Wrote this over a year ago, but, it still applies:
the post replicated:
Picture your most annoying noncompliant alcohol dependent patient, why him/her is so difficult to work with, then when you have the image and feelings up front…………..
then picture your most recent “struggling” benzodiazepine patient who is just basically demanding more meds and dismissing any other interventions.
See a difference? I don’t.
What do noncompliant, substance seeking, insight limited people offer in the office?
always erratic: never on time, extremely early or more often late, cancel appts late, if they show at all, stories never make sense and either take longer or are abruptly short in session.
inconsistent: with everything!
intolerant: never accept any boundaries, and take no responsibility for overt mistakes
usually unemployed or underemployed: and always complaining about payments until proven otherwise.
focus in the office is always first and last about medication, and quick to want more.
almost always with legal matters: even if not felonies, then civil matters, or themselves are taking legal action against others, even threatening the provider.
if at all involved in therapy, usually minimally participating, yet with enough psychosocial stressors for two or more people in treatment.
finally, few if any collateral supports of honest validity to their claims and situations.
Do these people ever come in and have a direct, uneventful visit? Do they ever genuinely seem satisfied with their current course of life? Do they ever offer the idea of lowering medication dosages? Do they ever offer ideas of how to improve their lives spontaneously?
How many between visit calls do you get from these patients, especially after they miss or late cancel an appt prior? And the final jeopardy question, why is it there is always an excuse they claim you should accept WHEN their controlled substance prescription runs out before it is due for refill?
This is why I am tired of the bullshit from benzo seekers. They are alcohol dependent people who get their drinks from a tablet. And they are quick to draw you into their convoluted, disrupted, and rationalized world of better living through chemistry, and will never accept there is a ceiling to dosage use. And from a liability standpoint, you have little ground to stand on to defend prescribing habits unless not only you challenge them repeatedly WHEN they pull stunts and are noncompliant, but document it repeatedly and make a statement of what you will do should the behaviors not cease.
below is my handout at the CMHC I give to people who just hassle me with their lame efforts at making me their dealer du joir:
My advice to providers: set limits up front once the patient is showing no other interest than just getting a controlled substance that is intended for misuse or abuse. If/when the patient has a negative outcome and you are seen as a potential villain by the family, show you made a sincere effort to set limits, and document every time you did so.
Not only is the road to hell paved with good intentions, you may become the guardrail that did not keep the reckless vehicle on the pavement.
It is time to make benzos controlled 2 substances, if at the very least to discourage PCPs and other nonpsychiatrists from writing them like pez. And then being the pez dispensers I recently label XAN-I-DO!!!
Good luck with your treatment efforts!
NOW BACK TO MAY 23 2014:
And then there is this ongoing bullshit by the APA and other self interest groups who are just trying to further dumb down and diminish psychiatry as a legitimate and needed intervention, I scan the middle of the article to avoid any readers who can’t access it should http://www.clinicalpsychiatrynews.com make you join to read their articles:
Can we have a reality break here, please? Yes, patients go to PCPs and FPs and NPs for psychiatric interventions first, and by in large patients don’t want to see a psychiatrist for fear of being labeled or being hospitalized or just drugged incessantly, but, what do the non psychiatrists do with these patients in their offices at the end of the day? They minimize the patient’s concerns often, just throw drugs at the symptoms, and then set little if any boundaries what patients do in follow up until the reckless assessments and interventions fuck things up so much further, that when some patients do come to a psychiatrist’s office, the presentation is complicated. That is not INTEGRATED CARE, but INCOMPETENT CARE, and frankly, I think the APA just wants to screw up general outpatient psychiatry, period!
And what does the article focus on first and foremost, what this costs, not what is accomplished. This is the god damn mantra of politicians, not clinicians!!! So yes, at the end there, “We need to make sure we’re all working together to provide that care” is true and outwardly responsible, but, who is going to start by NOT preaching drugs first and continually? Not most PCPs and other non psychiatric providers, their agenda is entrenched and fixed, drug reps thank you very much!
To wrap this up and tie it in from the top, the prescribing of benzos is beyond out of control, it borders if not on criminal misconduct, at least gross negligence and malfeasance by providers, and that needs to be pursued legally. How do I get away with saying that, well, what did I read on Wednesday from the USA Today, front page?
Note in there the recurrent mention of benzos, specifically xanax! I am seeing it almost daily the past 2 months at this Family Practice site I am stuck at for another month. Benzos for people over the age of 60, what the hell were my predecessor and the other doctors there thinking? Obviously NOT!
I think they should open up a liquor store next to the clinic and use prescriptions to make the clinic more money, kick backs accepted, it’s good for community solidarity. “1-2 shots q2h until distress or unhappiness abates or just fall asleep, dispense 250cc bottle, 2 refills”. Oh wait, there is a bar already next door there and they sell package goods, so let’s get that RX component up and running, shall we?
No, not including me!