There are wins sometimes

[clausewitz2]

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December 2020: Patient presents for intake on following combination of medications (among others) from elderly out of state psychiatrist who is not good about responding to communication but patient kind of idolizes:

Diazepam 15 mg qAM, 10 mg qnoon, 10 mg q4PM, 15 mg qHS
Adderall IR 20 mg TID
temazepam 30 mg qHS
Ambien 15 mg qHS
gabapentin 600 mg qAM + 300 mg qHS

Patient had struggled to get off suboxone they were put on for chronic pain in the past but had been sober for a few years. History of severe alcohol use disorder in the past. Diazepam had been prescribed for tremor attributed to lithium (which patient was still taking) but no tremor was noticeable on exam. Feels they will be incapacitated without diazepam because they fear tremor will be so bad. Many psychiatric hospitalizations in the past for real-deal sort of mania (fleeing the state with their child in the middle of the night because they are convinced that they are protecting it from demons, convinced they control storms with their mind). Works as a MH professional, with all of the difficulties that can entail, and working at VA unhappily.

Basically the kind of patient you only take in private practice if you really relish a challenge and/or are just starting out and are less picky in building your panel.

May 2023:
Adderall 20 mg qAM, 10 mg qnoon, 10 mg q4 PM
no more temazepam
no more ambien
no more gabapentin
1 mg diazepam daily, plans to discontinue entirely this week

Patient has discovered self-help CBT resources for functional neurological disorder and tremor is no longer a concern. Questioning how much they really need adderall because obtaining it has become such a hassle due to shortage. Idly considers throwing a party to celebrate not taking benzos anymore and feeling much better about life generally than has for many years. Patient is successful in private practice.

Just a PSA for all the folks who certain kind of med list and can just feel the enthusiasm for clinical work being sucked out of their marrow - sometimes you pull out a win. It wasn't fast, but I do believe this person has a good chance of staying off BZDs long term.

 

[wolfvgang22]

December 2020: Patient presents for intake on following combination of medications (among others) from elderly out of state psychiatrist who is not good about responding to communication but patient kind of idolizes:

Diazepam 15 mg qAM, 10 mg qnoon, 10 mg q4PM, 15 mg qHS
Adderall IR 20 mg TID
temazepam 30 mg qHS
Ambien 15 mg qHS
gabapentin 600 mg qAM + 300 mg qHS

Patient had struggled to get off suboxone they were put on for chronic pain in the past but had been sober for a few years. History of severe alcohol use disorder in the past. Diazepam had been prescribed for tremor attributed to lithium (which patient was still taking) but no tremor was noticeable on exam. Feels they will be incapacitated without diazepam because they fear tremor will be so bad. Many psychiatric hospitalizations in the past for real-deal sort of mania (fleeing the state with their child in the middle of the night because they are convinced that they are protecting it from demons, convinced they control storms with their mind). Works as a MH professional, with all of the difficulties that can entail, and working at VA unhappily.

Basically the kind of patient you only take in private practice if you really relish a challenge and/or are just starting out and are less picky in building your panel.

May 2023:
Adderall 20 mg qAM, 10 mg qnoon, 10 mg q4 PM
no more temazepam
no more ambien
no more gabapentin
1 mg diazepam daily, plans to discontinue entirely this week

Patient has discovered self-help CBT resources for functional neurological disorder and tremor is no longer a concern. Questioning how much they really need adderall because obtaining it has become such a hassle due to shortage. Idly considers throwing a party to celebrate not taking benzos anymore and feeling much better about life generally than has for many years. Patient is successful in private practice.

Just a PSA for all the folks who certain kind of med list and can just feel the enthusiasm for clinical work being sucked out of their marrow - sometimes you pull out a win. It wasn't fast, but I do believe this person has a good chance of staying off BZDs long term.

Strong work, doctor! 💪

 

[calvnandhobbs68]

Nice work! any general overview of how you got from point A to point B? What came off first, how did you engage the patient about it and sustain that motivation to keep things moving forward with them?

 

[Stagg737]

How motivated was the patient to get off most of these meds? I've been fairly successful with those wanting to come off. For patients who are unmotivated I can usually limit polypharmacy but getting them off has been a huge struggle. Lots of MI?

 

[Sushirolls]

I do one of two things. If you work with me I will taper you off. Or, keep getting it from your PCP, and between you and them.

Those benzo victories are some of the best! But dang, some can be very draining.

 

[Celexa]

Love it. We should celebrate our successes more.

The lengthy timeline speaks to the patience required to do it. Adding to some of the questions above, I'm curious how long it took to start making any changes at all, in terms of their other meds and their controlled substances. What was the lead in in terms of rapport building before you started getting into the changes you really wanted to do? And how often did you have visits where meds were unchanged?

 

[Candidate2017]

Diazepam 15 mg qAM, 10 mg qnoon, 10 mg q4PM, 15 mg qHS
Adderall IR 20 mg TID
temazepam 30 mg qHS
Ambien 15 mg qHS
gabapentin 600 mg qAM + 300 mg qHS

There's enough benzos here to manage 2-3 patients undergoing acute alcohol withdrawal. With the gabapentin, probably a 4th mild case too.

Love it. We should celebrate our successes more.

Clinical successes and failures belong to the patient, not us.

 

[Celexa]

Clinical successes and failures belong to the patient, not us.

That's a rather unnecessarily extreme self abnegation. Is there not enough success to go around for both patient and provider to share? By that logic the patients life would be no different without the care provided by @clausewitz2, which seems very unlikely for someone on that many sedatives.

If we are providing a service with value than the value we bring does in part belong to us.

 

[clozareal]

Congratulations! I'm working on one crazy med regimen like this myself. Would love what you thought worked well for you.

 

[clausewitz2]

Nice work! any general overview of how you got from point A to point B? What came off first, how did you engage the patient about it and sustain that motivation to keep things moving forward with them?

Patient was on the younger side (early 50s) but we started by talking about the downsides of chronic benzos, especially regarding fall risk as she got older. She was extremely dubious at first but it turns out her elderly mother who she has a strained relationship with is also on chronic benzos, and I think she did not want that to be her future. It helped that the tremor was starting to happen regardless of her dosing and she had a hard time functioning towards the end of her work day.

First few months was about trying alternatives for her tremor that might be useful (they were not). First thing that came off was temazepam, actually; after we had several conversations about what a taper might look like, she decided she didn't need it anymore, and just stopped it straight away. She did just fine, which I think was tremendously helpful.

Next came the proper Ashton-style taper. Based on my notes it looks like it did take ~110 weeks, so we were not able to start until the third/fourth month of our work together. At first there was a lot of stopping and starting, but we absolutely never for any reason increased the dose. After she got to the point that month on month she was making consistent reductions every week, it basically snowballed. The last 4-5 months she consistently made cuts slightly ahead of where we had planned and she started getting really excited about the prospect of getting off it completely.

Ambien was harder, she went through periods of doing okay with a smaller dose, a few months here and there with returning to previous dose, and has only been consistently not taking/needing it since January. Honestly it was not my primary focus tapering wise.

Gabapentin she just kind of stopped a year ago, didn't think it was doing anything for her.

How motivated was the patient to get off most of these meds? I've been fairly successful with those wanting to come off. For patients who are unmotivated I can usually limit polypharmacy but getting them off has been a huge struggle. Lots of MI?

Love it. We should celebrate our successes more.

The lengthy timeline speaks to the patience required to do it. Adding to some of the questions above, I'm curious how long it took to start making any changes at all, in terms of their other meds and their controlled substances. What was the lead in in terms of rapport building before you started getting into the changes you really wanted to do? And how often did you have visits where meds were unchanged?

As far as motivation etc...this is going to sound corny as heck, but mostly a very light touch, I think. For the first few months I was pushing at every appointment (we met monthly) to get her to think about tapering and we got absolutely nowhere. I recognized I was getting extremely frustrated and I think I may have given up on it for a month or two. After that, all of a sudden, she's asking more question about the taper and how it would work, but I'm not tremendously invested internally. I design the schedule with her, talk about potential difficulties, lay it all out, thinking all the while that this is kind of futile but whatever. And...all of a sudden, it stops being "here's how you'd theoretically do this" and "oh you're actually doing it."

In retrospect I recognize this boils down to genuinely rolling with resistance. Until I stopped pushing there was no movement. I kept my foot off the gas, inquiring and updating the taper schedule as appropriate, but never arguing or objecting if she wanted to slow it down, just asking always about how she'd like to restart it when we do.

I think perhaps 20% of our visits after starting the taper did not lead to any changes in these meds.

I was slightly pushier about getting her to see a neurologist for her tremor (she never had). She saw one apparently who was talking about possibly referring her to a neurosurgeon for DBS and this terrified her. That's when she started looking into functional tremor resources in earnest.

I also end up having her email me after each appointment with her understanding of what medications she was taking and needed to be refilled after some acrimonious miscommunications earlier on. I think this gave her a bit more sense of control over the whole process. Also, during one of those previous miscommunications, she had basically teetered on the edge of calling me a liar, to which I responded by saying that I would not be able to continue to work with her productively if she had serious doubts about my truthfulness. She backpedalled and we never had this problem again. So I suppose the benefit of repairing a rupture of alliance as well.

I haven't thought about this in a structured way, this is very much thinking out loud, but hopefully there is something useful in it.

 

[randomdoc1]

But I NN...N...EEEEEED thooose. jk jk.

But in all seriousness, that is such excellent work.

 

[Candidate2017]

That's a rather unnecessarily extreme self abnegation. Is there not enough success to go around for both patient and provider to share? By that logic the patients life would be no different without the care provided by @clausewitz2, which seems very unlikely for someone on that many sedatives.

If we are providing a service with value than the value we bring does in part belong to us.

I just do my job as best I can, but it is the patient who chooses the path (and chooses to do or not do the work). Sometimes patients choose good paths, sometimes they choose bad paths.

But if we are to share credit for "wins," we must also share credit for "losses". This is the flawed logic behind Zero Suicide. There are many things that can go terribly wrong during a lengthy taper of a large amount of benzos/hypnotics/sedatives in a patient with a history of opioids and alcohol, for which credit may be placed on OP inappropriately by society. There are some cases, though, where the doctor does deserve 100% of the credit, especially the doctor(s) who originally served up the iatrogenic all you can eat buffet of benzos.

Anyway, this is still a feel good story, which OP should celebrate, for the time being.

 

[Shikima]

These doctors are the ones that need MOC.

 

[Cath Up]

I just do my job as best I can, but it is the patient who chooses the path (and chooses to do or not do the work). Sometimes patients choose good paths, sometimes they choose bad paths.

But if we are to share credit for "wins," we must also share credit for "losses". This is the flawed logic behind Zero Suicide. There are many things that can go terribly wrong during a lengthy taper of a large amount of benzos/hypnotics/sedatives in a patient with a history of opioids and alcohol, for which credit may be placed on OP inappropriately by society. There are some cases, though, where the doctor does deserve 100% of the credit, especially the doctor(s) who originally served up the iatrogenic all you can eat buffet of benzos.

Anyway, this is still a feel good story, which OP should celebrate, for the time being.

Yes of course physicians bear some responsibility on “losses”. I doubt there is much shortage, particularly among us younger doctors/residents who second guess/lay awake wondering which mistake we made. Everyone makes mistakes, and everyone has knowledge gaps. We should recognize those and reflect particularly when bad outcomes occur but also definitely celebrate success that expertise via years of education and experience result in. I’m surprised to see that even being questions.

 

[shoomer]

Next came the proper Ashton-style taper. Based on my notes it looks like it did take ~110 weeks, so we were not able to start until the third/fourth month of our work together.

Did you basically follow the Ashton manual method or did you modify it in some way?

 

[clausewitz2]

Did you basically follow the Ashton manual method or did you modify it in some way?

Followed the ashton manual pretty closely, I have never had someone be unable to tolerate it provided they cope with transition to valium in the first place. Unfortunately the folks coming off Klonopin seem least likely to be able to make the leap, valium is a bit more intensely sedating it seems like for some people and people chronically on clonazepam are rarely people who like feeling even the slightest bit out of control.

 

[Merovinge]

I just do my job as best I can, but it is the patient who chooses the path (and chooses to do or not do the work). Sometimes patients choose good paths, sometimes they choose bad paths.

But if we are to share credit for "wins," we must also share credit for "losses". This is the flawed logic behind Zero Suicide. There are many things that can go terribly wrong during a lengthy taper of a large amount of benzos/hypnotics/sedatives in a patient with a history of opioids and alcohol, for which credit may be placed on OP inappropriately by society. There are some cases, though, where the doctor does deserve 100% of the credit, especially the doctor(s) who originally served up the iatrogenic all you can eat buffet of benzos.

Anyway, this is still a feel good story, which OP should celebrate, for the time being.

Why would that be the case? In trauma surgery you have a tiny percent chance of cardiac massage to work, on the rare cases it does, you are a hero, but no one would/should blame you when it doesn't. There exist many systems in which someone coming in is part of the win but bares no responsibility for the losses (firefighters, back up quarterback, teachers). There's lots of flawed logic behind Zero Suicide, I completely agree, and the patient is the one making the decisions, but that doesn't mean any supporter must share credit for losses if they take part of wins.

 

[Sushirolls]

@SmallBird just had a post in another thread. Jogged my memory.

Not a recent win but a win from several years ago.

Back when I was doing some inpatient at a Big Box Shop. "bipolar" patient on unit, got my diagnostic change up for Borderline PD and more indepth discussion of what it means, nuances, treatment, etc. Just another day then. Discharged eventually.

Fast forward few years, when I pit stopped at another Big Box shop that had IP and PHP, patient was depressed, briefly admitted, bounced into the PHP. Was excited to see me again - didn't remember the patient - but patient remembered me. Was like, "you!" and proceed to describe how the Borderline PD diagnosis and discussion was able to start to turn life around, focus on therapy, did DBT, quit the drugs, life was going well for years until that episode of depression needing more services. Meds were minimal, more realistic. Still needed the cannabis talk though...

Definitely was a win.

 

[psychemdoc]

@SmallBird just had a post in another thread. Jogged my memory.

Not a recent win but a win from several years ago.

Back when I was doing some inpatient at a Big Box Shop. "bipolar" patient on unit, got my diagnostic change up for Borderline PD and more indepth discussion of what it means, nuances, treatment, etc. Just another day then. Discharged eventually.

Fast forward few years, when I pit stopped at another Big Box shop that had IP and PHP, patient was depressed, briefly admitted, bounced into the PHP. Was excited to see me again - didn't remember the patient - but patient remembered me. Was like, "you!" and proceed to describe how the Borderline PD diagnosis and discussion was able to start to turn life around, focus on therapy, did DBT, quit the drugs, life was going well for years until that episode of depression needing more services. Meds were minimal, more realistic. Still needed the cannabis talk though...

Definitely was a win.

The rare wins. More of this please!

 

[Merovinge]

@SmallBird just had a post in another thread. Jogged my memory.

Not a recent win but a win from several years ago.

Back when I was doing some inpatient at a Big Box Shop. "bipolar" patient on unit, got my diagnostic change up for Borderline PD and more indepth discussion of what it means, nuances, treatment, etc. Just another day then. Discharged eventually.

Fast forward few years, when I pit stopped at another Big Box shop that had IP and PHP, patient was depressed, briefly admitted, bounced into the PHP. Was excited to see me again - didn't remember the patient - but patient remembered me. Was like, "you!" and proceed to describe how the Borderline PD diagnosis and discussion was able to start to turn life around, focus on therapy, did DBT, quit the drugs, life was going well for years until that episode of depression needing more services. Meds were minimal, more realistic. Still needed the cannabis talk though...

Definitely was a win.

We need a mandatory reading of Brave New World and then a discussion of Soma q weekly on IP units.

 

[clausewitz2]

Had to share another win:

Patient in their mid-20s with pretty severe contamination OCD to the point of being unable to live independently, had a long stay in McLean residential program where surgery was suggested at one point, struggled to tolerate any meds, and also anxious to the point of seeking voluntary hospitalization when parents went out of town for a week, starts treatment early 2022. Gradually ease them on to sertraline and low dose of risperidone over time, manage to get them through initial GI complaints. Start working with a therapist doing actual E/RP.

Fast forward to today, they are working a full-time job in a technical field, excited about potentially getting their first apartment on their own. They are describing some contamination ritual they used to get stuck on at home that they have since ditched entirely. Off-hand they say "...and I've started doing a little work from home and it was just taking up so much time and I got pretty sick of it. So I realized if I stopped doing it I'd have a lot more time to do other stuff and my life would be easier."

"Okay, hold on. I want to just draw your attention to the progress you've made. Like, what you said about your life being easier if you stopped doing your ritual, obviously true, you save all kinds of time. But I'm pretty sure that if I had asked you a year ago if you had just, y'know, considered stopping your rituals because it would be easier not to do them, you would have looked at me like I was stupid."

"...*sheepish grin*...yeah, probably."