Wow, I like that the picture keeps moving around, sets the Deja Vu image perfectly;
Two posts from way back to introduce readers to comments past that still fit today, ironically from the current Temp job I am suffering through for another 5 weeks. So, I present to you what happens when primary care physicians think they are psychiatrists, and as Mr Serling would say, “picture a man who thinks he knows what he is doing…”
First from Dec 9 2012:
To all my colleagues out there, what do you remember we learned in med school and internship when treating an infection? Try to get a culture for growth and antibiotic sensitivity to maximize using the right antibiotic to eradicate the infection, right? I mean, you don’t want to use an antibiotic incorrectly, because that could just complicate the problem. Oh, and also use a broad spectrum one first, we don’t want to turn to vancomycin or gentamicin first, eh?
Ok, so if that is true, then help me understand why is it more and more PCPs, NPs, PAs, GYNs, and other non psychiatric providers out there are writing for benzodiazepines like penicillin these days, if not like pez. I am seeing more and more patients who are coming from other provider offices on, now brace for it as not an exaggeration, 6mg+ xanax/day, or 4mg+ Klonopin/day, or perhaps 4mg+ Ativan/day, still writing for Valium, and believe it or not, benzo combinations like xanax and klonopin, or ativan and valium, hell, I had a patient see me within the past year on xanax, valium, and Restoril!
I just want to ask anyone out there either as a prescriber or patient, do you understand the risk/benefit profile of being on controlled substances? Do the concepts of tolerance and withdrawal elicit any meaningful response? And, do you also write or take multi combinations of similar meds for other disorders? Do you give patients propranolol and metoprolol simultaneously, or write for Percocet and Vicodin concurrently, or, sticking to the analogy at hand, write for penicillin and ampicillin together?
I hope most of readers answer “NO” fairly strongly to the above. Yet, here is my bone to pick with providers who think prescribing benzos is no big deal at moment one. Do you write for an antibiotic when your patient comes in with a sore throat? Ok, you’ll culture, but, if there are no accessible lesions and the presentation does not exude overt bacterial infection, do you hold off a bit before writing a script? And will the patient be appreciative of not having run the risk of developing a future antibiotic resistant infection if not over medicated with antibiotics for months prior? And what if the sore throat is repetitive, never shows an infectious cause, and there are complicating factors to the presentation, is it just about medications for treatment?
Here’s a better analogy, if the patient had a painfully sore throat, would you write for an opiate for pain management? Especially if the patient was medication naïve upon presentation. No NSAIDS or Tylenol first? And do you make a sincere effort to evaluate for substance abuse/dependency? Are there alternatives to pain management outside medications alone, if not first? And when do you draw the line of how much and how often a prescription is to be used?
Anyone interested in the facts of benzodiazepine use, seek them out. If you are looking for anxiety treatment, you should be wary being put on these drugs mentioned above, especially xanax, valium, and klonopin. And prn use prescriptions should have clear designations as to why and how much to use, and the script should be written with limits. Asking a patient to use a benzo Rx prn should not be given a month supply more than 30 tabs. 2 reasons: first, set a limit what you are expecting for a month use, because if you write for 30 or more, and then the script is gone in less than 2 weeks, either the patient needs daily standing use or is self medicating or worse, abusing; second, band aids are exactly what they are, they cover a wound and does not treat it, and that is what benzos do, symptomatically cover the mental wound of anxiety and does little to nothing to impact on improvement and resolution.
Hey, don’t believe me, just talk to anyone who has been prescribed a benzo with little to no advisement of what the risks are with a controlled substance. Or better yet, any reader who has been on one and gotten off it, and found success in anxiety management, it wasn’t just the meds that impacted, eh? Or, meet anyone lately who is an addict and not in recovery, find these individuals easy to work/live with?
Oh, and if you have a benzo script and have used it responsibly and cautiously, good for you! Just don’t share this information with anyone else. NO ONE ELSE! Would you leave gold coins lying around in a medicine cabinet or kitchen counter with a known thief around? If you do with a RX and have an addict in your midst, that is what you are doing.
Sore throats suck, I’ve had ‘em and will again, and sometimes I will need an antibiotic. But, I won’t ask for a tertiary level drug first, won’t just expect the pill to treat all the symptoms, and, won’t go running in to the doctor’s office if the symptoms are resolving within a couple days most. Isn’t it time to be thinking the same with anxiety? And to you as a provider, if you wouldn’t easily take a benzo first, why write one for someone else who is not in mental health care, i.e. seeing a therapist at least?
Standards of care folks, we need to reacquaint ourselves with them. Oh, by the way, if my next patient comes in with a sore throat, should I give them a RX for penicillin and tell them to follow up with you, the doctor, in a week or two later? Yeah, I know the answer, my question is, why don’t many providers know it too when it comes to benzos!?
You are not helping me by giving benzos without complement care in place as well. At least write for them briefly, not for months to years first.
It’s a good thing I wrote this, having to say it out loud might hurt my throat.
and then from Dec 1 2012:
“Not due to the direct physiological effects of a substance or a general medical condition.” This is an exclusion criterion in fairly much every diagnostic criteria for every diagnosis in DSM 4TR, and for good reason. Why are patients being diagnosed with a psychiatric disorder if they are actively intoxicated with regularity, or going through dramatic physiological withdrawal from said substance(s), or, have a serious medical illness that is affecting numerous organ systems, including, the brain?
And yet, how often do you think this exclusionary criterion gets ignored? My opinion, at least 20% of the time per what I have come across in my travels seeing patients who have been treated prior by other psychiatrists or somatic colleagues who are quick to write off the presentation as psychiatric. Even if the medical issue is comorbid and the patient has true psychiatric problems independent of a physiological problem, how do you know what the somatic issue contributes? Especially if the psychiatric interventions are not impacting to any significant degree after a reasonable period of time? And why is it so many colleagues at times get annoyed or dismissive when I raise the concern that a medical matter needs to be addressed if not redefined?
For this blog, I think the only details for the average reader is this: if you are told you have psychiatric issues and need to see a psychiatrist, and yet have legitimate, diagnosed medical matters that could be impacting on a psychological symptom(s), you should be wary to have it dismissed, ignored, or trivialized. Better to rule out that hypothyroidism, perimenopause, legitimate chronic pain, seizure disorder, sleep apnea, anemia, even new onset diabetes, much less many other medical disorders, all have psychological impacts and can have significant psychiatric improvement if treated effectively medically FIRST!
Here’s one axe to grind regarding hypothyroidism I offer moreso to any medical clinician reading here: why is Cytomel still being dismissed as a legitimate substitute for hypothyroidism when patients have failed Synthroid trials up to 400ug or more? How many psychiatric colleagues have seen a patient dramatically improve with depressive symptoms after titrating Cytomel from 5 to 25ug in the space of 2-3 months? I have, repeatedly, and still advocate for it to this day. Sure, some patients don’t improve, but don’t we owe it to them to make sure their depression is NOT DUE TO THE DIRECT PHYSIOLOGICAL EFFECTS OF A GENERAL MEDICAL CONDITION?
We’ll see if Obamacare, what I call PPACA as what it is from Congress, will have any positive impact on improving the somatic-psychological relationship. Don’t hold your breath waiting for this to be true though. You think that as PCPs and other somatic gatekeepers have more mental health demands placed on them, they will be attentive to the role of medical conditions on psychological symptoms?
Yeah, I’m sure that 5-8 minute visit will accomplish a lot! And that is not a shot at my colleagues who genuinely work hard in their offices day after day trying to help peoples’ lives while maintaining a livelihood as well. It is a reflection of the adage “hear the lie enough and it becomes the truth”! Because politicians have no time or interest in mental health needs. That is another posting though.
Hope ya liked em as a reality check, remember if you are a classic rock fan that the trend setters are crucial to appreciate the bold and fresh new ideas and agendas, eh?