Whats your approach to controlled substances?

[goldsummer]

When is comes to Testosterone, sleep (zolpidem/lunesta/etc), anxiety (BDZ), ADHD meds, opioids...

Do you prescribe these? If no, why?
Do you see these patients every 3 months/6 months/annually prior to continuing refilling these meds? Require specialist check in annually (ie. Psych with ADHD)?
Do you have a contract with all or just specific drugs?

And any other information you wanna share
Just curious what other providers' routine is when it comes to these meds.
Thanks.

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[hallowmann]

Yes to all in the appropriate situation. Every 3 mos at a minimum, sometimes monthly, sometimes more frequently depending on the situation. Contracts depending on standard of care, but generally I don't find requiring patients to sign these useful. I have policies in place that clarify what I can and cannot do with regards to these and I am very upfront with patients about what is appropriate/legal.

 

[Ironheme]

When is comes to Testosterone, sleep (zolpidem/lunesta/etc), anxiety (BDZ), ADHD meds, opioids...

Do you prescribe these? If no, why?

Yes, though less of the HRT, z drugs, BZD.

Do you see these patients every 3 months/6 months/annually prior to continuing refilling these meds? Require specialist check in annually (ie. Psych with ADHD)?
Do you have a contract with all or just specific drugs?

Depends. At least every 3 months for controlled substances, monthly for most cases. Specialist for establishing diagnosis if I need help. If condition is stable, then I usually will continue. If there are flare ups/outside of my comfort zone, then I will send back to the specialist.
Contract for controlled substances.

And any other information you wanna share
Just curious what other providers' routine is when it comes to these meds.
Thanks.

Always have a start and end plan. How long are you planning on continuing? Make sure your patient is on board. ADHD meds - only for school/dangerous occupations for the stimulants.

Example, whenever I prescribe BZD for short term use, I tell patients - this will feel like a magic pill. You will likely want to ask me for more, but understand I will tell you no because they are addictive and meant only for short term use. This is just until the other medication kicks in.

I had a patient come back to me and tell me 'you were right! It was like a magic pill!' but because I had explained the above, they did not ask me for further refills.

 

[B1GM0N3Y86]

Not at this time.

My last office I worked at was a pill mill in very small rural town. I had one colleague leave 2 months after I started. Guess who became their new pcp, the new guy. Saw too many of his patients on > 100 MME per day while being on maxed out Xanax, Neurontin plus some Muscle Relaxant. Found out he gave anyone controls that even remotely asked for them and escalate them over 6 months.

Thankfully I was able to leave that office after 2 years. I was able keep my dignity by helping these people, however it was too time consuming and mentally draining. Many of these people needed addiction medicine. So my next practice I joined was one that didn't spend much time prescribing this stuff.

However it was good to hear later from a nurse, that the 70yo doc who was still working at my old office being told by pharmacies they would not accept anymore controlled substances from him. The guy was a real POS, stethoscope should've been taken from him a decade ago.

 

[allantois]

From psych perspective I don’t see the value of requiring psych input annually. Either refer them out to us or keep them. Patients condition may change and no one can be rubber stamped with a treatment plan for a year. And please don’t start them on Xanax and punt to psych. It’s very rarely necessary to start someone on a BZO while their SSRI begins to work and hydroxyzine is worth a try first

 

[DJKitty]

Hi there! I'm a geriatric psychiatrist, so my input is mainly for patients 65 and up.
1) If you are thinking about starting a benzodiazepine for anxiety and/or sleep, please think again. It is not standard of care and benzodiazepines are on the AGS Beers List of Potentially Inappropriate Medications for Use in Older Adults. There a number of more appropriate options and if you end up referring to me, I'm going to taper them off any benzodiazepines. My go to medications for generalized anxiety disorder and panic disorder in older adults are sertraline 25 mg po daily x 2 weeks, then increase to 50 mg po daily thereafter or escitalopram 5 mg po daily x 2 weeks then increase to 10 mg thereafter. I avoid citalopram since max dose in older adults is 20 mg and I usually need a wider dose range. I also avoid paroxetine given high anticholinergic burden. Buspar is also good for generalized anxiety disorder. If someone needs something for breakthrough anxiety I usually go off-label with very low dose trazodone (like 12.5 mg), low dose gabapentin (100 mg po TID prn anxiety) or if the person is a really healthy 65 with no medical problems, low dose hydroxyzine (like 10 mg).

2) For sleep, please don't use temazepam in older adults or benzodiazepines just for sleep. Also, remember the maximum dose of zolpidem in older women is 5 mg po QHS. I'm not opposed to very short term courses (think 1-2 weeks) of lunesta 1 or 2 mg or low dose sonata in patients without risk factors for falls or cognitive impairment. I like to use low dose doxepin (3 to 6 mg) if no contraindication because it is NOT on the Beers List. Some people do well on ramelteon, but insurance usually requires a prior authorization. Mirtazapine is good for those who also have depression or are losing weight, but remember that it is actually the most sedating at the lowest doses (so if using for sleep, 7.5 mg is more sedating than 15 mg). I do tend to use a lot of trazodone in people without contraindications with pretty good effectiveness.

3) I don't really prescribe stimulants given my demographic, so I can't really comment on that aspect.

I do require a controlled substances agreement be signed and random urine drug screens at least once per year. I also agree that either the PCP OR the psychiatrist should be managing the psychotropic medications and not both. You get into a "too many cooks in the kitchen" situation and in the end it isn't good for the patient. What I've seen happen is patients end up on 2 different SSRIs at high doses-1 from the PCP and 1 from the psychiatrist and I've seen 1 case of serotonin syndrome from this happening.

Also, please, if you are going to start a benzodiazepine, please do not use alprazolam. I beg of you. It has a really short half life and patients end up withdrawing in between doses. This withdrawal looks like increased anxiety symptoms which leads to dose increases and then you get patients on some ridiculously high doses of alprazolam. In psychiatry, we typically use low dose clonazepam or low dose lorazepam. Diazepam has such a long half life that I don't use it in older adults, but for younger folks you are probably ok.

Thank you, PCPs for all you do for our shared patients. Y'all are amazing .

 

[filmfan10]

Rheum here.

So, I see a lot of chronic pain and arthritis patients. We are put in a bind a lot because cardiology or nephrology will tell patients they can't take NSAIDs. And then they come to my office with pain complaints.

I don't mind prescribing opioids for pain. However, I have limits.
I prescribe low to moderate strength opioids. If patients feel that they need high dose opioids, I refer them to pain management.

I am not comfortable with prescribing Benzos or Stimulants.

For some odd reason, in the last 2 months, I have seen a surge of patients specifically asking for stimulants. I don't know what is happening. I am not sure if this is like from TikTok or what.

When patients ask for stimulants for fatigue, I do a little lab workup. I do tell patients that they need to see a sleep medicine doctor and a psychiatrist.

I am just not trained in managed anxiety or stimulants

 

[allantois]

Rheum here.

So, I see a lot of chronic pain and arthritis patients. We are put in a bind a lot because cardiology or nephrology will tell patients they can't take NSAIDs. And then they come to my office with pain complaints.

I don't mind prescribing opioids for pain. However, I have limits.
I prescribe low to moderate strength opioids. If patients feel that they need high dose opioids, I refer them to pain management.

I am not comfortable with prescribing Benzos or Stimulants.

For some odd reason, in the last 2 months, I have seen a surge of patients specifically asking for stimulants. I don't know what is happening. I am not sure if this is like from TikTok or what.

When patients ask for stimulants for fatigue, I do a little lab workup. I do tell patients that they need to see a sleep medicine doctor and a psychiatrist.

I am just not trained in managed anxiety or stimulants

It's the fibromyalgia-ADHD-POTS triad

 

[ObsequiousAplomb]

It's the fibromyalgia-ADHD-POTS triad

I love treating this with an SNRI (or TCA if not suicidal) and psychotherapy. Fascinating how Effexor 75 or Cymbalta 20 suddenly makes this challenging combination stable when they're being seen by an MD weekly.

I, too, wonder about the benefit of having someone see me once a year for their ADHD. While ADHD is often comorbid, I don't see much utility in checking in on otherwise stable patients. I'm happy to take over the stimulant for ADHD patients to take the burden off of PCPs, and I'm also happy to have them see PCPs without my input.

I also agree that it's better to have one person prescribe all the psychotropics. I always feel for the PCPs that end up trying to satisfy patients I'm already seeing, especially since I inevitably fire patients who get psychotropics from a second provider while I'm seeing them.

Of course, for the patients where dual treatment is important, I always make myself as available as possible for PCPs who have questions - even going as far as scheduling "appointments" that are really phone calls for me to collaborate with the PCP.

 

[SLC]

I don’t start recurring Benzos, ever. I’ll prescribe a few tablets for procedural anxiety, fear of flying etc. but never for panic or generalized anxiety. Never any refills of any kind. You use them for the procedure/trip and then we stop them.

I don’t do chronic pain, at all.

I do manage ADD, and most of the time don’t start stimulants for adults. Kids, we do an eval and I will generally start them.

Testosterone: I’m not a believer in the clinical utility of T replacement; but am fairly willing to treat with a verified diagnosis.

I have a very long contract, it has lots of language about patients being required to come in every 12 weeks, never call for refills outside an office visit, never replace lost or stolen meds etc, all the standard stuff. But also that patients must be working earnestly to control their other chronic medical problems, attend their annual physical, stay up to date with health screenings, and participate fully in any assessment I order, any referral I order, and take any alternate medication I prescribe as a condition of being prescribed a controlled substance.

 

[Keona]

I very rarely start patients on controlled substances. Most recent was a short course of a benzo for a very traumatic young child death and having to deal with funeral, police, etc. saw them back recently and they thanked me for not continuing it long term because another family member dealing with same situation is now addicted to the meds after their dr kept refilling it and giving them higher doses. (I was very clear it wouldn’t be safe to do that).
Elderly people who have been on benzos since they were 17 I don’t try to wean off unless they’re having issues. Most of them I inherited at 0.25 mg up to twice a day. I have one who is carrying around her bottle from 2007. I don’t start it people on opiates but I’ve continued the ones I inherited in the practice. We do twice a year urine drug screens and update contracts annually. I refer people to pain management if they think they need started on opiates. Our local pain management has been able to keep a lot of them off of opiates with their interventions or do shorter courses. Adhd wise I want them to have appropriate testing and I’ll prescribe to kids and some adults. Like 2-3 total.

 

[ObsequiousAplomb]

I very rarely start patients on controlled substances. Most recent was a short course of a benzo for a very traumatic young child death and having to deal with funeral, police, etc. saw them back recently and they thanked me for not continuing it long term because another family member dealing with same situation is now addicted to the meds after their dr kept refilling it and giving them higher doses. (I was very clear it wouldn’t be safe to do that).
Elderly people who have been on benzos since they were 17 I don’t try to wean off unless they’re having issues. Most of them I inherited at 0.25 mg up to twice a day. I have one who is carrying around her bottle from 2007. I don’t start it people on opiates but I’ve continued the ones I inherited in the practice. We do twice a year urine drug screens and update contracts annually. I refer people to pain management if they think they need started on opiates. Our local pain management has been able to keep a lot of them off of opiates with their interventions or do shorter courses. Adhd wise I want them to have appropriate testing and I’ll prescribe to kids and some adults. Like 2-3 total.

I'm curious why you want testing for ADHD?

 

[sloh]

I love treating this with an SNRI (or TCA if not suicidal) and psychotherapy. Fascinating how Effexor 75 or Cymbalta 20 suddenly makes this challenging combination stable when they're being seen by an MD weekly.

You sure it’s the SNRI doing any significant lifting here or is it largely the buy-in from the patient and psychotherapy?

 

[PikminOC]

Hi there! I'm a geriatric psychiatrist, so my input is mainly for patients 65 and up.
1) If you are thinking about starting a benzodiazepine for anxiety and/or sleep, please think again. It is not standard of care and benzodiazepines are on the AGS Beers List of Potentially Inappropriate Medications for Use in Older Adults. There a number of more appropriate options and if you end up referring to me, I'm going to taper them off any benzodiazepines. My go to medications for generalized anxiety disorder and panic disorder in older adults are sertraline 25 mg po daily x 2 weeks, then increase to 50 mg po daily thereafter or escitalopram 5 mg po daily x 2 weeks then increase to 10 mg thereafter. I avoid citalopram since max dose in older adults is 20 mg and I usually need a wider dose range. I also avoid paroxetine given high anticholinergic burden. Buspar is also good for generalized anxiety disorder. If someone needs something for breakthrough anxiety I usually go off-label with very low dose trazodone (like 12.5 mg), low dose gabapentin (100 mg po TID prn anxiety) or if the person is a really healthy 65 with no medical problems, low dose hydroxyzine (like 10 mg).

2) For sleep, please don't use temazepam in older adults or benzodiazepines just for sleep. Also, remember the maximum dose of zolpidem in older women is 5 mg po QHS. I'm not opposed to very short term courses (think 1-2 weeks) of lunesta 1 or 2 mg or low dose sonata in patients without risk factors for falls or cognitive impairment. I like to use low dose doxepin (3 to 6 mg) if no contraindication because it is NOT on the Beers List. Some people do well on ramelteon, but insurance usually requires a prior authorization. Mirtazapine is good for those who also have depression or are losing weight, but remember that it is actually the most sedating at the lowest doses (so if using for sleep, 7.5 mg is more sedating than 15 mg). I do tend to use a lot of trazodone in people without contraindications with pretty good effectiveness.

3) I don't really prescribe stimulants given my demographic, so I can't really comment on that aspect.

I do require a controlled substances agreement be signed and random urine drug screens at least once per year. I also agree that either the PCP OR the psychiatrist should be managing the psychotropic medications and not both. You get into a "too many cooks in the kitchen" situation and in the end it isn't good for the patient. What I've seen happen is patients end up on 2 different SSRIs at high doses-1 from the PCP and 1 from the psychiatrist and I've seen 1 case of serotonin syndrome from this happening.

Also, please, if you are going to start a benzodiazepine, please do not use alprazolam. I beg of you. It has a really short half life and patients end up withdrawing in between doses. This withdrawal looks like increased anxiety symptoms which leads to dose increases and then you get patients on some ridiculously high doses of alprazolam. In psychiatry, we typically use low dose clonazepam or low dose lorazepam. Diazepam has such a long half life that I don't use it in older adults, but for younger folks you are probably ok.

Thank you, PCPs for all you do for our shared patients. Y'all are amazing .

What's your field?

 

[PikminOC]

I'm curious why you want testing for ADHD?

Because it's over diagnosed and the medicine is over prescribed. Best to get the accurate diagnosis

 

[PikminOC]

Rheum here.

So, I see a lot of chronic pain and arthritis patients. We are put in a bind a lot because cardiology or nephrology will tell patients they can't take NSAIDs. And then they come to my office with pain complaints.

I don't mind prescribing opioids for pain. However, I have limits.
I prescribe low to moderate strength opioids. If patients feel that they need high dose opioids, I refer them to pain management.

I am not comfortable with prescribing Benzos or Stimulants.

For some odd reason, in the last 2 months, I have seen a surge of patients specifically asking for stimulants. I don't know what is happening. I am not sure if this is like from TikTok or what.

When patients ask for stimulants for fatigue, I do a little lab workup. I do tell patients that they need to see a sleep medicine doctor and a psychiatrist.

I am just not trained in managed anxiety or stimulants

The venture capitalists who ran cerebral etc got shut down. Stimulant prescriptions went up 20 percent due to those types of online prescriptions.

 

[DJKitty]

What's your field?

Hi there, I am a fellowship-trained geriatric psychiatrist.

 

[VA Hopeful Dr]

I'm curious why you want testing for ADHD?

As an FP, why wouldn't I? Diagnosing ADHD in adults is fairly tricky.

 

[Keona]

I'm curious why you want testing for ADHD?

I want an accurate diagnosis. Adhd can mimic other issues and stimulant treatments make some worse. One of my patients in residency had carbon monoxide poisoning with residual deficits afterwards and thought they had adhd. Sent for testing to see if it patient did have it or not. I can’t remember outcome of it now. Anxiety is often a culprit for what looks like adhd but is a coping mechanism for how anxious the patient is.

 

[ObsequiousAplomb]

I want an accurate diagnosis. Adhd can mimic other issues and stimulant treatments make some worse. One of my patients in residency had carbon monoxide poisoning with residual deficits afterwards and thought they had adhd. Sent for testing to see if it patient did have it or not. I can’t remember outcome of it now. Anxiety is often a culprit for what looks like adhd but is a coping mechanism for how anxious the patient is.

I ask because ADHD testing will not distinguish reliably the cause, especially for the example you just gave. As a psychiatrist I absolutely never order ADHD testing - it has a terrible sensitivity and a terrible specificity. It's expensive and unreliable. There are very few conditions that are actually exacerbated by a short trial of a stimulant. Most of the medical phenomena presenting as ADHD (such as OSA) clearly and reliably sound more like OSA than ADHD on history. Chronic carbon monoxide poisoning will also sound more like carbon monoxide poisoning on history than a lifetime pattern of ADHD.

Anxiety is generally comorbid with ADHD and treating the ADHD makes the anxiety less prominent. Who wouldn't have a constant worry of messing things up if they can't pay attention to what they're doing?

 

[cj_cregg]

I ask because ADHD testing will not distinguish reliably the cause, especially for the example you just gave. As a psychiatrist I absolutely never order ADHD testing - it has a terrible sensitivity and a terrible specificity. It's expensive and unreliable. There are very few conditions that are actually exacerbated by a short trial of a stimulant. Most of the medical phenomena presenting as ADHD (such as OSA) clearly and reliably sound more like OSA than ADHD on history. Chronic carbon monoxide poisoning will also sound more like carbon monoxide poisoning on history than a lifetime pattern of ADHD.

Anxiety is generally comorbid with ADHD and treating the ADHD makes the anxiety less prominent. Who wouldn't have a constant worry of messing things up if they can't pay attention to what they're doing?

Maybe it's just my patient population but I also expect formal psych eval for diagnosis of ADHD before prescribing stimulants (ETA- to adults, not for young kids unless there is something atypical going on). Lots of drug seekers out there. I think if I had a slam dunk case in a patient without red flags that I knew and trusted, I'd probably feel comfortable prescribing, but that's rarely the case. Saying I'm happy to prescribe a stimulant for you IF we do XYZ for medical workup, AND you see a psych doc and they feel that's the right diagnosis, usually weeds out the folks who are just looking for a stimulant because they want a stimulant.

 

[shaggybill]

I don't prescribe many sedatives, opioids, or stimulants long term. I usually send them to a specialist. I'm very comfortable with testosterone though. After starting them on treatment, I have them come in every 6 weeks or so for the first few months and check levels and make sure we have addressed the symptoms. Once their dose is established and they are doing well, they can come in every 6 months or so.

 

[psycho-matic]

Hi there! I'm a geriatric psychiatrist, so my input is mainly for patients 65 and up.
1) If you are thinking about starting a benzodiazepine for anxiety and/or sleep, please think again. It is not standard of care and benzodiazepines are on the AGS Beers List of Potentially Inappropriate Medications for Use in Older Adults. There a number of more appropriate options and if you end up referring to me, I'm going to taper them off any benzodiazepines. My go to medications for generalized anxiety disorder and panic disorder in older adults are sertraline 25 mg po daily x 2 weeks, then increase to 50 mg po daily thereafter or escitalopram 5 mg po daily x 2 weeks then increase to 10 mg thereafter. I avoid citalopram since max dose in older adults is 20 mg and I usually need a wider dose range. I also avoid paroxetine given high anticholinergic burden. Buspar is also good for generalized anxiety disorder. If someone needs something for breakthrough anxiety I usually go off-label with very low dose trazodone (like 12.5 mg), low dose gabapentin (100 mg po TID prn anxiety) or if the person is a really healthy 65 with no medical problems, low dose hydroxyzine (like 10 mg).

2) For sleep, please don't use temazepam in older adults or benzodiazepines just for sleep. Also, remember the maximum dose of zolpidem in older women is 5 mg po QHS. I'm not opposed to very short term courses (think 1-2 weeks) of lunesta 1 or 2 mg or low dose sonata in patients without risk factors for falls or cognitive impairment. I like to use low dose doxepin (3 to 6 mg) if no contraindication because it is NOT on the Beers List. Some people do well on ramelteon, but insurance usually requires a prior authorization. Mirtazapine is good for those who also have depression or are losing weight, but remember that it is actually the most sedating at the lowest doses (so if using for sleep, 7.5 mg is more sedating than 15 mg). I do tend to use a lot of trazodone in people without contraindications with pretty good effectiveness.

3) I don't really prescribe stimulants given my demographic, so I can't really comment on that aspect.

I do require a controlled substances agreement be signed and random urine drug screens at least once per year. I also agree that either the PCP OR the psychiatrist should be managing the psychotropic medications and not both. You get into a "too many cooks in the kitchen" situation and in the end it isn't good for the patient. What I've seen happen is patients end up on 2 different SSRIs at high doses-1 from the PCP and 1 from the psychiatrist and I've seen 1 case of serotonin syndrome from this happening.

Also, please, if you are going to start a benzodiazepine, please do not use alprazolam. I beg of you. It has a really short half life and patients end up withdrawing in between doses. This withdrawal looks like increased anxiety symptoms which leads to dose increases and then you get patients on some ridiculously high doses of alprazolam. In psychiatry, we typically use low dose clonazepam or low dose lorazepam. Diazepam has such a long half life that I don't use it in older adults, but for younger folks you are probably ok.

Thank you, PCPs for all you do for our shared patients. Y'all are amazing .

I share all of these sentiments. I primarily work in geriatrics. I've not had success getting low dose doxepin covered by insurance. I normally use 10 mg. This dose is still low enough to avoid anticholinergic side effects. Evidence shows patients do not develop tolerance to this med. Doxepin is actually one of the best-researched meds for insomnia with long-term data establishing its safety and efficacy. Edit: It can cause weight gain.

I have used citalopram, up to 30 mg, in dementia patients with agitation. There is strong evidence in the literature to support this, in my opinion. I've also had good success treating insomnia in dementia patients with Belsomra. It is FDA indicated for this, and can improve cognition. It's much much safer than z-drugs. As it acts on orexin receptors, does not cause significant respiratory depression, making it safe in patients on opiods or benzos.

Lastly, please avoid high dose fluoxetine in the elderly, particularly in the elderly that are frail. It increases fall risk. Because it's active metabolite, norfluoxetine, has a half life of 2 to 3 weeks, this combined with slower metabolism can cause it to build up in the system, magnifying its adverse affects. It can be activating at high doses, making anxiety worse instead of better. Conversely, in healthier geriatric patients, it's long half life makes it a good choice for depression in patients that sometimes forget to take their meds, at lower doses. It's long half life means any significant discontinuance syndrome is avoided.

Be aware serotonin inhibits platelet function and increases bleeding risk. The risk is even higher with concomitant NSAIDSs. There's some evidence that SSRIs inhibit, via a complex pathway that's not completely understood, the brains ability to regulate or resist arterial blood flow. This increases the risk of hemorrhaging and stroke in the geriatric population.

I've found duloxetine to be well-tolerated and often use it in patients with radicular or neuropathic pain. Avoid this med in advanced liver disease.

Definitely weigh the risk vs benefit of any SSRI, taking into account their comorbidities.

In my anecdotal experience, pregabalin is better tolerated in the elderly than gabapentin.

Regarding doxepin, amitriptyline, etc. (any TCA), patient selection is important. Avoid in patients at risk of committing suicide. TCAs are highly lethal in overdose due to cardiac toxicity. For this reason, I do not fill 90 day supplies of TCAs. I only do a 30 day supply with refills.

 

[psycho-matic]

I don’t start recurring Benzos, ever. I’ll prescribe a few tablets for procedural anxiety, fear of flying etc. but never for panic or generalized anxiety. Never any refills of any kind. You use them for the procedure/trip and then we stop them.

I don’t do chronic pain, at all.

I do manage ADD, and most of the time don’t start stimulants for adults. Kids, we do an eval and I will generally start them.

Testosterone: I’m not a believer in the clinical utility of T replacement; but am fairly willing to treat with a verified diagnosis.

I have a very long contract, it has lots of language about patients being required to come in every 12 weeks, never call for refills outside an office visit, never replace lost or stolen meds etc, all the standard stuff. But also that patients must be working earnestly to control their other chronic medical problems, attend their annual physical, stay up to date with health screenings, and participate fully in any assessment I order, any referral I order, and take any alternate medication I prescribe as a condition of being prescribed a controlled substance.

What do you do when you inherit a geriatric patient on 6 mg of alprazolam a day x 20 years? Psychiatrist retired. Yes I've really seen this happen. You can't not prescribe a controlled substance in this situation. Your patient may die from acute benzo withdrawal. You can taper them off, but doing so is going to be very difficult and take a long time. It may not be completely realistic to stop the med completely. It may be more practical to settle for a lower dose of a longer acting med.

I ask this question to point out one cannot always avoid prescribing a benzodiazepine.

I sometimes change to alprazolam ER due to its longer half life and once daily dosing. It avoids withdrawal between doses. Insurance won't cover it but it's about $20 bucks with GoodRX.

 

[psycho-matic]

What's your field?

Did you actually read it? Lol

 

[PikminOC]

Did you actually read it? Lol

Was it written to you?

 

[SLC]

What do you do when you inherit a geriatric patient on 6 mg of alprazolam a day x 20 years? Psychiatrist retired. Yes I've really seen this happen. You can't not prescribe a controlled substance in this situation. Your patient may die from acute benzo withdrawal. You can taper them off, but doing so is going to be very difficult and take a long time. It may not be completely realistic to stop the med completely. It may be more practical to settle for a lower dose of a longer acting med.

I ask this question to point out one cannot always avoid prescribing a benzodiazepine.

I sometimes change to alprazolam ER due to its longer half life and once daily dosing. It avoids withdrawal between doses. Insurance won't cover it but it's about $20 bucks with GoodRX.

1st, I don’t “inherit” patients. I have people seeking to establish care with me. It’s a mutual decision whether or not we’re a good fit for one another. One physicians mistakes don’t automatically become my problem just because of retirement.

I 100% can avoid writing benzos recurrently. I have the ability to bridge someone to a new psychiatry consult.

I can absolutely choose what I am willing to take on with a new patient. There is no law stating that just because someone scheduled a new patient office visit with me, that I’m somehow roped into accepting all of their mismanagement and just going along with it.

 

[ObsequiousAplomb]

Maybe it's just my patient population but I also expect formal psych eval for diagnosis of ADHD before prescribing stimulants (ETA- to adults, not for young kids unless there is something atypical going on). Lots of drug seekers out there. I think if I had a slam dunk case in a patient without red flags that I knew and trusted, I'd probably feel comfortable prescribing, but that's rarely the case. Saying I'm happy to prescribe a stimulant for you IF we do XYZ for medical workup, AND you see a psych doc and they feel that's the right diagnosis, usually weeds out the folks who are just looking for a stimulant because they want a stimulant.

I hear you. That makes a lot of sense. Sending someone to a psychiatrist for an evaluation is entirely distinct from sending them for psych testing, which is what I was commenting on being counter to the standard of care.

Regarding what you said, I'm totally happy as a psychiatrist seeing these adults and referring them back to primary care, though generally I would prefer to keep them on my own caseload for a short while. After dose has been found and adequate follow-up to ensure stability I happily send them back to primary care if appropriate.

 

[psycho-matic]

1st, I don’t “inherit” patients. I have people seeking to establish care with me. It’s a mutual decision whether or not we’re a good fit for one another. One physicians mistakes don’t automatically become my problem just because of retirement.

I 100% can avoid writing benzos recurrently. I have the ability to bridge someone to a new psychiatry consult.

I can absolutely choose what I am willing to take on with a new patient. There is no law stating that just because someone scheduled a new patient office visit with me, that I’m somehow roped into accepting all of their mismanagement and just going along with it.

Of course you are not under an obligation to prescribe recurrent benzos for a new patient. You missed the point. It's not always an easy decision. I feel a provider would be under an ethical obligation to at least do a month long taper to prevent seizures or send them to inpatient detox. You can't ethically do nothing. The question was meant to make people think, not so much directed at you and certainly not meant to tell you how to practice. Good grief.

 

[psycho-matic]

I hear you. That makes a lot of sense. Sending someone to a psychiatrist for an evaluation is entirely distinct from sending them for psych testing, which is what I was commenting on being counter to the standard of care.

Regarding what you said, I'm totally happy as a psychiatrist seeing these adults and referring them back to primary care, though generally I would prefer to keep them on my own caseload for a short while. After dose has been found and adequate follow-up to ensure stability I happily send them back to primary care if appropriate.

I completely agree with you here.

 

[B1GM0N3Y86]

Of course you are not under an obligation to prescribe recurrent benzos for a new patient. You missed the point. It's not always an easy decision. I feel a provider would be under an ethical obligation to at least do a month long taper to prevent seizures or send them to inpatient detox. You can't ethically do nothing. The question was meant to make people think, not so much directed at you and certainly not meant to tell you how to practice. Good grief.

From a primary care standpoint, all patients that are scheduled as new are screened via PDMP. If something pops up, the patient is notifed by nursing staff prior to the establishment visit that we don't refill that particular medication and that if they wish to continue with it they will need to be seen by a specialist for evaluation and all further management of that condition. They are also re-advised that we will not bridge to a specialist visit if they wish to establish and be referred. They are also advised that we cannot guarantee what a specialist will or will not do since we are not mind readers.

It's true tho, patients talk. I now get very few potentially new patients any longer that come my way on messes that were started and/or continued by their prior PCP. I think the screening and informing satisfies the ethical part tho. It's not always the patients fault for being on the mess, however it isn't my job for cleaning everyone else's mess up.

 

[Keona]

I share all of these sentiments. I primarily work in geriatrics. I've not had success getting low dose doxepin covered by insurance. I normally use 10 mg. This dose is still low enough to avoid anticholinergic side effects. Evidence shows patients do not develop tolerance to this med. Doxepin is actually one of the best-researched meds for insomnia with long-term data establishing its safety and efficacy. Edit: It can cause weight gain.

I have used citalopram, up to 30 mg, in dementia patients with agitation. There is strong evidence in the literature to support this, in my opinion. I've also had good success treating insomnia in dementia patients with Belsomra. It is FDA indicated for this, and can improve cognition. It's much much safer than z-drugs. As it acts on orexin receptors, does not cause significant respiratory depression, making it safe in patients on opiods or benzos.

Lastly, please avoid high dose fluoxetine in the elderly, particularly in the elderly that are frail. It increases fall risk. Because it's active metabolite, norfluoxetine, has a half life of 2 to 3 weeks, this combined with slower metabolism can cause it to build up in the system, magnifying its adverse affects. It can be activating at high doses, making anxiety worse instead of better. Conversely, in healthier geriatric patients, it's long half life makes it a good choice for depression in patients that sometimes forget to take their meds, at lower doses. It's long half life means any significant discontinuance syndrome is avoided.

Be aware serotonin inhibits platelet function and increases bleeding risk. The risk is even higher with concomitant NSAIDSs. There's some evidence that SSRIs inhibit, via a complex pathway that's not completely understood, the brains ability to regulate or resist arterial blood flow. This increases the risk of hemorrhaging and stroke in the geriatric population.

I've found duloxetine to be well-tolerated and often use it in patients with radicular or neuropathic pain. Avoid this med in advanced liver disease.

Definitely weigh the risk vs benefit of any SSRI, taking into account their comorbidities.

In my anecdotal experience, pregabalin is better tolerated in the elderly than gabapentin.

Regarding doxepin, amitriptyline, etc. (any TCA), patient selection is important. Avoid in patients at risk of committing suicide. TCAs are highly lethal in overdose due to cardiac toxicity. For this reason, I do not fill 90 day supplies of TCAs. I only do a 30 day supply with refills.

I also can’t get the ultra low doses covered but the 10 mg dose is cheap if they’re paying cash or using a good rx card. Switched one patient from amitriptyline to doxepin at the advice of her oncologist and her memory loss resolved and she was able to sleep still. It’s a medicine i hadn’t used at all prior to that but have used on multiple other patients successfully.