Your favorite techniques for drug seekers

[peppy]

How do you guys like to approach that inevitable conversation we all end up having with patients about things like "Yes, I know that you said Xanax is the only medication that ever helped you, but I do not think that it is appropriate for me to prescribe it to you since you already have a problem with alcohol" ?

At one point I was working in an outpatient clinic where a ridiculous percentage of the clientele was coming in for their intake evaluation expecting to be given Xanax and I felt like I wasted so much time trying to have this conversation with people who thought they would be able to talk me into it even though it was not going to happen. Curious to see how you guys like to approach it and if anyone has found techniques to try to get them to accept that they're not going to get what they want before we go in circles over and over.

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[nexus73]

"Prescribing chronic benzodiazepines is not good medicine."

"If you take this all the time you'll get tolerant to it, then what will I give you if you're in crisis."

If you suspect someone only wants benzos, I'd recommend getting enough history to write a note and bill for the appointment, then broach the topic so they can choose to leave or stay and talk about other options.

 

[F0nzie]

My case managers tell all my new + transfer patients that I do not prescribe benzos. I also screen everyone at the pp for benzos before accepting. One lady called and was on 20mg of Xanax and wanted me to continue her treatment...They end up going elsewhere or seeing me and being agreeable to my recommendations.

I do prescribe benzos though, mostly for catatonia, severe TD, mania, fear of needles, fear of flying... I have very few on maintenance (people who fail multiple SSRIs and therapy) and have a flawless pharmacy record.

I've had 2 patients die while providing cross coverage and benzos were likely contributory. These patients were on benzos for years and their psychiatrists were not checking UDS.

 

[F0nzie]

I usually tell patients that there is no evidence for long term benzodiazepine therapy and that being on them long term may increase their mortality. Then see where the discussion goes from there...

 

[birchswing]

It's important to remember that benzodiazepines were some of the most widely prescribed drugs in the 20th century in the US with heavy direct-to-consumer marketing touting them as safe. Benzodiazepine prescriptions have increased in the 21st century, and I have seen direct-to-consumer marketing for Klonopin wafers and Xanax XR in waiting rooms.

I believe that the majority of bad information regarding the long-term effects of benzodiazepines has come from doctors and pharmaceutical manufacturers.

When I have searched for information on benzodiazepines, even recreational drug forum users seem to be caught up to speed, whereas there are doctors who are still prescribing benzodiazepines like it's the 1960s and think of them as they were thought of then.

To turn on a dime and decry the problem as coming from drug seekers is expedient.

People who like to get high for the fun of getting high seem to be aware both of the limitations of benzodiazepines in this way and their extraordinary risks of long-term misery.

I think the larger problem that most people are aware of is the iatrogenic problem caused in the community of anxious individuals who took these medications as would a person taking a blood pressure medication.

@F0nzie, I may be misinterpreting what you are saying, but do you not prescribe to new patients only or do you also not continue benzodiazepines on those who have been on long term "treatment"? What I see happening is that these long-term prescriptions are taking place by rather old psychiatrists who will eventually retire which will leave a large population of patients who are benzodiazepine dependent with a group of psychiatrists who rightly have a better understanding of benzodiazepines. If you take such a patient, what do you do? My psychiatrist is starting to reccommend patients to a 12-step inpatient "detox" treatment center--and these are people like me who are fastidiously careful and have never taken a pill more or less than prescribed. I've read horror stories from this treatment center. She says she doesn't have the time to help people any longer do outpatient withdrawal as she can't monitor for high blood pressure, tachycardia, etc. I frankly don't know the solution. I have a dilated thoracic aorta at the sinus of valsalva and I have to keep my blood pressure low. I can increase my beta blockers when I make a cut, but it's still extremely rough. I have little convulsions as I'm falling asleep even making the smallest possible cuts to my dose, which I've videotaped for my doctor to see if she thought they were seizures, and she said that things like that are why she is starting to send people inpatient because she can't diagnose something like that and doesn't know what to do for me.

Edit: I should clarify what my actual question is and make the question less specific in scope so it doesn't seem like it's related to my care: Do you inherit benzo-dependent patients, and if so, do you have a path for them? I understand your position against long-term treatment, but my question is whether that means you can't accept them at all, or if you can accept them with an agreement that takes them off the benzos, which presumably involves the prescription of benzos (unless there is some safe path to being benzo-free that doesn't involve the prescription of benzodiazepines I'm unaware of) ?

 

[F0nzie]

It's important to remember that benzodiazepines were some of the most widely prescribed drugs in the 20th century in the US with heavy direct-to-consumer marketing touting them as safe. Benzodiazepine prescriptions have increased in the 21st century, and I have seen direct-to-consumer marketing for Klonopin wafers and Xanax XR in waiting rooms.

I believe that the majority of bad information regarding the long-term effects of benzodiazepines has come from doctors and pharmaceutical manufacturers.

When I have searched for information on benzodiazepines, even recreational drug forum users seem to be caught up to speed, whereas there are doctors who are still prescribing benzodiazepines like it's the 1960s and think of them as they were thought of then.

To turn on a dime and decry the problem as coming from drug seekers is expedient.

People who like to get high for the fun of getting high seem to be aware both of the limitations of benzodiazepines in this way and their extraordinary risks of long-term misery.

I think the larger problem that most people are aware of is the iatrogenic problem caused in the community of anxious individuals who took these medications as would a person taking a blood pressure medication.

@F0nzie, I may be misinterpreting what you are saying, but do you not prescribe to new patients only or do you also not continue benzodiazepines on those who have been on long term "treatment"? What I see happening is that these long-term prescriptions are taking place by rather old psychiatrists who will eventually retire which will leave a large population of patients who are benzodiazepine dependent with a group of psychiatrists who rightly have a better understanding of benzodiazepines. If you take such a patient, what do you do? My psychiatrist is starting to reccommend patients to a 12-step inpatient "detox" treatment center--and these are people like me who are fastidiously careful and have never taken a pill more or less than prescribed. I've read horror stories from this treatment center. She says she doesn't have the time to help people any longer do outpatient withdrawal as she can't monitor for high blood pressure, tachycardia, etc. I frankly don't know the solution. I have a dilated thoracic aorta at the sinus of valsalva and I have to keep my blood pressure low. I can increase my beta blockers when I make a cut, but it's still extremely rough. I have little convulsions as I'm falling asleep even making the smallest possible cuts to my dose, which I've videotaped for my doctor to see if she thought they were seizures, and she said that things like that are why she is starting to send people inpatient because she can't diagnose something like that and doesn't know what to do for me.

It's a risk benefit discussion. I don't have any problems with maintenance therapy as long as the patient is adherent, not using drugs, and low risk for overdosing. The problem is many of them are. They come in like ticking time bombs with huge attitude, and do not want to hear what I have to say. I would say the most common reason for CMHC patients requesting a new doctor is because they're pissed about their benzos.

 

[birchswing]

It's a risk benefit discussion. I don't have any problems with maintenance therapy as long as the patient is adherent, not using drugs, and low risk for overdosing. The problem is many of them are. They come in like ticking time bombs with huge attitude, and do not want to hear what I have to say. I would say the most common reason for CMHC patients requesting a new doctor is because they're pissed about their benzos.

I see. That makes sense. I do see that benzodiazepines are concomitant in a number of overdose cases (the ones I come across in the news), and the epidemic of benzodiazepine dependence and addiction seems incredibly great compared to how much attention it receives versus that for opiates. NIDA seems to spend a disportioncate amount of effort into opiate abuse compared to mis-prescription, abuse, and tolerance of benzodiazepines. I guess from their point of view the overdoses are occurring with a mix of drugs, and so they focus on the opiate part of the combination. Maybe overdose versus long-term health effects is more of their focus.

But when it comes to withdrawal where there seems to be no national health focus for benzodiazepine users, I've read on some of these drug enthusiast forums where the people will talk about the experience of getting off of heroin versus a benzo, and they say there's no comparison--that benzos are in a class of their own. [I think in this case, these are people who use the drugs more sporadically and in larger volumes in a short period of time. With me, I'm rather binary. I'm terrified of taking medicines, but once it's prescribed, I take it at the exact same time (and in a way that assuages my OCD fears of not remembering which pill I took, etc; to be brief, it's very methodical).] Anyhow, at least with the opiates it seems that the programs for withdrawal are more codified and that withdrawal is not nearly as dangerous. Overdose is more of an issue that doesn't concern me personally as much. I am aware of the long-term effects the benzos have on my cognition and general health. But I am very, very careful when it comes to anything synergistically additive. I've never had a sip of alcohol in my adolescent/adult life. Don't even risk it when wine is cooked into something because I'm aware of how these drugs potentiate each other and you so easily slip to the other side. It seems like the national focus, at least from NIDA, is on that aspect but less so on the long-term health of benzodiazepine users who are not otherwise trying to get high. The programs for getting clean seem exclusively for opiate users--at least the ones that are set up in some non-ambiguous way. I am someone who really, really wants assurances of safety. And it's a bit ironic that opiate withdrawal is something that is handled more methodically, whereas benzodiazepine withdrawal which actually can be fatal is sort of a very unexplored area, and is done case by case based on the practitioner with very different techniques that seem to be based on more guesses than knowledge.

 

[TexasPhysician]

My favorite technique is initiating substance abuse treatment.

 

[MacDonaldTriad]

"If you take this all the time you'll get tolerant to it, then what will I give you if you're in crisis."

If you use this argument, count to three and poof, you have a patient in crisis. "But you said... So you don't care about me?"

 

[sunlioness]

Sometimes I think I should put posters of Elvis and MJ on my wall and when people ask me for stuff they shouldn't have, I could turn to the posters and say, "I don't know. Gentlemen, what do think?" And then say, "oh wait. They don't have an opinion. They're dead."

I haven't done this, mind you. But I've thought about it.


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[Shikima]

My favorite technique is initiating substance abuse treatment.

No. You're welcome to find someone else for a 2nd opinion.

 

[smalltownpsych]

" As a psychologist, I don't prescribe medications." They don't like to hear that line. Sometimes I will follow it up with "The only medications that are going to be as effective as the ones you have been abusing can also be abused so you might have to learn to cope with life without using alcohol or drugs." I actually told a guy yesterday that most people can get through the day without getting high, why can't you? I don't think he rescheduled. I do have substance abusers that I work with who are trying to get better, and I do enjoy working with them, but when they are still in active addiction with no desire to change then the best thing I can do is get 'em out of my office.

 

[Monkey House]

Always checking your state's prescription drug data base (if you have one) is often interesting and fruitful. If the patient has been getting benzos filled elsewhere and that is documented - the conversation changes very quickly.

 

[WalterDonnie]

I could very well stand alone on this position, but if all drugs were simply legalized, and regulated, this wouldn't even be a topic of conversation. Let opiate addicts buy opiates, and benzo addicts buy benzos. Then use all that money wasted on the drug war to provide quality services for addicts that want to recover. Drastically reduce crime/ decimate drug cartels overnight. Addicts are gonna get the drugs regardless, and you can't convince me that opiates or benzos are more dangerous than alcohol or tobacco.

 

[NickNaylor]

I could very well stand alone on this position, but if all drugs were simply legalized, and regulated, this wouldn't even be a topic of conversation. Let opiate addicts buy opiates, and benzo addicts buy benzos. Then use all that money wasted on the drug war to provide quality services for addicts that want to recover. Drastically reduce crime/ decimate drug cartels overnight. Addicts are gonna get the drugs regardless, and you can't convince me that opiates or benzos are more dangerous than alcohol or tobacco.

I don't think this position is particularly relevant in the case of drugs that are being prescribed, unless your position is that no drugs should be limited to being prescribed and could be purchased OTC/"on the street."

 

[chicagochildpsych]

I'm pretty straightforward with patients. Usually I say "I wouldn't give you (Xanax, klonopin, adderall) if you were my family member. I know you disagree, but I need to do what is medically appropriate "

 

[WalterDonnie]

I don't think this position is particularly relevant in the case of drugs that are being prescribed, unless your position is that no drugs should be limited to being prescribed and could be purchased OTC/"on the street."

Ya, that's my position. Let the addicts buy their Xanax and oxycodone at the 711. Problem solved. Then they can come to you when they want help, and nobody is wasting anyone's time.

 

[shan564]

Here's my usual overall paradigm, with tweaks according to the patient's psych history, med history, intellectual capacity, etc:

1. Start a full evaluation with appropriate empathy to make it clear to the patient that their well-being is my primary interest. Every time they ask about benzos during the eval, I'll say something like "OK; I understand that this has helped you in the past, but I can't make my treatment recommendations until I'm finished getting all of the information I need in order to fully understand your situation."

2. Explain what I think their actual problem is, and what the appropriate management is.

3. Explain benzos - I start by explaining mechanisms (at a level commensurate with patient's education/intellect), compare them to alcohol in terms of MoA, then validate the fact that they work short-term to make people feel better briefly, then explain the long-term effects, and then say something like "there was a time when these drugs were prescribed more because we didn't yet know about these long-term effects," and sprinkle in a few statements like "this is why I don't prescribe that drug."

4. Make it clear that I will not prescribe the drug, and that this is non-negotiable.

When the patient inevitably says something like "this is the only thing that works for me," I'll point out that there are several better treatments that haven't been tried yet, so that's not a reasonable statement. I'll also usually say something like "if your anxiety is worse than ever (as they usually say that it is), then clearly it didn't really work for you - it just made you feel better for a few hours, but had an overall negative long-term impact on your brain." I also often make the analogy that "just because things work doesn't mean that you should use them - you probably remember that alcohol made you feel good in the short-term too." If a patient can handle this analogy, I"ll say something like "a lot of things make people feel good for a little while... heroin makes people feel good too, but I won't be prescribing that to you either."

I'll also insist that a patient undergo a full course of CBT before I even consider a benzo (and still probably won't use one). That tends to effectively separate the pure drug-seekers from the people who actually want help, and are just demanding benzos because they have poor coping skills and they genuinely believe that it's the right treatment. I think many patients are demanding because of personality pathology that leads to all-or-nothing type of thinking.

 

[smalltownpsych]

In my experience, the people that do best with benzos are the people with no addiction hx who are worried that if they take them, they might get addicted. These folks also tend to be more motivated for psychotherapy and will say things to me like "I took a Xanax one day last week because I was having a panic attack and I am really worried that I might get hooked on them". Now a more sophisticated or intelligent addict might try to mimic this but usually not as effectively, especially since we know how much they are taking which is why the medication is frequently "lost" or "stolen".

p.s. They aren't always lying about the meds getting stolen either, as addicts tend to hang out with other addicts and stealing drugs from each other is inevitable.

 

[Ceke2002]

In my experience, the people that do best with benzos are the people with no addiction hx who are worried that if they take them, they might get addicted. These folks also tend to be more motivated for psychotherapy and will say things to me like "I took a Xanax one day last week because I was having a panic attack and I am really worried that I might get hooked on them". Now a more sophisticated or intelligent addict might try to mimic this but usually not as effectively, especially since we know how much they are taking which is why the medication is frequently "lost" or "stolen".

p.s. They aren't always lying about the meds getting stolen either, as addicts tend to hang out with other addicts and stealing drugs from each other is inevitable.

Just speaking from personal observation and experience, if someone has a former hx of addiction, and they're on a maintenance dose of benzos and are looking to do the right thing and not scam medication, they will usually be aware that due to their history there will be some mistrust so they will try and make sure they keep everything on the level as much as they possibly can. For me, currently being on a low dose of Valium, that meant when I had to change GPs I spoke to the new Doctor well in advance (ie I didn't just turn up on the day I'd run out of meds and demanded a script), I ascertained if they were okay with continuing the scripts for Valium first, I then gave them the contact details of my previous Doctor and had all of my notes transferred across to them. When I was doing the taper off of Xanax previously, and I did have a couple of unfortunate events where I was stupid enough to knock an entire bottle into a sink full of water, and a few months later had my bag stolen in a snatch and grab, I kept the bottle of dissolved mushy tablets for proof of what had happened, and I made sure I got a police report to show my Doctor at the time as well. What I didn't do was just turn up to an appointment and go 'Oh yeah something happened, and I totally can't prove it happened, but gimme my Xanax anyway'. My GP also now works alongside my Psychiatrist in regards to the Valium scripts, so they both know how much I'm taking and I can't trick either one of them into giving me more than I'm prescribed (not that I'd do that to either one of them anyway, because they are both excellent Doctors and I have too much respect for them, but these days I still like to make sure everything is kept above board when it comes to any benzo use). Generally speaking, in my experience at least, if a patient is wanting to do the right thing then their actions will show that.

 

[PistolPete]

Good stuff guys. I think this is all too easy to read as say to yourself "I can say/do that," but when it actually comes time to do so, NOT writing a prescription for something can be hard. I've learned this over the years, but I think that's the reason why so many doc prescribe benzos, simply because it's easier to write a script and get the patient out the door, then not write it and then have a long discussion as to why.

 

[AcronymAllergy]

Good stuff guys. I think this is all too easy to read as say to yourself "I can say/do that," but when it actually comes time to do so, NOT writing a prescription for something can be hard. I've learned this over the years, but I think that's the reason why so many doc prescribe benzos, simply because it's easier to write a script and get the patient out the door, then not write it and then have a long discussion as to why.

Or have folks start screaming about how Xanax is "the only thing that helps me, why can't you understand that?!"

Hear it at least a few times per week, through their closed office doors, from our psychiatrists' patients, many of whom have been on benzos for 20+ years through their PCP. I certainly understand it's an exceedingly distressing and scary change for the patients. But wow, do they get angry.

Folks get upset enough at me when I tell them their cognitive test results are normal, or that they don't have ADHD and don't need psychostimulants. I don't envy y'all at all.

 

[OldPsychDoc]

Good stuff guys. I think this is all too easy to read as say to yourself "I can say/do that," but when it actually comes time to do so, NOT writing a prescription for something can be hard. I've learned this over the years, but I think that's the reason why so many doc prescribe benzos, simply because it's easier to write a script and get the patient out the door, then not write it and then have a long discussion as to why.

"It takes 30 seconds to say 'Yes' and 30 minutes to say 'No'."

 

[MacDonaldTriad]

"Good news!, you don't have an illness."
"Yes I do you #@%&$..."
Suspicion antenna extend to 100%

 

[sunlioness]

So guy comes in. I've not seen him before. It's a 15 minute open med check. He brings his brother because he wants him to explain to me how bad things are. He starts telling me how the other docs are idiots who don't listen. That his problem isn't depression, it's anxiety and he doesn't know why he's been getting scripts for all these antidepressants that don't work. Chart lists allergy to gabapentin and a history of substance abuse. He starts telling me how Valium is the only thing that's ever worked for him. But then it takes a turn. He's been talking to his brother who's also a patient and he wants to try amitriptyline. "Can I do that?"

Um. Yeah, sure. He leaves happy.

Go figure.


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[smalltownpsych]

So guy comes in. I've not seen him before. It's a 15 minute open med check. He brings his brother because he wants him to explain to me how bad things are. He starts telling me how the other docs are idiots who don't listen. That his problem isn't depression, it's anxiety and he doesn't know why he's been getting scripts for all these antidepressants that don't work. Chart lists allergy to gabapentin and a history of substance abuse. He starts telling me how Valium is the only thing that's ever worked for him. But then it takes a turn. He's been talking to his brother who's also a patient and he wants to try amitriptyline. "Can I do that?"

Um. Yeah, sure. He leaves happy.

Go figure.


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The takeaway from that is that not all med seekers are drug addicts. Some are looking for relief for their symptoms and have a dependent flavor to their personality. Much different than the patient who is looking to get high although some of the behaviors overlap. UDS can help sort them out, but so can countertranserence. For me, I don't mind the true addicts to much and can usually engage in a humorous way whereas the dependent personality types, just keep whining no matter what and I feel like laughing at them not with them. Both categories are notoriously resistant to paychotherapy, but the dependent types will keep showing up. They just won't get better.

 

[notdeadyet]

The takeaway from that is that not all med seekers are drug addicts.

I'd also make a plug that not all drug addicts are med seekers.

 

[smalltownpsych]

I'd also make a plug that not all drug addicts are med seekers.

Very true. There are a lot more effective ways to get high than dealing with the medical system. Alcohol is cheap and very easy to access and illicit drug dealers never cut you off so long as you have a little cash.

 

[clausewitz2]

Very true. There are a lot more effective ways to get high than dealing with the medical system. Alcohol is cheap and very easy to access and illicit drug dealers never cut you off so long as you have a little cash.

Yeah we got a lot fewer folks looking to score opioids after some boys came down from Detroit with AKs and a cheap connect for heroin, by all accounts.

 

[smalltownpsych]

Yeah we got a lot fewer folks looking to score opioids after some boys came down from Detroit with AKs and a cheap connect for heroin, by all accounts.

Out here in the West it is the Mexican mafia and they develop the distribution with the meth first, then the heroin is soon to follow.

 

[WisNeuro]

Out here in the West it is the Mexican mafia and they develop the distribution with the meth first, then the heroin is soon to follow.

Much better than out East dealing with the Amish mafia. You DO NOT want to get addicted to their product. Do you know how expensive handmade wooden deck furniture is?