Prescribing controlled substances to patients with dual diagnosis

[lockian]

I just accepted a job in an area that's relatively underserved and fraught with substance use.

I know the standard of care and where I stand on things. I have no issue with controlled substances as long as they are indicated and proper monitoring is observed (treatment contracts, UDS, pill counts, the whole shabang.) I would not start controlled substances on someone who is actively using to the point of being unable to pass a planned UDS. (Appointment = UDS, you can plan for that). If someone is already on a controlled med, I would taper it in anyone I catch using drugs or misusing prescriptions. In the spirit of being reasonable and collaborative, I'd give patients the chance to demonstrate sobriety for 3 mos via consecutive UDS, and then consider reinstatement. If someone's actively in drug treatment, I would consider controlled substances, but not as a go-to.

The downsides:
I have inside info that one of my future practice partners is a candyman. That in and of itself is not the worst thing in the world, as long as I'm careful in my documentation of refills if and when I cover for him. Based on their coverage system, I'm highly unlikely to have to cover for him.

Explicitly, I've been told there are likely to be patients with SUD, many of whom have no desire to get sober. I've also been told that there are likely to be people inherited from... let's just say unorthodox prescribers in the community. I also know someone recently left the practice because they got burned out on power-struggles with patients on inappropriate inherited regimens.

Questions:
1. Has anyone been in a situation where their institution or practice partners didn't support their clinically appropriate prescribing practices? I don't have to practice like Dr. Candyman down the hall, but if I'm going to be pressured to adopt his style, I'm out.

2. Any experiences dealing with patients who have either SUD+controlled substances or inherited inappropriate regimens in a setting where patients *couldn't* go elsewhere? In private practice, if they leave you can be sure they'll probably find someone else, but at safety net institutions patients have nowhere else to go.

3. Tips for not getting burned out when dealing with the above patients?

PS:
It's a challenging job, but it's important work to me, and I'll be paid handsomely for my trouble. The general practice environment has a lot of good things about it, too, i.e. 30 minute appointments (!), stellar nursing support, lots of different types of therapy in-house, etc. I'd rather not renege on my offer. I at least want to give it a try.

---

Members don't see this ad.

 

[dl2dp2]

Do you have addiction specific training? Your answers don't have straightforward yes/no answers and vary depending on what SUD and what controlled substance you are talking about.

Buprenorphine is a controlled substance. Methadone is a controlled substance.

There's very high-quality evidence that says treating people's ADHD with longer-acting stimulants prevents relapse, and at least does not promote abuse/diversion. In particular, for cocaine, there's now solid evidence that says high dose stimulant reduce heavy using days.

It's in general probably beneficial to use ambien or klonopin for cannabis use patients who are interested in cutting down and treat them symptomatically.

Do you know how to do outpatient alcohol detox with 4-10mg daily of Klonopin and a supervised taper?

I would argue that the correct answer to Mr. Candyman is to have an evidence-based practice policy, not interpersonal conflict. If the clinic you are signing on doesn't have the right expertise, it's best to get someone who does to write the policy and then follow it.

 

[Sushirolls]

Remeron before ambien/klonopin for Cannabis.

 

[Stagg737]

Do you know how to do outpatient alcohol detox with 4-10mg daily of Klonopin and a supervised taper?

I’ve heard people refer to a supervised taper quite a few times but to me this means inpatient. How do you supervise it as outpatient? Make them come back to clinic daily for monitoring? Give X days of meds at a time? This just seems like a legal disaster waiting to happen to me...

 

[lockian]

Do you have addiction specific training? Your answers don't have straightforward yes/no answers and vary depending on what SUD and what controlled substance you are talking about.

Buprenorphine is a controlled substance. Methadone is a controlled substance.

There's very high-quality evidence that says treating people's ADHD with longer-acting stimulants prevents relapse, and at least does not promote abuse/diversion. In particular, for cocaine, there's now solid evidence that says high dose stimulant reduce heavy using days.

It's in general probably beneficial to use ambien or klonopin for cannabis use patients who are interested in cutting down and treat them symptomatically.

Do you know how to do outpatient alcohol detox with 4-10mg daily of Klonopin and a supervised taper?

I would argue that the correct answer to Mr. Candyman is to have an evidence-based practice policy, not interpersonal conflict. If the clinic you are signing on doesn't have the right expertise, it's best to get someone who does to write the policy and then follow it.

I'm mostly talking about BZDP's and stimulants. There'll be no expectation of prescribing any others, though I do have a buprenorphine waiver. I don't have an AODA fellowship, just what exposure I had in residency. But the guy I trained under in residency was a draconian who basically assumed everyone was diverting and getting high all the time. I don't really want to replicate his exact approaches. I do not know how to do an outpatient alcohol detox with clonazepam, and even if I did, I wouldn't do it for the reasons @Stagg737 mentioned.

I'm aware of the evidence for treating ADHD to prevent relapse and promote adherence to SUD treatment. I would generally give BZDP's or stimulants to people if they are indicated and if the person is willing to pursue sobriety or at least cut down.

The trouble is with patients who have no interest in cutting down or quitting, and still want to stay on their ridiculous regimens from Dr. Recently Retired Candyman In The Community. But the intuitive thing there is MI, education, discussion of alternatives, and taper.

 

[Jules A]

If it is as you describe I would not count on this being a long term situation unless they are getting rid of the problematic doc and acknowledge the prescribing has been unsafe and non-therapeutic. It would be rare that admin currently allowing this will support a judicious prescribing style and even if they do you will literally get beat down by the patients which will likely include threats and possibly actual reports to the board. From what I hear reports to the board even if frivolous are a huge pita. You will also need every second of the 30 minute f/u to thoroughly document. Everything you described would make it a no go for me, even at a high rate. I'm a hound for the dollar but will never put myself in a situation like this again even for a short term high paying contract.

 

[clausewitz2]

I’ve heard people refer to a supervised taper quite a few times but to me this means inpatient. How do you supervise it as outpatient? Make them come back to clinic daily for monitoring? Give X days of meds at a time? This just seems like a legal disaster waiting to happen to me...

In our system we have a very robust ambulatory detox program so I can speak somewhat to this. You can make them come daily or at very regular intervals to the clinic for monitoring and short term prescriptions. Extensive education about withdrawal side effects. Being comfortable taking vitals correctly. Being very clear about what will happen if meds get "lost".

A lot of the risk management meat is in the initial eval. At least around here any history suggesting complex withdrawal means you are not eligible, so anyone who has seized before gets sent to a higher level of care for detox. But it is a hugely helpful program for people who want to keep living a life while they work on getting a handle on their drinking.

 

[Merovinge]

Remeron before ambien/klonopin for Cannabis.

I like this idea a lot given the anorexia, poor sleep, and anxiety are in best cases the exact three things Remeron works best for and it's relatively rapid compared to SSRIs, although certainly less than direct GABA drugs. Is there evidence for using it this way?

 

[Sushirolls]

Limited.

Clinically I find it works quite well, whether its a PRN, or scheduled used.

I'm also averse to prescribing benzos and z drugs for any reason.

 

[lockian]

If it is as you describe I would not count on this being a long term situation unless they are getting rid of the problematic doc and acknowledge the prescribing has been unsafe and non-therapeutic. It would be rare that admin currently allowing this will support a judicious prescribing style and even if they do you will literally get beat down by the patients which will likely include threats and possibly actual reports to the board. From what I hear reports to the board even if frivolous are a huge pita. You will also need every second of the 30 minute f/u to thoroughly document. Everything you described would make it a no go for me, even at a high rate. I'm a hound for the dollar but will never put myself in a situation like this again even for a short term high paying contract.

Someone's got to do this type of work, though. I wonder how they manage.

 

[clausewitz2]

Someone's got to do this type of work, though. I wonder how they manage.

They're really comfortable saying "no" and DEAR MAN the h*ll out of the resulting conversation. Efficient but thorough documenters. Probably helps to be genuinely concerned about the consequences of not changing things rather than having the attitude of "f**king drugseekers" regardless of the words that you say, many people can pick up on the difference. I was going to say you probably enjoy being classically withholding but I actually think it would be too hard to keep an edge of glee or smugness from creeping into your manner.

 

[Jules A]

Someone's got to do this type of work, though. I wonder how they manage.

I'm not sure what you mean about this type of work? Dual diagnosis? Socioeconomic inequities? Both? Of course many work in these settings. I do a combination of inpatient and outpatient inner city but will not work at a poorly run clinic that embraces inappropriate prescribing. If you are going to attempt an overhaul of the practice's policies that will be difficult but noteworthy however if you think you can go there and work in a silo that is probably unrealistic. Maybe others can share positive experiences of working at a clinic with inappropriate prescribing.

 

[Sushirolls]

I worked at a place that the other docs and 'providers' had a range of benzos and z drugs. When they were out on vacation I got their refills. Would either do 30 day supply or a few days until that person came back in the office, noted on Rx and in chart, covering provider, and documented if any concerns about use, also looked up the Rx monitoring program too. Wasn't much of an issue. Except on those coverage days. Always a shock to go from 0 benzos to having a bunch piled in a short time span.

 

[lockian]

I'm not sure what you mean about this type of work? Dual diagnosis? Socioeconomic inequities? Both? Of course many work in these settings. I do a combination of inpatient and outpatient inner city but will not work at a poorly run clinic that embraces inappropriate prescribing. If you are going to attempt an overhaul of the practice's policies that will be difficult but noteworthy however if you think you can go there and work in a silo that is probably unrealistic. Maybe others can share positive experiences of working at a clinic with inappropriate prescribing.

Well, there is only one doc of several who prescribes poorly. Just because he does, doesn't mean it's embraced, or that the place is poorly run. I believe a lot of clinics have one or two "bad apples" who prescribe poorly. Even highly reputable places like my residency program. This particular department has existed for <5 years, so prescribing culture and policies are still at a malleable phase. I did, perhaps naively, express the desire to take on a leadership role in shaping the future of the practice.

My concern was less about that doc and more about SUD patients who are transferring in from other institutions on wild west regimens. There seem to be a lot of people who have been cared for by a PCP who didn't know what they were doing, or by aging docs with solo practices who retired. That's the type of work I meant - inheriting people who are using and on questionable regimens and have no desire to change. @clausewitz2 answered my question well. A doc who was recently there got burned out on power struggles with the patients. But at the end of the day, it's only a power struggle if you let it be a power struggle.

 

[lockian]

I'm not sure what you mean about this type of work? Dual diagnosis? Socioeconomic inequities? Both? Of course many work in these settings. I do a combination of inpatient and outpatient inner city but will not work at a poorly run clinic that embraces inappropriate prescribing. If you are going to attempt an overhaul of the practice's policies that will be difficult but noteworthy however if you think you can go there and work in a silo that is probably unrealistic. Maybe others can share positive experiences of working at a clinic with inappropriate prescribing.

That said, I appreciate how transparent you have been about the potential pitfalls of certain clinic environments.

 

[Jules A]

That said, I appreciate how transparent you have been about the potential pitfalls of certain clinic environments.

Its interesting and encouraging to hear from @Sushirolls that he wasn't bothered by it where he worked. Please keep us posted and I hope you decide to take on a leadership role and are able to improve things.