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Stimulants and benzos

Discussion in 'Psychiatry' started by resident1985, Nov 30, 2017.

  1. resident1985

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    Been reading previous threads on the use of these meds together. My take is that these meds are antagonistic and I don’t prescribe them together. Searching the forum because I’m inherenting patients on both and there’s a subset of people saying it is reasonable to use them together but never specify their reasoning. Can anyone speak to this?
     
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  3. WingedOx

    WingedOx Not here for your bullsh-t
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    "Yeah doc, I need energy and need to focus, but I'm also really anxious. That's why I take the adderall, and the klonopin helps the anxiety" -

    [​IMG]
     
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  4. resident1985

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  5. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    The general consensus seems to be that there are a lot of bad doctors out there with questionable prescribing habits. This question is the akin to when I ask why my elderly patients with early symptoms of dementia and only mild anxiety are given maintenance benzos.
     
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  6. resident1985

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    that’s my feeling bad prescribing but I have seen others say yes I do it and am interested to hear the reasoning behind that
     
    #6 resident1985, Dec 1, 2017
    Last edited: Dec 1, 2017
  7. WingedOx

    WingedOx Not here for your bullsh-t
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    Because it makes the patient shut up.

    That's the reason. It's not a good or ethical one.
     
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  8. Mr. Bub

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    If you have them on standing Klonopin with Xanax for breakthrough anxiety and Vyvanse with some adderall IR for when they get tired in the afternoon, you can really find that perfect balance.
     
  9. resident1985

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    I know you’re being facetious but I see this not uncommonly
     
  10. medium rare

    medium rare Psychologist & Psych NP

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    When I inherit patients like this, I immediately make it clear if they are going to work with me, one of these agents will be eventually eliminated or, in the case of benzodiazepines, used only rarely in times of true necessity (1-2/month or less). It’s easier said than done. Best to avoid this combination from the get-go in most cases.
     
  11. Merely

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    I am a med student so forgive my ignorance but your title says you are a psychologist, can you manage meds as a psychologist? I'm just trying to learn not start a fight, thank you
     
  12. medium rare

    medium rare Psychologist & Psych NP

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    I’m also a psychiatric nurse practitioner - as I indicate in my title.
     
  13. SourceOfDenial

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    In oncology and palliative I see the combination quite regularly. Stimulant for fatigue + benzo for anxiety(or nausea or sleep). Is it perfect? No. Do patients sometimes report that it improves their quality of life? Yes.

    On the geriatric side we say no no no to benzos, but sometimes a low dose works, and you can argue that the risk isn't much different than other psychotropics.
     
  14. st2205

    st2205 Attending

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    Cancer patients are among my favorite as you can use things that will have noticeable benefit but not have any of the long-term worries of other patients with dysfunctional coping skills. It’s fairly satisfying.
     
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  16. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Very different from the more frequent outpatient issues of "I can't focus without MY Adderall" and "My anxiety's through the roof--I need more Klonopin" in the same otherwise healthy young patient.
     
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  17. hamstergang

    hamstergang may or may not contain hamsters

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    I use benzos and stimulants together in 2 groups of patients (I do only child/adolescent):

    1) Patients I inherit on one or both classes already. Sometimes I have them on both temporarily while working to change that (maybe start an SSRI for anxiety and leave the benzo for another month). Occasionally these patients end up elsewhere (leave me for another outpatient or go inpatient) before I finish, so I'm sure some other psychiatrist sees that I prescribed stimulants and benzos simultaneously and questions my competence.

    2) Severely autistic kids. Frequently, these will already be on stimulants for hyperactivity and impulsivity but then come to me as it is providing some but inadequate help. Depending on circumstances, I sometimes use benzos here, also planned to be temporary (typically with those in which nothing else pharmacologically or otherwise seems to be helping).
     
  18. SourceOfDenial

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    The tricky part is when the cancer is cured or goes into remission...then the earlier great ideas seem less great.
     
  19. SourceOfDenial

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    Unfortunately, folks with dysfunctional coping skills get cancer too. Amazingly at the same rate ;)
     
  20. st2205

    st2205 Attending

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    Indeed, but the selection bias with which we see that population skews our view of how “normal” it is, so when different populations who don’t often frequent psychiatrists get cancer, they end up having problems that select for a higher likelihood of seeing us, so from that angle it gives a different avenue of why people see us.

    In any case, if someone with pre-existing poor coping skills — compensated with medication-assisted avoidance — had terminal cancer, would you suggest there’s utility in trying to change that, and that doing so would improve the quality of their (end of) life?
     
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  21. lobelsteve

    lobelsteve SDN Lifetime Donor
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  22. Ceke2002

    Ceke2002 Purveyor of Strange

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    Good gravy! I had a $150 a day heroin addiction and 60mg of Methadone once a day was enough to get me cruising nicely in the beginning. How the bleedin' heck does someone take 100mg QD and remain breathing?
     
  23. splik

    splik Professional Cat at Large
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    100mg is the standard dose of methadone maintenance... 60 would be below the average range. i have seen pts on 300mg lol now that is something to raise an eyebrow about
     
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  24. Ceke2002

    Ceke2002 Purveyor of Strange

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    QD is twice a day though? So 200mgs a day? I know about a 100 is fairly standard for maintenance, but anything above 180 raises some eyebrows here.
     
  25. hamstergang

    hamstergang may or may not contain hamsters

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    No, once daily. BID is twice daily.
     
  26. Ceke2002

    Ceke2002 Purveyor of Strange

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    Oh, okay, my bad. In that case 100 mgs for a maintenance dose of Methadone is quite within the expected range, at least in my experience. I wouldn't be shocked at that amount being prescribed to someone.
     

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