argue that it should be something you follow up on. Are they lying to score more and divert? Are they lying because of general underlying trust issues which they should be seeking therapy for? Are they lying because they have a personality disorder that hasn't been addressed/documented? Are they lying because they have a true use disorder and would benefit from treatment? Obviously you can't force them to tell the truth, but I think ignoring it or failing to dig a little deeper is doing the patient a disservice.
If you're telling me that all people with substance abuse problems associated with mood disorders have trait variability and that treating the underlying mood disorder can never lead to resolution of the substance abuse (which sounds like what you're implying), then I'll say your theory is either missing something or there's not enough data. As I don't believe for a second that every single individual with substance abuse issues related with mood disorders are due to trait variability.
You’re the one bringing up things that were not specifically part of the topic of this conversation. I was never talking about people in whom the medication wasn’t working because of the substance use. Additionally, the case that a medication that has never worked for someone is only not working because of the substance use is usually an entirely speculative one. In my experience, this is usually an argument made for affective illness (i.e. the antidepressant never had a chance because they’re continuing to abuse crack). If one is being really honest about such cases, though, they would admit that they don’t really know this and actually have no idea. With limited exception, our mood drugs are not so predictable in generating response that someone can make this case with any degree of actual certainty.
You’re right that in such cases where the medication is not working and the person is using drugs, the medication should be stopped. But I don’t think the drugs are really relevant in that decision. The medication should be stopped either way because it was never noted to be effective. The substance use might be relevant later if you’re considering a repeat trial when the person stops using drugs but that’s not actually the decision we were talking about.
If you’re talking about a situation where a medication was initially effective but then lost its efficacy when someone started using drugs then an ultimatum might be appropriate. That said, this is a very specific circumstance and the appropriateness of the ultimatum has nothing to do with some stupid moralistic take on substance use and everything to do with the logical validity of the assertion that the person can either stop drugs and use the medication or continue using drugs and stop the medication because it makes no sense to continue to prescribe the medication in circumstances known to make the medication ineffective.
It's not my theory, it's the current state of the literature.
And yours doesn't hold up. Unless you try to treat methamphetamine induced anxiety disorder by treating the anxiety alone.
I don't follow what you mean here.Most people who also show up at the psychiatrist you mean? Aka not most people who habitually smoke marijuana?
Why does anyone get prescribed benzos long term anymore anyway?[
You dramatically overestimate the legal risks here, at least wrt marijuana. Our early psychosis service would have have to close down that doesn't mean none of them get benzos in an appropriate fashion.
You need to be writing high volumes of controlled scripts for the DEA to care. Do read accounts of board or federal enforcement actions to get a better sense of the circumstances under which action is taken.
Someone getting 1 mg Klonopin daily who smokes weed a few times a day ain't it.
[/QUOWhat
Ok, but first you have to try the weed/cocaine/cigarette/meth/heroin etc. (leaving out caffeine and etoh since they are generally accepted ). Don’t you think there is a reason certain people are even willing to try something they know is harmful? I do realize that substance abuse can be generational and use can be started at a very young age, but That’s not always the caseWhile a common clinical theory, the data does not support this idea.
What is supported is that there are people who are trait vulnerable to substance abuse, with some variations in substances. In those specific individuals who are already abusing substances, state anxiety can increase some forms of substance abuse. Which in most substances increase anxiety in the long run. This is very different that the anxiety causing substance abuse, which had never existed prior. The data does not support that treatment of the psychiatric disorder alone results in significant changes in substances abuse.
This may sound very technical, but there are significant treatment and social implications.
Some practicing psychiatrists are in their 80s.Why does anyone get prescribed benzos long term anymore anyway?
for many people, it's practically a cultural expectation for them to lie to their doctors, particularly about "certain" things and particularly if they think those things "won't matter that much."