Tired of this

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The lack of barbiturate's that's bothering you? Or were you hoping for Adderall 30mg TID to be added on top to make the Elvis special?

Edit: But seriously thank you to all the adult psychiatrists dealing with this stuff. People think CAP is tough but I look at list and realized I haven't seen anything close in my entire career.
 
Merovinge said:
The lack of barbiturate's that's bothering you? Or were you hoping for Adderall 30mg TID to be added on top to make the Elvis special?

Edit: But seriously thank you to all the adult psychiatrists dealing with this stuff. People think CAP is tough but I look at list and realized I haven't seen anything close in my entire career.
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Apparently she was on adderall but it was stopped a couple months ago
 
That's if the patient doesn't argue with you and say those are the only things that work, while still saying they are depressed/anxious etc...
Or yell at you.
Or threaten to kill you.
Or for the ensuing months/year bring up every appointment the nostalgia of xanax days and how it just worked.

The thank you at the end is nice once clarity sets in, but damn its a long road.

Could be ambein CR 12.5mg, and xanax 2mg QID, where's the dilaudid or methadone? Naturally no CPAP for the OSA. You forgot the cannabis and alcohol.
 
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Attending1985 said:
Here’s the med list for my consult today:
Diazepam 10 mg daily
Xanax 0.5 mg qid
Hydrocodone 7.5 mg qid
Ambien 10 mg at hs

So sick of dealing with this
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Honestly seems like a bit of a Cadbury* list to me. Unless they're doing an ashton taper I don't really see the need for both valium and xanax to be on board.

So in my completely no professional opinion they either:

1) Really do need all of those medications.
2) Have been convinced that they need all of those medications when they don't, and you'll have the fun of convincing them otherwise.
3) Have been convinced that they need all of those medications when they don't, and nothing you say will convince them otherwise and/or they will not be open to medication free approaches to treat whatever.
4) Have convinced themselves that they need all of those medications when they don't, and will hold aloft their medications list like some sort of attention seeking war banner (just you try to take their identity as a professional sick person off of them).

(*Calling someone a ''Cadbury" is Australian slang for someone who can't hold their liquor or someone who appears to gets high off low doses of drugs/medications. It stems from advertising for Cadbury chocolate here which has the catch phrase of "A glass and half of full cream milk in every block", so a Cadbury is someone who only needs a glass and a half to get drunk/high/etc)
 
I don't think it should mandate board complaints. It should mandate a prescriber to prescriber direct conversation with the previous prescribers to explain what was going on and what the plan was going forward.
 
Shikima said:
This kind of prescribing should mandate board complaints.
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I don't know if most boards have the staff available to field complaints if we reported things like this. I see these things on a weekly basis in my populations.
 
So it went okay. She’s also on Wellbutrin lamictal and latuda and prn gabapentin in addition. Agreed to taper the Valium and reduce the ambien. Plan is to get her off the ambien long term. As far at the Xanax she’s 66 years old and been on it since 2009 so probably not possible to get off of it. Maybe a dose reduction if I’m optimistic.

Ive seen patients from this recently retired prescriber in the past and they’re all a mess like this. Since he’s no longer practicing a board complaint is pointless. All his patients tell me how wonderful he was.
 
Attending1985 said:
So it went okay. She’s also on Wellbutrin lamictal and latuda and prn gabapentin in addition. Agreed to taper the Valium and reduce the ambien. Plan is to get her off the ambien long term. As far at the Xanax she’s 66 years old and been on it since 2009 so probably not possible to get off of it. Maybe a dose reduction if I’m optimistic.

Ive seen patients from this recently retired prescriber in the past and they’re all a mess like this. Since he’s no longer practicing a board complaint is pointless. All his patients tell me how wonderful he was.
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Right or in other cases the docs are going to retire in a few years anyway so are trying to cut down their patient panel and don't really give a crap about board complaints.
 
TheRightMedication said:
At least you know what your plan is for the next 6 to 12 months. And who knows how much better their life will get if they stick with you.
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yep...primum non nocere...

"Tx Plan? Eliminate the 'nocere' and go from there..."
 
Attending1985 said:
This seems like someone no one ever does. Must be some sort of unspoken doctor code.
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It’s not that it’s a code it’s that it would be ridiculous to do it having practiced medicine and knowing what the practice entails. Unless you spoke with the doctor who prescribed it and have an understanding and context into what they were thinking trying to take away their license (by reporting them) is just ridiculous, everyone has patients on these sorts of regimens at some point in time so we would all just end up reporting each other. For example imagine this patient leaves your office and goes to the ER, I see her and see this regimen that you continued for one month (with recommendation to taper that I don’t know about) then report you to the board..
 
forchinet121 said:
It’s not that it’s a code it’s that it would be ridiculous to do it having practiced medicine and knowing what the practice entails. Unless you spoke with the doctor who prescribed it and have an understanding and context into what they were thinking trying to take away their license (by reporting them) is just ridiculous, everyone has patients on these sorts of regimens at some point in time so we would all just end up reporting each other. For example imagine this patient leaves your office and goes to the ER, I see her and see this regimen that you continued for one month (with recommendation to taper that I don’t know about) then report you to the board..
Click to expand...
Yes I totally get that but even in cases where you work closely enough with someone to know that they routinely prescribe unsafely I’ve never seen it done
 
Does anyone even do evidence based psychopharmacology anymore? Like, I know the DSM has some weak constructs but it’s a start. Did I miss the clinical trial with this combo? Or am I too conservative to strive to only prescribe what the science affirms. I bet Stahl would consider me not “heroic” enough lol
 
I’m often floored by the regimens some patients tolerate

I bet she doesn’t sleep well on ambien either; shouldn’t be too hard to come off that one at least

No major pharmacy would fill this around me
 
allantois said:
I’m often floored by the regimens some patients tolerate

I bet she doesn’t sleep well on ambien either; shouldn’t be too hard to come off that one at least

No major pharmacy would fill this around me
Click to expand...
Where do you live..
 
Merovinge said:
Edit: But seriously thank you to all the adult psychiatrists dealing with this stuff. People think CAP is tough but I look at list and realized I haven't seen anything close in my entire career.
Click to expand...
Really? During my outpatient year in residency I called this "Thursday morning", because that's when I rotated through our CMHC...
 
This isn’t that bad in the grand scheme of terrible regimens. I advise my patients that need a change that psychiatrists are specialists. Our goal is to maximize the regimen which may involve tapering some meds. If they are happy with the same regimen for years, they should contact their PCP to just continue the regimen. If the PCP won’t continue it, it likely means the regimen isn’t appropriate.
 
Attending1985 said:
Here’s the med list for my consult today:
Diazepam 10 mg daily
Xanax 0.5 mg qid
Hydrocodone 7.5 mg qid
Ambien 10 mg at hs

So sick of dealing with this
Click to expand...
I’m a rheumatologist. I see this type of nonsense multiple times every day in patients sent to me for fibromyalgia (and sometimes in patients referred for other things also), usually accompanied by gabapentin/pregabalin (sometimes both!), a stimulant, an SNRI, multiple muscle relaxers (especially Soma), a tricyclic added as a cherry on top, etc etc.

Yes, I have filed board complaints over this crap. Talking with the PCPs and other docs who come up with this type of crap usually does absolutely nothing; after all, they are idiots. I currently see a fibro patient who was on over 30 medications when she was sent to me - with all the above and more (she was on both milnacipran and duloxetine). Step one for me was to cut the milnacipran and then try to whittle down the rest of her polypharmacy. Within days of my appointment, her PCP had quickly seen her for an urgent appointment and started levomilnacipran. Without discontinuing anything else. Despite my strongly worded note that the idiotic neurotransmitter stew he had created was dangerous. Oh yeah, and she still had pain. And was wondering what else I could start for her.

All of this is a big part of the reason why I increasingly refuse to see new fibro referrals.
 
allantois said:
I’m often floored by the regimens some patients tolerate

I bet she doesn’t sleep well on ambien either; shouldn’t be too hard to come off that one at least

No major pharmacy would fill this around me
Click to expand...
In some of the polypharmacy fibro patients I’ve seen, my procedure is just to start tapering meds. I’ve tapered some fibro patients off virtually everything they were taking, only to find out that they feel better off everything.
 
Stagg737 said:
Really? During my outpatient year in residency I called this "Thursday morning", because that's when I rotated through our CMHC...
Click to expand...
To clarify, I saw it regularly during adult residency. Since I have shifted to CAP I haven't seen a single patient like that.
 
Attending1985 said:
Here’s the med list for my consult today:
Diazepam 10 mg daily
Xanax 0.5 mg qid
Hydrocodone 7.5 mg qid
Ambien 10 mg at hs

So sick of dealing with
Click to expand...

Find out who is rxing it, bring them to the attention of state ethics board. DEA if you really wanna be a dick
 
forchinet121 said:
It’s not that it’s a code it’s that it would be ridiculous to do it having practiced medicine and knowing what the practice entails. Unless you spoke with the doctor who prescribed it and have an understanding and context into what they were thinking trying to take away their license (by reporting them) is just ridiculous, everyone has patients on these sorts of regimens at some point in time so we would all just end up reporting each other. For example imagine this patient leaves your office and goes to the ER, I see her and see this regimen that you continued for one month (with recommendation to taper that I don’t know about) then report you to the board..
Click to expand...

Maybe. If you’ve ever worked in or near a rural area, though, you know that the prescribing habits of the local docs and midlevels can be simply atrocious.

Example: there is a rheumatologist in a town near mine who also dabbles in “pain management”. Her weapons of choice? Methadone and fentanyl patches. She likes to start this stuff in random rheumatology patients and then drop them as a patient almost as randomly. What do they do then? Well, they turn up in my office begging for methadone refills, bawling their eyes out. I recently had to have security escort one out, as this person would not leave until she had a refill from me.

I reported this person to the board and the DEA after I lost count of how many unnecessarily addicted patients I had seen like this. My last two jobs have been in rural areas, and the level of weapons-grade stupidity I’ve seen among the docs out here would just blow your mind. If it’s one patient you inherit on a crazy regimen, that’s one thing, but when it’s a day in/day our pattern, that’s just outrageous. In my opinion, the boards aren’t aggressive enough when it comes to policing this sort of nonsense.
 
dozitgetchahi said:
Maybe. If you’ve ever worked in or near a rural area, though, you know that the prescribing habits of the local docs and midlevels can be simply atrocious.

Example: there is a rheumatologist in a town near mine who also dabbles in “pain management”. Her weapons of choice? Methadone and fentanyl patches. She likes to start this stuff in random rheumatology patients and then drop them as a patient almost as randomly. What do they do then? Well, they turn up in my office begging for methadone refills, bawling their eyes out. I recently had to have security escort one out, as this person would not leave until she had a refill from me.

I reported this person to the board and the DEA after I lost count of how many unnecessarily addicted patients I had seen like this. My last two jobs have been in rural areas, and the level of weapons-grade stupidity I’ve seen among the docs out here would just blow your mind. If it’s one patient you inherit on a crazy regimen, that’s one thing, but when it’s a day in/day our pattern, that’s just outrageous. In my opinion, the boards aren’t aggressive enough when it comes to policing this sort of nonsense.
Click to expand...
The system in the US is largely to let the malpractice lawsuits take the place of the boards. I don't know nearly enough about US medical history to know how we got to this spot, but this is in staunch contrast to other countries where it is relatively easy to lose or have a license on probation but virtually impossible to lose your own personal assets in a lawsuit. I am not sure either system is perfect, but I agree that it largely appears anyone can prescribe anything for virtually any reason without repercussions from boards. We apparently have licensed doctors prescribing marijuana for asthma if SDN is to be believed...
 
Merovinge said:
The system in the US is largely to let the malpractice lawsuits take the place of the boards. I don't know nearly enough about US medical history to know how we got to this spot, but this is in staunch contrast to other countries where it is relatively easy to lose or have a license on probation but virtually impossible to lose your own personal assets in a lawsuit. I am not sure either system is perfect, but I agree that it largely appears anyone can prescribe anything for virtually any reason without repercussions from boards. We apparently have licensed doctors prescribing marijuana for asthma if SDN is to be believed...
Click to expand...
I agree. The boards will not be on you as a doctor unless you leave a long trail of dead/maimed patients behind you, and even then it seems to take a while.
 
shuban92 said:
Find out who is rxing it, bring them to the attention of state ethics board. DEA if you really wanna be a dick
Click to expand...

Nothing there is worth reporting. State boards want to see harm. Xanax 2.5mg daily equivalent is nothing. Even if you add Ambien that gets you to what, maybe 3mg. The opioids would get the psychiatrist flagged in my state if it was the same prescriber. Assuming separate prescribers and this is nothing. The DEA can see everything we write. If it was that obscene, they would already be knocking.

Xanax is FDA approved at 2mg TID. The FDA cleared that dose as safe and effective.
 
Rural doesn't mean bad.

Cities have their people too, but the smaller population density of rural means that one bad, echoes more strongly than in larger cities.

My rural area has a bunch of PCPs who are just as anti benzo as myself.

Medical boards, at least do investigations. ARNP boards? lol.
 
Sushirolls said:
Rural doesn't mean bad.

Cities have their people too, but the smaller population density of rural means that one bad, echoes more strongly than in larger cities.

My rural area has a bunch of PCPs who are just as anti benzo as myself.

Medical boards, at least do investigations. ARNP boards? lol.
Click to expand...

I’ve worked in cities and rural areas and in my experience, the general quality of most medical practitioners seems to decline dramatically the further away you get from cities. It is no secret that most doctors don’t want to live in these areas, and thus the ones that end up out here are often not members of the “A team” (or even the “B team”).
 
Merovinge said:
The system in the US is largely to let the malpractice lawsuits take the place of the boards. I don't know nearly enough about US medical history to know how we got to this spot, but this is in staunch contrast to other countries where it is relatively easy to lose or have a license on probation but virtually impossible to lose your own personal assets in a lawsuit. I am not sure either system is perfect, but I agree that it largely appears anyone can prescribe anything for virtually any reason without repercussions from boards. We apparently have licensed doctors prescribing marijuana for asthma if SDN is to be believed...
Click to expand...
This is the argument malpractice lawyers make for why they are needed
 
I dealt with similar, sometimes worse, regimens with an inherited a panel. The most useful thing I learned from tapering is:
If a fat kid eats two cakes daily, don't give him 30 cakes all at once and expect it to last 30 days.

annoyedpsychiatrist said:
Lately ive been really struggling with intakes as well. All of them on adderall, benzos, sedative hypnotics, etc
Click to expand...

Are you required to see and enter into a relationship with these people? If you are employed by The Man, you are probably expected to see most everyone in return for a little bit of money, not unlike a certain older profession that's been around for a while. But, have you thought about refusing to see these intakes? Just like a 2 year old, the more I say no, the more I grow as an autonomous individual.
 
Candidate2017 said:
I dealt with similar, sometimes worse, regimens with an inherited a panel. The most useful thing I learned from tapering is:
If a fat kid eats two cakes daily, don't give him 30 cakes all at once and expect it to last 30 days.



Are you required to see and enter into a relationship with these people? If you are employed by The Man, you are probably expected to see most everyone in return for a little bit of money, not unlike a certain older profession that's been around for a while. But, have you thought about refusing to see these intakes? Just like a 2 year old, the more I say no, the more I grow as an autonomous individual.
Click to expand...
Haha I like the analogy, I think you should be allowed to see the patient then refuses to see them after that if you don’t like them for whatever reason
 
Candidate2017 said:
I dealt with similar, sometimes worse, regimens with an inherited a panel. The most useful thing I learned from tapering is:
If a fat kid eats two cakes daily, don't give him 30 cakes all at once and expect it to last 30 days.



Are you required to see and enter into a relationship with these people? If you are employed by The Man, you are probably expected to see most everyone in return for a little bit of money, not unlike a certain older profession that's been around for a while. But, have you thought about refusing to see these intakes? Just like a 2 year old, the more I say no, the more I grow as an autonomous individual.
Click to expand...

Its tricky- ultimately I have to see them but i can choose what I prescribe. Im very honest with expectations and explain if they want this combo they will likely need to see someone else for it. But then these people leave a nasty review after.
 
annoyedpsychiatrist said:
Its tricky- ultimately I have to see them but i can choose what I prescribe. Im very honest with expectations and explain if they want this combo they will likely need to see someone else for it. But then these people leave a nasty review after.
Click to expand...
And this is one of those things with Big Box Shops that sets some doctors up for failure. Depending on how much they emphasize reviews, could be a predestined plan of having no psychiatrists or just a turn over mill.

If there isn't the support in a dept for us to be the bad guys to say no, to taper people off, it won't get done. PCPs just keep on clicking. Or psych ARNPs fill the seats and keep the gravy train going. Or new fresh Psych grads come in, get chewed up, burned out, and spit out, until the next one comes.

I was seeing this support dwindle at one of my historic Big Box shop jobs and their attempts to even link "quality" metrics to pay. It was a path to failure.

I regained autonomy with a private practice.
 
I'm 50 now. I remember being in residency complaining about this very same thing on this forum and some guy claiming to an attending from NYC claimed this stuff never happens.

Also where I did residency, it was near Philadelphia. What some of the Philly psychiatrists were doing is if they had a very low functioning patient and annoyed them they'd put them on a casino bus (Atlantic City had free buses going to to the city from NYC and Philly that even gave the person $50 when they stepped off the bus cause they all dropped it in the casino). When you have what amounted to dozens of people all from the same city, all low functioning schizophrenics, all from the same 3 hospitals, all showing up to your doorstep, "they drove me to this bus stop and told me if I got on the bus I'd get $50.....) Our ER had at least a few of these dump jobs in our ER a week. Same attending claimed this was completely fake and no doctor would do such a thing.

Then later it was found and proven the same thing was going on in Vegas (coincidence it as also a casino town) but instead of people being dumped to Vegas, the Vegas system was dumping them to California. California sued Nevada over this. So it's proven, and I confronted him on it, said "attending" never talked about it again. I remember this guy's forum handle but he hasn't been here for years.

Same attending a few times mentioned that residents shouldn't complain. The then forum head (forgot his name) argued this is a residents' forum so if residents weren't allowed to vent out their frustrations here where could they and diplomatically told the guy to shut up.

www.nbclosangeles.com

Las Vegas Hospital Accused of Dumping Psychiatric Patients in California

Las Vegas health officials are accused of shipping psychiatric patients, with a one way ticket, on Greyhound buses to Los Angeles, San Francisco and other California cities.
www.nbclosangeles.com www.nbclosangeles.com
 
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whopper said:
I'm 50 now. I remember being in residency complaining about this very same thing on this forum and some guy claiming to an attending from NYC claimed this stuff never happens.

Also where I did residency, it was near Philadelphia. What some of the Philly psychiatrists were doing is if they had a very low functioning patient and annoyed them they'd put them on a casino bus (Atlantic City had free buses going to to the city from NYC and Philly that even gave the person $50 when they stepped off the bus cause they all dropped it in the casino). When you have what amounted to dozens of people all from the same city, all low functioning schizophrenics, all from the same 3 hospitals, all showing up to your doorstep, "they drove me to this bus stop and told me if I got on the bus I'd get $50.....) Our ER had at least a few of these dump jobs in our ER a week. Same attending claimed this was completely fake and no doctor would do such a thing.

Then later it was found and proven the same thing was going on in Vegas (coincidence it as also a casino town) but instead of people being dumped to Vegas, the Vegas system was dumping them to California. California sued Nevada over this. So it's proven, and I confronted him on it, said "attending" never talked about it again. I remember this guy's forum handle but he hasn't been here for years.

Same attending a few times mentioned that residents shouldn't complain. The then forum head (forgot his name) argued this is a residents' forum so if residents weren't allowed to vent out their frustrations here where could they and diplomatically told the guy to shut up.

www.nbclosangeles.com

Las Vegas Hospital Accused of Dumping Psychiatric Patients in California

Las Vegas health officials are accused of shipping psychiatric patients, with a one way ticket, on Greyhound buses to Los Angeles, San Francisco and other California cities.
www.nbclosangeles.com www.nbclosangeles.com
Click to expand...
Our State Hospital closed its doors during the deinstitutionalization wave in the 90s, but up until then was pretty well known for taking all comers. I'm not in any position to see it now, but while I was in residency, it was not unheard of for folks to arrive at the bus station from other parts of the state, or even neighboring states, and say that they were "told to go to Bull Street."
 
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Dumping absolutely happens. I doubt you would ever be able to tie it down single doctors in particular since hopefully they aren't intimately planning out the details of the discharges, but institutionally, it's a huge deal.
 
I think that attending, who will go unnamed but hasn't been here for years, was suffering the Ivory Tower effect. I suspect he was likely a research doctor who had no real-world clinical experience in seeing WTF really happens.
 
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