Saying "No" to medication

[wolfvgang22]

So, as many of you probably do, I see a lot of patients who want an immediate, quick fix for anxiety. I try to practice evidence based psychiatry, so I avoid long term benzos. Many patients I see in the VA put in the bare minimum of effort in psychotherapy, or lack the predisposition to participate in therapy, though we have lots of good therapists.

Today I got a 50 year old male patient who has alcoholism in early remission (3 months sober after 25 years of drinking), labeled as Anxiety Disorder NOS, Depressive Disorder NOS. He is on Citalopram 40mg PO QAM, and Doxepin 100mg QHS for the past 4 weeks. He feels these have been helpful, but still complains of anxiety. He had been on Acamprosate 666mg PO TID, but felt this had no effect whatsoever, and wasn't taking it anymore. He also had been on Hydroxyzine 25mg PO TID but complained this worsened irritability and caused some daytime sedation, so he quit taking it. He asked to continue the Citalopram and Doxepin, because he says some other antidepressant medications in the past caused intolerable side effects or he was drinking and they didn't work. He then asked for "something else" to make anxiety go away "right now." I declined to change his meds and referred him for weekly therapy with the psychologist, and told him to keep attending AA.

So, of course the gentleman was very disappointed I did not come up with an instant cure for his anxiety. Maybe a lot of this is my own counter transference, but I feel in my gut this patient who has alcoholism is just looking for another way to self medicate away all his problems ( no job, poor social skills, etc.) Based on past experience, I think he is going to continue to have chronic anxiety. I'm not sure he is even intellectually able to get much out of CBT, anyway, he is a concrete thinker of low average intelligence. I imagine he will respond better to an interpersonal or problem solving approach ( I hope).

To the point: how do you deal with such patients who want an instant cure? I feel a bit like I failed, but I still think refusing to throw yet another medication at this patient is the right choice right now. That would be typical VA care and I'm trying to avoid that.

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[smalltownpsych]

Right on the money with this. Tell him that the only way to deal with anxiety is to face it, not avoid it or try to make it go away. It's called exposure therapy. If he wants a better life, then he will do what it takes. Medication will not take away all of his emotional distress the way a few shots of liquor will. He needs to know that 25 years of drinking and screwing up your life won't get better after a few months. After a year, he might actually begin to feel better on a consistent basis, especially if he tries learning other methods for coping. In five years, he might be as good at coping with life as the average non-addict. It takes time and work.

 

[Merovinge]

Right on the money with this. Tell him that the only way to deal with anxiety is to face it, not avoid it or try to make it go away. It's called exposure therapy. If he wants a better life, then he will do what it takes. Medication will not take away all of his emotional distress the way a few shots of liquor will. He needs to know that 25 years of drinking and screwing up your life won't get better after a few months. After a year, he might actually begin to feel better on a consistent basis, especially if he tries learning other methods for coping. In five years, he might be as good at coping with life as the average non-addict. It takes time and work.

Agreed. I always told my VA vets with sub abuse that getting clean for x weeks is amazing/fantastic but that the road is long and that the treatment team be there with them the whole way but it sure as hell won't be easy and things will have to be different than when they were using. I think sub abuse vets compared to any cohort appreciate straightforwardness and they definitely need a huge helping of compassion as well.

 

[PistolPete]

I would have done exactly what you did. Good job. Sometimes it's very hard NOT to write for an additional med, but it's often the right thing to do.

 

[OldPsychDoc]

All that said, the anxiety puts him at high risk for relapse and other bad things.
Will the VA let you prescribe baclofen or gabapentin? Decent evidence and low risk.

 

[WisNeuro]

"Xanax/Valium is the only thing that works!"

 

[Merovinge]

All that said, the anxiety puts him at high risk for relapse and other bad things.
Will the VA let you prescribe baclofen or gabapentin? Decent evidence and low risk.

I was approved gabapentin for EtOH dependence related anxiety at my VA. Absolutely agree that some evidence and much lower risk then benzos is a good thing. I also like trazodone for sleep if they need help sleeping, which is most ex-alcoholics.

 

[wolfvgang22]

Sorry, I did not mention he is already on Gabapentin 400mg QAM and Qnoon and 900mg QHS from primary care for polyneuropathy. He doesn't think it helps much with anxiety or polyneuropathy.

In fact, I have few veterans not on Gabapentin from primary care. Since the FDA tightened regulations on opiates (hydrocodone/apap), everyone is now getting more muscle relaxers and gabapentin and lyrica from primary care. I'm sure he will go get some Tramadol at some point from our ER later, so I can worry about serotonin syndrome (I'm being a little sarcastic here.)

Trazodone 50mg QHS caused too much morning grogginess in this patient before. I am not sure I want to add Trazodone back at 25mg QHS while he is taking Doxepin 100mg QHS and Citalopram 40mg QAM. I'm not certain low dose Trazodone would out perform the Doxepin for anxiety or insomnia, so I didn't consider stopping the Doxepin for something else for very long today, especially since he says it has helped him some. I do consider serotonin syndrome and prolonged QTc as risks. I don't think the citalopram is causing activation in this patient, though I could be wrong.

I did not get the feeling this patient was fishing for benzos. He, like many patients, just wants a cure right now, with minimal effort. I'm under immense pressure to make sure every single veteran is satisfied with his care by the VA, but it doesn't look like that is going to happen.

 

[Shikima]

Add on Buspar 7.5mg TID and increase from there. Weekly therapy as you suggested.

The hard part is digging your heels in and saying no to BZD and no to quick fixes. He tried that already and ended up as an alcoholic. Enough already with the poor life skills and remind him that anxiety is very uncomfortable but it will not kill him!

A side note; The 70+ y/o person who has been on a "nerve pill" since the 90s for anxiety and coming off of it now is even more difficult than the VA alcoholic.

 

[birchswing]

I don't think wanting to fix a problem is the same thing as wanting something deleterious. It just happens to be that the most effective anti-anxiety agents are deleterious in the long run.

All those years on alcohol, his GABA-A receptors would be desensitized. The concrete thinking is common in ex-alcoholics. With protracted benzodiazepine withdrawal (long after a person has stopped), there is investigational use of low-dose flumazenil to "flush" and re-sensitize the receptors to be receptive to endogenous GABA. Could presumably help alcoholics, as well? I'm sure there are tons of other alternative treatments. Ones that come to mind are NAC, fish oil, phosphatidylserine. Anything to target an over-excited glutamergic system.

Wanting to fix the problem is not necessarily the same as wanting "a fix." And wanting to keep searching for something that works is not a bad thing, even if you don't immediately know what that solution is.

It seems like instead of trying to find something to treat "anxiety" it might be better to find something to treat the damage already caused by the alcohol. That's the path I would be looking at least.

EDIT: Also saw you mentioned SS. As someone recently diagnosed, it was treated as if it were anxiety, tachycardia NOS, and high blood pressure for years. Going down on Paxil is changing my life in wonderful ways. Your patient is on two serotonergic drugs, and mild SS can present as anxiety.

EDIT 2: Saw he already tried anti-glutamergic drug with acamprosate. Hmm...

 

[wolfvgang22]

Yeah, acamprosate seems to help about 1/3 of the patients with alcoholism who have received it in my practice. Same for Naltrexone. Following guidelines, I offer one of these medications to every patient in recovery from alcohol. Most patients take these agents for a couple of weeks, then stop while continuing their antidepressant, telling me the antidepressant at least does something.

 

[F0nzie]

A cognitively limited guy in a protracted withdrawal state trying to put an end to 25 years of self destruction. I can't help but feel great admiration for this guy. The psychotherapy referral was the right move, along with massive praise.


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[splik]

Yeah, acamprosate seems to help about 1/3 of the patients with alcoholism who have received it in my practice. Same for Naltrexone. Following guidelines, I offer one of these medications to every patient in recovery from alcohol. Most patients take these agents for a couple of weeks, then stop while continuing their antidepressant, telling me the antidepressant at least does something.

The evidence shows naltrexone works when you prescribe it to patients who are still drinking alcohol. It doesn't really make sense that it would be all that helpful if you aren't drinking alcohol (as the whole point is that it blocks the reinforcing pleasurable effects of alcohol via the endogenous opioid system and then reduces cravings). It is not going to be able to do this if you start on it abstinent from alcohol. I do recall reading some years ago that this was supported by the research but can't remember where I read this now so if anyone has a link that would be great. Also IIRC the data suggests naltrexone is more effective at helping reduce alcohol intake rather than for abstinence though I certainly have had some patients who feel it has helped promote abstinence, though many more who aren't sure what it is doing but take it anyway.

I don't think that we should force people into therapy if they don't want it. We can certainly work to explore what people want but the reality is it is only helpful for a minority of patients, and many patients really do have limited capacity to benefit from psychotherapy because of their lack of psychological mindedness, cognitive difficulties, cognitive inflexibility etc or because their lives are such as cluster**** that it is unlikely that therapy is going to be all that more helpful than is medication. Michael Balint said the most powerful drug is "doctor", that we are essentially a medication that the patient takes in.

Many of our patients dont "get" the concept of exposure therapy and pushing too hard too fast is unlikely to be helpful. I would try to reflect back his feelings that feeling anxious seems so terrible he just wants relief right now. That you would love to be able to cure his anxiety just like that, and if such as cure existed you would give it to him, but you would also likely be a billionaire if you had the secret to it. You might consider introducing him to the idea that he has been so used to dulling away at his feelings with alcohol for so long that he can't deal with normal emotions and that anxiety is a warning signal that something is wrong in our life, that the threat of loss looms large and we need to understand what is making us feel that way rather than trying to obliterate it. But for some patients that is just gonna go way over their heads.

I think it is natural to be torn between not wanting to feed in to gratifying their phantasy for obliteration of emotions versus entering a countertransference enactment as the cold, withholding parent but sometimes gratifying the wish might be appropriate. I really feel you about not wanting to add to the polypharmacy and break the cycle, but have reasoned sometimes it is the least worse situation. What I tend to do is say "look, you want relief from your suffering. you want to obliterate your feelings. but those feelings are coming from somewhere, your life is a mess right now. I'm not sure there is a pill that's gonna make everything better. Now we can try x if you really want, but my recommendation is we wait it out, or better still I'd love it if you met with our psychologist to look at the things in your life that are making you feel this way and problem solve." If they choose the drug, I've given my disclaimer while maintaining the alliance. It will be more inclined to prescribe early in the course of treatment when the goal is to keep them engaged and given them a positive experience, and will be more confrontational later in the course of the relationship.

 

[tr]

To the point: how do you deal with such patients who want an instant cure? I feel a bit like I failed, but I still think refusing to throw yet another medication at this patient is the right choice right now. That would be typical VA care and I'm trying to avoid that.

Reflection, Empathy, Stroking, I-Feel, Inquiry.

Don't let him put you in the position of being the antagonist who withholds his access to what he wants. Position yourself on his side, where you belong. Refuse to accept his implied accusation that you are withholding an effective treatment. E.g.,

"It sounds like you are really suffering badly from the anxiety and you wish I had an instant cure for you, maybe even something that feels as good as alcohol used to feel when you were still drinking.
I really wish I had a miracle cure for your anxiety. I feel badly that I don't have something safe and instantly effective to offer you. I would love it if such a thing existed.
At the same time, I think you've done a fantastic job staying sober; I know it's been really hard and I am doing the best I can to help and support you in maintaining sobriety and managing your anxiety.
Psychotherapy is hard work but it is absolutely the most effective and long-lasting intervention. I am confident in your ability to stick with psychotherapy and I am sure you will see the benefits soon.
I really admire the work you've put into managing your mental health and I feel honored to be able to help you with this. Is there anything else you'd like to tell me about how you feel about this approach?"

 

[tr]

Whoops I see splik beat me to it.
By the way who put your patient on 40 mg Celexa plus tid Atarax? Those have a cardiac interaction.

 

[wolfvgang22]

As far as polypharmacy goes in VA patients, this combo isn't that bad so I'm not calling anyone out over it, just moving forward. I worried a little less about cardiac interaction than hyponatremia/ SIADH with this combo.

Why? Because I saw a different gentleman on an SSRI and Depakote yesterday with new onset hyponatremia of 117 from the previous day's primary care visit lab which I noted on my review of the chart. Either the IM doc in primary care was not impressed or didn't see it, I don't know. I ordered a repeat CMP and found his non fasting glucose was over 1,100 ( he says he ate 4 hours before lab), Na still 117, so I figured hyperglycemia as the probable the cause and sent him to the ER. He is not diagnosed with diabetes (yet). He was completely asymptomatic and said he felt fine but I made him go to the ER anyway.

 

[smalltownpsych]

The evidence shows naltrexone works when you prescribe it to patients who are still drinking alcohol. It doesn't really make sense that it would be all that helpful if you aren't drinking alcohol (as the whole point is that it blocks the reinforcing pleasurable effects of alcohol via the endogenous opioid system and then reduces cravings). It is not going to be able to do this if you start on it abstinent from alcohol. I do recall reading some years ago that this was supported by the research but can't remember where I read this now so if anyone has a link that would be great. Also IIRC the data suggests naltrexone is more effective at helping reduce alcohol intake rather than for abstinence though I certainly have had some patients who feel it has helped promote abstinence, though many more who aren't sure what it is doing but take it anyway.

I don't think that we should force people into therapy if they don't want it. We can certainly work to explore what people want but the reality is it is only helpful for a minority of patients, and many patients really do have limited capacity to benefit from psychotherapy because of their lack of psychological mindedness, cognitive difficulties, cognitive inflexibility etc or because their lives are such as cluster**** that it is unlikely that therapy is going to be all that more helpful than is medication. Michael Balint said the most powerful drug is "doctor", that we are essentially a medication that the patient takes in.

Many of our patients dont "get" the concept of exposure therapy and pushing too hard too fast is unlikely to be helpful. I would try to reflect back his feelings that feeling anxious seems so terrible he just wants relief right now. That you would love to be able to cure his anxiety just like that, and if such as cure existed you would give it to him, but you would also likely be a billionaire if you had the secret to it. You might consider introducing him to the idea that he has been so used to dulling away at his feelings with alcohol for so long that he can't deal with normal emotions and that anxiety is a warning signal that something is wrong in our life, that the threat of loss looms large and we need to understand what is making us feel that way rather than trying to obliterate it. But for some patients that is just gonna go way over their heads.

I think it is natural to be torn between not wanting to feed in to gratifying their phantasy for obliteration of emotions versus entering a countertransference enactment as the cold, withholding parent but sometimes gratifying the wish might be appropriate. I really feel you about not wanting to add to the polypharmacy and break the cycle, but have reasoned sometimes it is the least worse situation. What I tend to do is say "look, you want relief from your suffering. you want to obliterate your feelings. but those feelings are coming from somewhere, your life is a mess right now. I'm not sure there is a pill that's gonna make everything better. Now we can try x if you really want, but my recommendation is we wait it out, or better still I'd love it if you met with our psychologist to look at the things in your life that are making you feel this way and problem solve." If they choose the drug, I've given my disclaimer while maintaining the alliance. It will be more inclined to prescribe early in the course of treatment when the goal is to keep them engaged and given them a positive experience, and will be more confrontational later in the course of the relationship.

Psychotherapy should almost never be forced or coerced. I disagree that concrete thinkers or less intelligent patients won't benefit from psychotherapy. It is better to say that they won't benefit from insight oriented therapy or being told what to do by a therapist who is caught up in a paternal enactment be used they know better than their stupid patient. I often have some of my greatest successes with lower functioning patients and would be even more successful if I could get them off the polypharmacy regimen that the incredibly intelligent provider put them on cause they think a trauma response from a low IQ patient is a psychotic episode.

I was a little blunter in my delivery of exposure therapy than I typically am with patients, but sometimes that directness is needed and welcomed. It takes a long time to get past the hope that there is a medicine that will work unfortunately and it is shortened if the one prescribing has solid psychotherapy skills as well cause then they know how to play the game as some of the posters in this thread clearly do. Unfortunately, my patients don't have access to that type of sophisticated psychiatric care. They just get pills and told what to do.

 

[WisNeuro]

Psychotherapy should almost never be forced or coerced. I disagree that concrete thinkers or less intelligent patients won't benefit from psychotherapy. It is better to say that they won't benefit from insight oriented therapy or being told what to do by a therapist who is caught up in a paternal enactment be used they know better than their stupid patient. I often have some of my greatest successes with lower functioning patients and would be even more successful if I could get them off the polypharmacy regimen that the incredibly intelligent provider put them on cause they think a trauma response from a low IQ patient is a psychotic episode.

Especially for CBT based treatments for anxiety. There isn't much research out there, but what is out there suggests high levels of effectiveness irrespective of intelligence. Specifically, a few studies looking at more fluid intelligence. Yeah, the "quick fixes" generally end up doing more harm than good for these patients. Might as well just write them a letter for an emotional support animal and some reiki while we're at it.

 

[wolfvgang22]

I apologize for the low average intelligence remark, I'm wrong to underestimate the patient. I appreciate your comments. I remember doing DBT with a patient with intellectual disability as a resident, and the mindfulness techniques and group therapy really did help her a lot.

 

[splik]

Psychotherapy should almost never be forced or coerced. I disagree that concrete thinkers or less intelligent patients won't benefit from psychotherapy. It is better to say that they won't benefit from insight oriented therapy or being told what to do by a therapist who is caught up in a paternal enactment be used they know better than their stupid patient. I often have some of my greatest successes with lower functioning patients and would be even more successful if I could get them off the polypharmacy regimen that the incredibly intelligent provider put them on cause they think a trauma response from a low IQ patient is a psychotic episode.

I was a little blunter in my delivery of exposure therapy than I typically am with patients, but sometimes that directness is needed and welcomed. It takes a long time to get past the hope that there is a medicine that will work unfortunately and it is shortened if the one prescribing has solid psychotherapy skills as well cause then they know how to play the game as some of the posters in this thread clearly do. Unfortunately, my patients don't have access to that type of sophisticated psychiatric care. They just get pills and told what to do.

I never said anything about intelligence or concreteness so I don't know why you quoted my posted!

 

[smalltownpsych]

I never said anything about intelligence or concreteness so I don't know why you quoted my posted!

My mistake. I was reading that into it when you were talking about why some wouldn't benefit from psychotherapy for a variety of reasons. As I reread it, I get what you were saying and agree with the gist of it. Still glad I posted what I did because it is a misperception I have run into before with other clinicians.

 

[PikminOC]

I do not give people meds I'm not comfortable giving. Drug seekers can find another sucker

 

[Ceke2002]

I apologize for the low average intelligence remark, I'm wrong to underestimate the patient. I appreciate your comments. I remember doing DBT with a patient with intellectual disability as a resident, and the mindfulness techniques and group therapy really did help her a lot.

I was going to mention mindfulness, I've found it especially useful for not only initially reducing, but eventually completely stopping certain unhealthy coping habits. For me it worked for cutting - even after practicing it for just a few minutes a day over a very short period of time I was noticing I was getting the same benefit, if not more, in terms of stress reduction that an obviously negative coping mechanism was giving me. After a while it just began to seem like a huge head blank whenever I was getting to a certain stress breaking point to pull out my blades, get everything ready, blah blah blah, get maybe 15-30 minutes relief max while I faffed about cleaning and sticky plastering myself up, before falling into a pit of shame and embarrassment, when I could just sit comfortably for a few minutes, practice a mindfulness meditation and get the same or better amount of benefit.

I could see it potentially applying to a situation where alcohol was the unhealthy coping mechanism that needed to be replaced with something healthier as well.

 

[PikminOC]

I haven't used doxepin. Is it helpful for sleep? Not worried about that side effects?

 

[thoffen]

If you can avoid them latching on to the impression your motivation is to deny them benzos, you can try to come to a mutual understanding of the problem first. Otherwise, you have to be frank about no benzos now or ever and offer them every opportunity to understand why, their side of things, and alternatives.

If you can find a collaborative spot, the key is to understand your interest is treating their anxiety disorder rather than their symptom of anxiety only because if you do otherwise you expose them to risks of medication for short term benefit that will only reinforce the anxiety coming back worse.

Separately, there are some people on long term low dose benzos that seem to do well.

 

[wolfvgang22]

I haven't used doxepin. Is it helpful for sleep? Not worried about that side effects?

Doxepin 10mg PO QHS has been very helpful for many of my patients with insomnia. I haven't seen a lot of adverse events reported with it compared to other meds.

Most patients have already trialed Melatonin, Gabapentin, then Trazodone, hydroxyzine, amitriptyline, low dose seroquel, in usually that order, and been educated on sleep hygiene practices by other prescribers before I see the patient. When they then go to primary care and ask for an increase in Zolpidem for sleep, the PCP refers to psychiatry. Doxepin is usually one thing they didn't try yet. I also prescribe mirtazepine frequently. I keep encouraging CBT-I, but patients won't commit to it.

 

[WisNeuro]

I keep encouraging CBT-I, but patients won't commit to it.

Which, is sad. For many of the people I've seen actually go through the full course of it, it can be life changing. As opposed to the people I see on maintenance sleep meds who still usually report terrible quality sleep, and now hangover effects in the morning. Don't even get me started on my older patients who are sometimes inexplicably prescribed benadryl for sleep...

 

[wolfvgang22]

Which, is sad. For many of the people I've seen actually go through the full course of it, it can be life changing. As opposed to the people I see on maintenance sleep meds who still usually report terrible quality sleep, and now hangover effects in the morning. Don't even get me started on my older patients who are sometimes inexplicably prescribed benadryl for sleep...

Low dose benadryl may be the less bad option for some Geri patients compared to some of the sleep meds I mentioned already. If CBT-I is not palatable to these patients, the alternative is to not prescribe at all. I am ok with that, but my employer really, really doesn't like and believes they can't afford patient complaints, to the point I'm pretty sure a prescriber who says "no" to prescribing medication for insomnia frequently enough will be encouraged to move on, though overtly it is said safety comes first. Maybe I'm wrong, and just paranoid?

 

[WisNeuro]

Low dose benadryl may be the less bad option for some Geri patients compared to some of the sleep meds I mentioned already. If CBT-I is not palatable to these patients, the alternative is to not prescribe at all. I am ok with that, but my employer really, really doesn't like and believes they can't afford patient complaints, to the point I'm pretty sure a prescriber who says "no" to prescribing medication for insomnia frequently enough will be encouraged to move on, though overtly it is said safety comes first. Maybe I'm wrong, and just paranoid?

This is one of the most common meds I see causing anticholinergic effects in my elderly patients, this and oxybutynin. As soon as we take them off those, find an alternative, it's amazing how much their cognition improves.

 

[666357]

Why not keep it simple and increase his Neurontin?

 

[masterofmonkeys]

1) I talk with them about the long-term alterations in biochemistry from alcoholism, as well as the fact that they likely had anxiety before. We talk about how PRN medications especially the ones that 'work' will actually compound, worsen, and sustain th poor biochemistry. Meaning benzos would literally make him sicker nad I wasn't going to do that to him.

2) We talk about timeframes. 6mos-2 years for improved gaba/glutamate balance following chronic EtOHism.

3) We normalize anxiety as something everyone will deal with (I also do this for pain), and that 'getting rid of' anxiety is not a reasonable goal since our brains were literally designed to feel it (depending on intellectual curiosity/ability, may go into an explanation of various structures including SNS and limbic system), and that our goal is to find a way to make anxiety a 'normal' and not overwhelmig experience. Mindfulness and ACT principles brought up at htis point.

4) Praise the crap out of him and tell him you believe in him. I'm not opposed to some ego-lending early on in treatment.