Use of multiple benzos with stimulants

[Claydoe]

Hi all, I'm wondering if you could offer any insight about a patient who came into my pharmacy today with scripts for Ritalin 30 mg qid xanax 0.5 bid and klonopin 2mg bid. I really don't pretend to be a psych expert so i called the office and got a response of "just fill it". I didn't end up filling it but I guess my questions are where do you guys typically draw the line on titrating stimulant doses, what's the rationale behind prescribing stimulants with benzodiazepines, and what's the rationale behind using multiple benzodiazepines?

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[nitemagi]

It's not a good rule of thumb to mix benzos, period. Or to have them on it longstanding. Or to mix them with other abusable medications.

But there's a lot of bad polypharmacy out there that isn't a good idea but isn't technically illegal. Sometimes it's a good reason like a cross-titration for two of the same class. I've most often seen it used for those with ADHD and anxiety, especially for the demanding impatient patient who wants immediate relief and had fifty reasons to not try an SSRI.

 

[Shikima]

Every.single.day.

 

[WisNeuro]

Rationale for multiple benzos? What's the rationale for using a single benzo in the vast majority of cases?

 

[MacDonaldTriad]

The rational is that it is desired by patients and it isn't illegal. That is a good enough rational for a lot of doctors out there, but good for you for not doing it. I can agree with nitemagi's reasoning, but in those cases, they shouldn't be coming to you to refill if they are on a tapper with someone else.

 

[st2205]

The rational is that it is desired by patients and it isn't illegal. That is a good enough rational for a lot of doctors out there, but good for you for not doing it. I can agree with nitemagi's reasoning, but in those cases, they shouldn't be coming to you to refill if they are on a tapper with someone else.

Perhaps I'm not understanding you correctly, but OP is presumably a pharmacist and not the one being asked to prescribe.

 

[Merovinge]

Hi all, I'm wondering if you could offer any insight about a patient who came into my pharmacy today with scripts for Ritalin 30 mg qid xanax 0.5 bid and klonopin 2mg bid. I really don't pretend to be a psych expert so i called the office and got a response of "just fill it". I didn't end up filling it but I guess my questions are where do you guys typically draw the line on titrating stimulant doses, what's the rationale behind prescribing stimulants with benzodiazepines, and what's the rationale behind using multiple benzodiazepines?

Options include:
1) Psychiatrist/PCP who is treating adult ADHD and anxiety disorder; likely in a higher functioning patient paying them cash or has good private insurance and they want to keep the patient (this is at the top of my differential). Something something this is the only way I can focus and not have panic attacks, you're saving my life doc, and both people feel good about it.

2) Pt is really just selling the drugs, although I would expect to see Xanny bars (2mg dosage) and Adderall in lieu or methylphenidate products which have way less euphoria for much adults

3) Really really bad MD

Ritalin should not be dosed QID, this just does not make sense. If you need longer duration, use a longer acting. This seems like they just want a stockpile around to give/sell to friends who need help studying.

Dual benzo's is complete garbage. If you want to have 5 xanax in a Rx PRN prior to a procedure/flight for someone on baseline clonazepam I wouldn't be terribly offended but this is the only scenario that makes sense for dual benzo use.

 

[Claydoe]

Options include:
1) Psychiatrist/PCP who is treating adult ADHD and anxiety disorder; likely in a higher functioning patient paying them cash or has good private insurance and they want to keep the patient (this is at the top of my differential). Something something this is the only way I can focus and not have panic attacks, you're saving my life doc, and both people feel good about it.

2) Pt is really just selling the drugs, although I would expect to see Xanny bars (2mg dosage) and Adderall in lieu or methylphenidate products which have way less euphoria for much adults

3) Really really bad MD

Ritalin should not be dosed QID, this just does not make sense. If you need longer duration, use a longer acting. This seems like they just want a stockpile around to give/sell to friends who need help studying.

Dual benzo's is complete garbage. If you want to have 5 xanax in a Rx PRN prior to a procedure/flight for someone on baseline clonazepam I wouldn't be terribly offended but this is the only scenario that makes sense for dual benzo use.

I voiced my concern about that many ir Ritalin and brought up er dosing, wasn't really given an answer though. I also thought the dual benzos was garbage but I've only been in the game for less than a year so I figured I'd get some insight from over here. I think you hit it with point 1 though as i got a custody battle single mom sob story.

 

[FlowRate]

I would not have refused to dispense all of the above. No reason to put the patient in benzo withdrawal. At least give out the clonaz.

 

[Shikima]

Rationale for multiple benzos? What's the rationale for using a single benzo in the vast majority of cases?

Another doc told me once that he first started off thinking benzos were the devil but then later found religion in that it helps masses of people live ordinary lives where they would be consistently conflicted by anxiety.

 

[WisNeuro]

Another doc told me once that he first started off thinking benzos were the devil but then later found religion in that it helps masses of people live ordinary lives where they would be consistently conflicted by anxiety.

I'm hoping this is a sarcastic story. I've seen plenty of people put on maintenance benzos for years. Guess what proportion are out there, engaging with the world, with vastly improved quality of life? Not many. Deluded doctors like this are just willfully blind to the damage that they are doing to their patients. This is a personal pet peeve of mine as I used to treat panic disorder and PTSD before my neuro days. Highly effective treatments. Once someone is on a benzo, fat chance of getting them to go through an actual course of therapy.

 

[birchswing]

Another doc told me once that he first started off thinking benzos were the devil but then later found religion in that it helps masses of people live ordinary lives where they would be consistently conflicted by anxiety.

In my experience those doctors disappear in one way or another. Would be curious if there are psychiatrists who start patients on benzos and follow them for 20 years and feel the same way.

 

[WisNeuro]

In my experience those doctors disappear in one way or another. Would be curious if there are psychiatrists who start patients on benzos and follow them for 20 years and feel the same way.

I'm not seeing this disappearance just yet. I still get plenty of people coming in from outside prescribers on benzo cocktails.

 

[birchswing]

And I should have clarified by disappear I didn't mean lost license or anything, just that they either moved out of state or retired. In general there seems to be more turnover with psychiatrists where I am than other professions.

 

[st2205]

I'm hoping this is a sarcastic story. I've seen plenty of people put on maintenance benzos for years. Guess what proportion are out their, engaging with the world, with vastly improved quality of life? Not many. Deluded doctors like this are just willfully blind to the damage that they are doing to their patients. This is a personal pet peeve of mine as I used to treat panic disorder and PTSD before my neuro days. Highly effective treatments. Once someone is on a benzo, fat chance of getting them to go through an actual course of therapy.

Have you approached this subject in person with those prescribing these medications? It seems you've come here multiple times to displace this frustration on people who largely agree with you.

 

[WingedOx]

Another doc told me once that he first started off thinking benzos were the devil but then later found religion in that it helps masses of people live ordinary lives where they would be consistently conflicted by anxiety.

Yes, but in that case, they could always get a service dog.

/ducks and runs from thread.

 

[WisNeuro]

Have you approached this subject in person with those prescribing these medications? It seems you've come here multiple times to displace this frustration on people who largely agree with you.

I generally make a recommendation in my report, especially when the prescribing is egregious (e.g., benzo in geriatric patient with dementia with mild anxiety) and if it is the provider who ordered the consult, we discuss it. It's mostly outside providers at this point, the VA has gotten much better about this over the past decade.

 

[WingedOx]

I generally make a recommendation in my report, especially when the prescribing is egregious (e.g., benzo in geriatric patient with dementia with mild anxiety) and if it is the provider who ordered the consult, we discuss it. It's mostly outside providers at this point, the VA has gotten much better about this over the past decade.

outside PCPs especially.

 

[WisNeuro]

outside PCPs especially.

The bulk, yes. Although we still get some from outside psychiatrists. Usually the a handful of the same ones, I assume because they have a reputation for being lenient for certain meds, or are the ones that the patients get to after they've provider-shopped around for a while.

 

[Shikima]

I'm hoping this is a sarcastic story. I've seen plenty of people put on maintenance benzos for years. Guess what proportion are out their, engaging with the world, with vastly improved quality of life? Not many. Deluded doctors like this are just willfully blind to the damage that they are doing to their patients. This is a personal pet peeve of mine as I used to treat panic disorder and PTSD before my neuro days. Highly effective treatments. Once someone is on a benzo, fat chance of getting them to go through an actual course of therapy.

This is not a sarcastic story, rather a very real story.

Pills before skills.

 

[nitemagi]

I'm hoping this is a sarcastic story. I've seen plenty of people put on maintenance benzos for years. Guess what proportion are out their, engaging with the world, with vastly improved quality of life? Not many. Deluded doctors like this are just willfully blind to the damage that they are doing to their patients. This is a personal pet peeve of mine as I used to treat panic disorder and PTSD before my neuro days. Highly effective treatments. Once someone is on a benzo, fat chance of getting them to go through an actual course of therapy.

From my experience this is often from the slippery slope of mistaking patient subjective report of "but I feel better" for actual functional improvement. It's easier for me as a new provider coming in, rather than if I've gotten caught in adding something as an emergency and then through various crises continued the benzo for too long. If I catch it, though, it's a good opportunity to use the leverage to nudge them to more exploratory/exposure behaviors, if they want to continue the med. "I'll give you another 2 weeks supply if you get out of the house daily and go apply for X job in person."

 

[WingedOx]

From my experience this is often from the slippery slope of mistaking patient subjective report of "but I feel better" for actual functional improvement. It's easier for me as a new provider coming in, rather than if I've gotten caught in adding something as an emergency and then through various crises continued the benzo for too long. If I catch it, though, it's a good opportunity to use the leverage to nudge them to more exploratory/exposure behaviors, if they want to continue the med. "I'll give you another 2 weeks supply if you get out of the house daily and go apply for X job in person."

I've tried this a bit lately. I recently inherited a guy on 2 mg xanax TID who's doing about as well as you'd expect someone on 6 mg of xanax a day to be doing. I can dig back through his old records and it's full of sentences like "recommended to patient that he lower the xanax dose" as the script continued to increase over time. I told him I wouldn't make any changes this first appointment, but if he failed to show up for his CBT sessions that I'd refuse to continue on a treatment regimen that I felt was hurting him at the next appointment.

 

[nitemagi]

I've tried this a bit lately. I recently inherited a guy on 2 mg xanax TID who's doing about as well as you'd expect someone on 6 mg of xanax a day to be doing. I can dig back through his old records and it's full of sentences like "recommended to patient that he lower the xanax dose" as the script continued to increase over time. I told him I wouldn't make any changes this first appointment, but if he failed to show up for his CBT sessions that I'd refuse to continue on a treatment regimen that I felt was hurting him at the next appointment.

Exactly. It's the line between encouraging and enabling.

 

[WingedOx]

Exactly. It's the line between encouraging and enabling.

I think he showed to the first two therapy appointments then stopped coming. Not sure when the next one with me is. He may be hoping he can cancel on me too in the hope I'll just continue his script in perpetuity.

I also just finished with a "I'm at work/school all day and I'm tired in the evening when I get home. I need more stimulant" patients.... grrr.

 

[tr]

I think he showed to the first two therapy appointments then stopped coming. Not sure when the next one with me is. He may be hoping he can cancel on me too in the hope I'll just continue his script in perpetuity.

Yes this is a big thing - people avoiding appointments and hoping/expecting their prescriptions will just be auto-renewed. When I inherit someone like this I let them know that I do not prescribe bzds for chronic use; ideally we will collaboratively design a tolerable taper schedule, but if not and/or they pull the fade I will just cut their prescription down by 5 pills per month every time I renew it until they are off the bzd.

 

[WingedOx]

Yes this is a big thing - people avoiding appointments and hoping/expecting their prescriptions will just be auto-renewed. When I inherit someone like this I let them know that I do not prescribe bzds for chronic use; ideally we will collaboratively design a tolerable taper schedule, but if not and/or they pull the fade I will just cut their prescription down by 5 pills per month every time I renew it until they are off the bzd.

I've only had to do a couple "hostile tapers" in the last year or so. Both have been ugly. One was a patient who was taking lorazepam 5-7(!) times per day not so long ago. She had a legendary psychiatrist who had a reputation for giving the patients whatever they wanted whenever they wanted, including opiates. I have her down to 0.5 mg BID, which in the grand scheme of things I'm actually surprised I've gotten it down this far.

The other one had a history with the same doc, 74 years old, on a "stable" TID regimen but just wouldn't stop lying to me about the fact that he was driving an hour each way to get norcos from an outside doctor. I'd ask him every time I saw him if he was getting them. He'd deny it. I'd show him the state Rx monitoring program screen showing me he was lying. Repeat every month. I handed him a consent and told him he either signs and lets me talk to the pain clinic he's going to or I taper off. He insisted it was "none of my business" what other controlled substances he was getting and refused. He complained to my supervisor and just about every other higher up in the hospital about me for it. Needless to say it didn't help.

 

[Liquid8]

Ritalin 30mg QID really bothers me – the total dose is much too high for my liking, and most of the patients with genuine ADHD that I’ve seen will report incredible difficulty managing taking the medication twice a day, let alone 4 times.

Also, with this regime it seems likely that stimulants are being taken too late in the day which may be Impacting on the patient’s sleep and I did wonder if that was the reason for benzos in this case. It would make more sense to use a long acting stimulant, and then perhaps the need for benzos will decrease.

 

[PikminOC]

Op, contact dea and state board for overprescribing and let them look into it

 

[WingedOx]

Ritalin 30mg QID really bothers me – the total dose is much too high for my liking, and most of the patients with genuine ADHD that I’ve seen will report incredible difficulty managing taking the medication twice a day, let alone 4 times.

Also, with this regime it seems likely that stimulants are being taken too late in the day which may be Impacting on the patient’s sleep and I did wonder if that was the reason for benzos in this case. It would make more sense to use a long acting stimulant, and then perhaps the need for benzos will decrease.

Yeah, glad I'm not the only one to notice that too. Only other time I saw a patient come to me on anything even close to that much was a guy who was pretty clearly hypomanic. I don't remember if he also had benzos on board too, but had been on the stimulant dose for years and commented on how great his last psychiatrist was for "giving me all this energy!".

 

[OldPsychDoc]

Yeah, glad I'm not the only one to notice that too. Only other time I saw a patient come to me on anything even close to that much was a guy who was pretty clearly hypomanic. I don't remember if he also had benzos on board too, but had been on the stimulant dose for years and commented on how great his last psychiatrist was for "giving me all this energy!".

Let me guess, ultradian rapid cycling bipolar disorder...

 

[WingedOx]

Let me guess, ultradian rapid cycling bipolar disorder...

Ha. Thankfully none of that. It was being prescribed as almost a Nootropic. Patient loved only sleeping a few hours per night.

His previous psychiatrist was also an OMM truther, whish was interesting too.

 

[dl2dp2]

Options include:
1) Psychiatrist/PCP who is treating adult ADHD and anxiety disorder; likely in a higher functioning patient paying them cash or has good private insurance and they want to keep the patient (this is at the top of my differential). Something something this is the only way I can focus and not have panic attacks, you're saving my life doc, and both people feel good about it.

This is off topic but I don't think this kind of a case is really a cash cow in cash...Mixing benzo with adderall, esp. both at immediate release, is often a sign of underlying character pathology. In a cash mainly med mgmt practice, you want to AVOID taking too many people with substantial character pathology. I see this more often in community practice when people just don't have time to deal with it.

 

[Merovinge]

This is off topic but I don't think this kind of a case is really a cash cow in cash...Mixing benzo with adderall, esp. both at immediate release, is often a sign of underlying character pathology. In a cash mainly med mgmt practice, you want to AVOID taking too many people with substantial character pathology. I see this more often in community practice when people just don't have time to deal with it.

Can agree to disagree then. Suburban mom's (stereotype here for imagery, plenty of guys fall in this boat) love benzo + stim combinations and will provide at least top flight private insurance if not cash to acquire them with very little hassle for the PP psychiatrist. This is not a rare thing around my area and these folks are very "high functioning" by some metrics.

 

[nitemagi]

Can agree to disagree then. Suburban mom's (stereotype here for imagery, plenty of guys fall in this boat) love benzo + stim combinations and will provide at least top flight private insurance if not cash to acquire them with very little hassle for the PP psychiatrist. This is not a rare thing around my area and these folks are very "high functioning" by some metrics.

I agree. Writing the prescriptions and not asking questions makes people like this easy. Most agitated drug-seekers will get quite calm if you give them what they want. Behaviorally it's an escalation approach on their part.

 

[Strider_91]

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