When your patient overdoses...

Started by F0nzie
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F0nzie

F0nzie

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I can't help but feel betrayed when a patient overdoses a medication I prescribe them to help them out. It feels like a big F U.

Is there any psychodynamic interpretation behind this? Like underlying hostility toward the med, me, their mother or am I being crazy?

How does it make you guys feel?
 
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Obviously I can't speak for other patients who have attempted (or completed) suicide, but I know in my case the attempts I've made (one I almost succeeded with, one that would be considered farcical if it weren't for the seriousness of the subject matter) have never been aimed towards anyone but myself, and the thought process behind them has never really gone beyond a basic exercise in problem solving (and then putting things in place once the solution to the problem had been arrived at). There was one time when I was 14 that I made a suicidal gesture, fuelled by teen angst and bullying, where it was a definite case of "I'll show you", but the others it wasn't about getting back at anyone, or making any sort of a statement, or really anything that went beyond 'perceive problem -> solve problem -> proceed to implement problem solving decision'. For me at least it was a very 'tunnel focused' process of thinking.

There are some excellent websites with stories from suicide attempt survivors that might be helpful to understand things from a more 'personal narrative' point of view.

http://livethroughthis.org/

http://lifelineforattemptsurvivors.org/

http://talkingaboutsuicide.com/the-interviews/
 
What practical measures are there to counter this. Restricting benzodiazepine prescriptions to a 30-day supply with no refills?
 
DrBacchi said:
What practical measures are there to counter this. Restricting benzodiazepine prescriptions to a 30-day supply with no refills?
Click to expand...

Depends on the situation. I have list of questions running through my mind before I decide to give 30 days of benzos.

Is a benzo indicated for long term use?

Is the patient on opioids?

Was a urine drug screen performed?

Have alternative medications for anxiety been considered?

Has the patient engaged in therapy to treat their anxiety?

Is the patient actively using drugs or alcohol? Does the patient have a history of substance abuse?

Does the patient have a history of suicide attempts by overdose?

What is the status of the latest state prescription monitoring report?

Has the patient requested early refills or frequently lost their medications?

Will the medications be administered by a family member or group home?

If you want additional measures to restrict their supply you can write on your rx (please do not dispense more than 7 days at a time) forcing your patient to go to their pharmacy weekly.

I have a lady who stockpiles her medications because they make her feel safe in case she wants to attempt suicide. All I give her is monthly Invega IM.
 
F0nzie said:
Depends on the situation. I have list of questions running through my mind before I decide to give 30 days of benzos.

Is a benzo indicated for long term use?

Is the patient on opioids?

Was a urine drug screen performed?

Have alternative medications for anxiety been considered?

If you want additional measures to restrict their supply you can write on your rx (please do not dispense more than 7 days at a time) forcing your patient to go to their pharmacy weekly.
Click to expand...

While the 7 day supply thing makes perfect sense to me, some attendings have said that can put you in some dicey territory liability wise because then a lawyer can be like, "you didnt think it was safe to give them 60 pills, but you gave them 14 which was just as deadly when combined with that liter of vodka" or "you thought they were so dangerous you didn't think it it was safe for them to have psychiatric medications, but you didn't hospitalize them"

Curious what everyone's thoughts are
 
Armadillos said:
While the 7 day supply thing makes perfect sense to me, some attendings have said that can put you in some dicey territory liability wise because then a lawyer can be like, "you didnt think it was safe to give them 60 pills, but you gave them 14 which was just as deadly when combined with that liter of vodka" or "you thought they were so dangerous you didn't think it it was safe for them to have psychiatric medications, but you didn't hospitalize them"

Curious what everyone's thoughts are
Click to expand...

Look at my entire post. That's how you justify a benzo from a medical standpoint. If you can't justify it don't prescribe it at all.
 
F0nzie said:
Look at my entire post. That's how you justify a benzo from a medical standpoint. If you can't justify it don't prescribe it at all.
Click to expand...

I understand that, what I'm saying can you justify only giving a 7 day supply. Some attendings have said if you can't justify giving 30 days then you can't justify giving 7 either. (When it comes to dealing w/ a lawsuit)
 
Armadillos said:
I understand that, what I'm saying can you justify only giving a 7 day supply. Some attendings have said if you can't justify giving 30 days then you can't justify giving 7 either. (When it comes to dealing w/ a lawsuit)
Click to expand...

I have only written that way for people who are transferring to me from inpatient or another clinic if I am tapering their dose or detoxing them. I usually do not have time to meet with them weekly.
 
Probably the most unfortunate consequence is that it turns a lot of clinicians into defensive, timid, conservative shells of their former prescribing selves, which is detrimental to all the other patients we serve. Some docs will stop prescribing some meds (TCAs, lithium) after one bad outcome. Even now, I'll admit that when I usually see a patient who has overdosed on a TCA I'll Monday morning quarterback and tell myself I would have probably prescribed that patient something safer, even though I usually have no idea what the patient looked like when the Rx was written.

For more and more borderlines with past ingestions, I've just been giving them omega 3s and calling it a day.
 
cookymonster said:
Probably the most unfortunate consequence is that it turns a lot of clinicians into defensive, timid, conservative shells of their former prescribing selves, which is detrimental to all the other patients we serve. Some docs will stop prescribing some meds (TCAs, lithium) after one bad outcome. Even now, I'll admit that when I usually see a patient who has overdosed on a TCA I'll Monday morning quarterback and tell myself I would have probably prescribed that patient something safer, even though I usually have no idea what the patient looked like when the Rx was written.

For more and more borderlines with past ingestions, I've just been giving them omega 3s and calling it a day.
Click to expand...

Instead of looking at it as defensive, timid, conservative think risk vs. benefit. Makes our job a lot harder.
 
F0nzie said:
Instead of looking at it as defensive, timid, conservative think risk vs. benefit. Makes our job a lot harder.
Click to expand...
I agree... my point is that when the effects of recency bias and a case hitting close to home come in to play, we probably tend to overestimate risk, which can adversely affect how we practice. We all have a good understanding of the factors that contribute to a patient's suicide risk, including those that can and can't be modified, but a few bad outcomes over the course of a doctor's career will nevertheless carry a large impact. And of course, the more we worry about our patients between appointments, the more we're deterred from trying "risky" (but perhaps more beneficial) interventions.
 
I had a patient in residency that resented psychiatrists for trying to help him and viewed treatment as prolonging his suffering. He had disdain for psychiatric meds because he felt taking them represented his own inadequacy and therefore better off dead. He had never overdosed but had fantasies of killing himself with the very drugs that were trying to help him. I have not worked with him in several years but for some reason he popped in my head.
 
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F0nzie said:
Been UDSing everyone on a benzo. When they decline the drug screen I tell them "ok I will assume you are using" and decline the benzo rx. Whenever that happens I sleep like a champion at night.
Click to expand...
I like this idea. Ever consider getting alcohol biomarkers (%cdt)? I assume more patients on benzos are misusing this than other drugs.
 
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F0nzie said:
I can't help but feel betrayed when a patient overdoses a medication I prescribe them to help them out. It feels like a big F U.

Is there any psychodynamic interpretation behind this? Like underlying hostility toward the med, me, their mother or am I being crazy?

How does it make you guys feel?
Click to expand...

"It feels like a big F U. "

Sounds like a pretty good psychodynamic interpretation to me.
 
Yeah been there. I had the same reaction with one of my patients.

I've also had the unpleasant feeling of having failed/disappointed my patients (20 yo can't accept their diagnosis, act out by not taking meds, I try to process this with them - then they've requested another resident - though at least came back and was able to discuss things with me, now we're on the same page).

And for the benzos thing - I have one patient on a benzo out of the 4 or so sites I'm at. Took one guy off a crazy Valium dose (him also being on suboxone). He was signed out to me as "whatever you do, don't take him off his Valium, he'll make your life hell," (ummm, whatever that means). Gave him one chance to do a slow taper, used my script in 10 days and went to another provider (at the same place, and amazingly got another script). I took him down over 3 weeks. He HATED ME. But, he kept coming. After 2 months, he thanked me for getting him off of it, because he realized now that he was abusing it just like he used to abuse alcohol. Now he's doing better without them.

Unless it's very necessary, you're coming to therapy, not missing appointments, reliable, no drug history - none from me
 
Armadillos said:
I understand that, what I'm saying can you justify only giving a 7 day supply. Some attendings have said if you can't justify giving 30 days then you can't justify giving 7 either. (When it comes to dealing w/ a lawsuit)
Click to expand...
well they don't know what they are talking about. a 7 day supply is not as lethal as a 30 day supply (usual not lethal at all) and as most suicides are impulsive there is good evidence that means restriction is an effective intervention and lawyers who do this sort of litigation work know this. on the other hand there is no evidence supporting hospitalization as an intervention for suicide prevention (probably more evidence that it may increase suicide)
 
F0nzie said:
I can't help but feel betrayed when a patient overdoses a medication I prescribe them to help them out. It feels like a big F U.

Is there any psychodynamic interpretation behind this? Like underlying hostility toward the med, me, their mother or am I being crazy?

How does it make you guys feel?
Click to expand...

Quite simply - I couldn't care less about any underlying hostility, whatever the reason and to whomever it is directed. After doing proper due diligence, the patient is given a particular medication in good faith, and to help them. Instructions are given to the patients about how to take the medications properly. If they misuse the medication in any way, this is completely and totally on them.
 
splik said:
well they don't know what they are talking about. a 7 day supply is not as lethal as a 30 day supply (usual not lethal at all) and as most suicides are impulsive there is good evidence that means restriction is an effective intervention and lawyers who do this sort of litigation work know this. on the other hand there is no evidence supporting hospitalization as an intervention for suicide prevention (probably more evidence that it may increase suicide)
Click to expand...

I've done that with benzos, but ran into this weird thing in my state with Medicaid patients. They can only get 3-4 scripts filled per month total (I forget if it's 3 or 4). When 4 of those scripts are for weekly benzos and they're on other meds too, it just doesn't work. I've tried to explain to them what I am doing and why to get an exception, but that tends not to go over very well.
 
F0nzie said:
I can't help but feel betrayed when a patient overdoses a medication I prescribe them to help them out. It feels like a big F U.

Is there any psychodynamic interpretation behind this? Like underlying hostility toward the med, me, their mother or am I being crazy?

How does it make you guys feel?
Click to expand...

I kinda feel the same way when I send my wife or friends a text that they read, yet they don't respond. Might as well be staring at the phone and screaming **** you with a middle finger extended. Dicks...
 
It's interesting how the conversation went from benzos to overdose. I have never been warned about an overdose risk for benzos; in fact when I told one psychiatrist I used to see that I've never drunk he was surprised and asked me why I didn't (and this was when I was on 4 mg of Ativan--this is another one who was recently given a board of medicine reprimand for his prescribing--the first one I've seen that actually related to prescribing). I've never had even a sip of alcohol since I was 15 when I went on benzos because of the synergistic effect they have together. It seems like most overdoses I read about involve either a benzo or alcohol and an opiate. I don't think there's enough education on the effects a benzo and alcohol can have with each other—I've seen about 12 psychiatrists in my life, and none have ever mentioned it. And I hear people talking about it quite casually--especially when they fly, I'll hear people say they take a couple Xanax with a drink.

Anyhow, I'm not sure why there was the conversation pivoted to benzos though. While I detest them for many reasons, they were heralded as being so wonderful because they're difficult to overdose on when taken in isolation--especially if you compare them to lithium or TCAs, which from what I've read are far more toxic and have a much narrower range of safety, even when taken without other drugs.
 
sunlioness said:
I've done that with benzos, but ran into this weird thing in my state with Medicaid patients. They can only get 3-4 scripts filled per month total (I forget if it's 3 or 4). When 4 of those scripts are for weekly benzos and they're on other meds too, it just doesn't work. I've tried to explain to them what I am doing and why to get an exception, but that tends not to go over very well.
Click to expand...

So they come back in for an apt every week or are just able to write for a week with three fills?
 
jettavr6 said:
Quite simply - I couldn't care less about any underlying hostility, whatever the reason and to whomever it is directed. After doing proper due diligence, the patient is given a particular medication in good faith, and to help them. Instructions are given to the patients about how to take the medications properly. If they misuse the medication in any way, this is completely and totally on them.
Click to expand...
Until the DEA or Med board gets involved..
 
splik said:
well they don't know what they are talking about. a 7 day supply is not as lethal as a 30 day supply (usual not lethal at all) and as most suicides are impulsive there is good evidence that means restriction is an effective intervention and lawyers who do this sort of litigation work know this. on the other hand there is no evidence supporting hospitalization as an intervention for suicide prevention (probably more evidence that it may increase suicide)
Click to expand...
Means restriction is important for patient safety. So is hospitalisation/intervention for crisis/interpersonal conflict resolution, arranging psychosocial support,brief therapy and arranging continuity of care.
 
PikminOC said:
Until the DEA or Med board gets involved..
Click to expand...

Even more so at that point. All the medical board or DEA wants to see is that one did their due diligence and prescribed an appropriate medication for the patient. Patient was told risks vs. benefits, etc. At that point, it's out of your hands.
 
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medimedimedi said:
I like the idea of meeting with the family after a patient's suicide, but that made me wonder if there are any patient privacy concerns in disclosing information about the patient's diagnoses/therapy to the family posthumously. Is there such a thing as a posthumous HIPAA violation?
Click to expand...

First and foremost, consult with your medical malpractice carrier for their opinion. It may at times be appropriate to meet with a family, but it's always best to get legal advice as well.
 
Issuance of Multiple Prescriptions for Schedule II Substances
DEA has revised its regulations regarding the issuance of multiple prescriptions for schedule II controlled substances. Under the new regulation, which became effective December 19, 2007, an individual practitioner may issue multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a schedule II controlled substance provided the following conditions are met:
  1. Each separate prescription is issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice.
  2. The individual practitioner provides written instructions on each prescription (other than the first prescription, if the prescribing practitioner intends for that prescription to be filled immediately) indicating the earliest date on which a pharmacy may fill each prescription.
  3. The individual practitioner concludes that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse.
  4. The issuance of multiple prescriptions is permissible under applicable state laws.
  5. The individual practitioner complies fully with all other applicable requirements under the Controlled Substances Act and Code of Federal Regulations, as well as any additional requirements under state law.
It should be noted that the implementation of this change in the regulation should not be construed as encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing schedule II controlled substances. Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so.

http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm--
this is regarding Schedule 2 meds, not benzos.
 
When this^ went into effect, I wondered why not just allow 2 refills? So I go to the DEA website FAQ and it says not allowed as schedule II are not allowed refills. Makes no sense as that is essentially what is allowed with the 3 script rule. Waste of paper IMO.
 
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