SCPA Posted August 19, 2016 Share Posted August 19, 2016 soma, xanax, gabapentin, ambien Adderall, Ambien, Xanax.. Norco, Xanax... ETC.. Getting a lot of these patients trickling down to me from a doc who recently retired and left our practice. It's a major PITA as they feel oh so very entitled to their ''medications.'' I'm trying at best to give one Rx, document very well and state they must go to pain clinic or making them choose one med or the other and asking to not see them again etc... "I have horrible adult ADD and crazy anxiety.. I can't live without my adderall or my klonopin ... when will the doctor be back? " "Ma'am, it's possible that your 60 mg of Adderall qd could be contributing to your anxiety and insomnia." "Oh, no, that can't be. I've always been anxious and had trouble sleeping, even before I started taking 60 mg of adderall for my adult ADD." UGH. It's soul sucking... Would you ever fill combos like this? Link to comment Share on other sites More sharing options...
HMtoPA Posted August 19, 2016 Share Posted August 19, 2016 I totally feel you. People are on crazy combinations of meds these days. It's not really what I had in mind when I imagined managing the occasional polypharmacy patient... What drives me really crazy is, like you say, I feel like these meds are actually contributing to their problems, but they're so psychologically (and sometimes physically) dependent on this stuff that they can't imagine living without it. Why would you want to take Ambien every night for the rest of your life just to get to sleep? Why would you want to pop a Xanax every time life gets the least bit complicated, in perpetuity? Granted, many patients will say that they don't "want" to depend on this stuff, but they sure don't make much effort to change. What bothers me about it is I end up feeling like some drug dealer filling scripts for weak-minded, entitled brats, and wonder if I'm not doing more harm than good. Link to comment Share on other sites More sharing options...
Marinejiujitsu Posted August 19, 2016 Share Posted August 19, 2016 Yep, it sad when more of your patients are on meth than smoke cigarettes. Crazy. I hope this is just the ER location I practice. Sent from my SAMSUNG-SM-N920A using Tapatalk Link to comment Share on other sites More sharing options...
taotaox1 Posted August 19, 2016 Share Posted August 19, 2016 As a PCP I tell patients that are on combinations like that that I am not qualified to manage their psych or pain conditions that require such powerful medication combinations and that they need to see a specialist and then refer them out. They get no option, I am not "able" to fill them beyond a short bridge. It makes for a very simple appointments honestly. I do not do chronic narcotic poly-pharmacy for patients as it is rarely to their benefit except in rare cases, and most of those rare cases actually DO need specialist care. It helps to be in clinic that the rest of the providers tow pretty much the same line. It would be really difficult in an office full of candyshop doctors..... Link to comment Share on other sites More sharing options...
TWR Posted August 19, 2016 Share Posted August 19, 2016 The sad part is most of these poly pharmacy patients were started on these meds by physicians! We just inherit them. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted August 19, 2016 Moderator Share Posted August 19, 2016 The quad-fecta is "Opioid + Benzo + Muscle Relaxer + Atypical antipsychotic". The best is when there's a fifth med to accompany that could come from a miscellaneous class- maybe trazodone, maybe ambien. I'm just glad the medical community is waking up as a collective to the dangers of patients on multiple sedating medications Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 19, 2016 Share Posted August 19, 2016 I too inherited a whole panel of patients from an older doc who retired. I truly think he thought he was helping people instead of creating the nightmare I am living. He actually wrote in one of his notes that he just didn't understand what all the fuss about ambien was..... At this point, I basically just tell the patient matter of factly that Ambien is no longer an option. Period. It increases risk of dementia and a 2.6 times higher rate of death for all causes. If I wouldn't let my family member take it - neither can you. Let's find an alternative or actually figure out WHY you don't sleep. Soma is bad. Let's move on. I tell the patients that all recent data says we are mixing drugs that can kill people for no apparent other reason - they just wake up dead one day. I print articles from reliable sources, hand them out and lay the plan out that we ARE going to make changes and that is best medical science. A few have moved on. Several have let me know I am NOT a doctor (gasp! surprise!) and that the old Dr. C would "never have put me thru this". Most all have said that I just truly don't understand their situation. Hmmmm, 4th person today on same nasty regimen of stupid drugs - I think I get it. So, I have my work cut out for me. I refuse to be a "customer service agent" or "drive thru hostess" and keep providing these potentially deadly combo of drugs. A healthy dose of coping mechanisms, detox and further investigation into their problems is by far the best answer I have come up with. I don't want to hurt anyone nor foster their fog filled life. Link to comment Share on other sites More sharing options...
Febrifuge Posted August 19, 2016 Share Posted August 19, 2016 There was a free CME a week or two ago at the Medscape site about Motivational Interviewing - I found it pretty interesting, and a good way to get people talking, then use a little conversational judo to get them thinking about why they should make changes. In a primary care setting, when you have the chance to work on people a little more, it might be helpful. ...But this assumes patients are capable of seeing a connection between unwanted effects and their use of the meds in the first place. Link to comment Share on other sites More sharing options...
taotaox1 Posted August 19, 2016 Share Posted August 19, 2016 Inheriting patients like this is the worst. They have had horrible expectations set. It sounds like you are doing the right thing. Lots of these patients will move on until they find a provider who does what they want... thats how they ended up with the doc you are taking over for. Just grind through, stick to your guns, and offer to refer out to pain/psych as appropriate. The problems will self select themselves out of your panel and you will eventually not have to deal with it. Some will stick with you and will be healthier for it. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 19, 2016 Share Posted August 19, 2016 Our next door neighbor at work is the Seattle Pain Clinic that just got shut down for narcotic issues including patient deaths. We never really referred to them because of some issues and suspicions about folks on greater than 120 MED of pain meds and some really creepy combinations. Our pain mgmt options are pretty limited on our side of the state and the few that exist don't want to take Medicaid or state ins patients. Unfortunately, a lot of folks on chronic pain meds don't work and are on state insurance..................... A lot of mine are older and long addicted or overmedicated. I know folks get busy and life has challenges - it just gets to me when they won't open to ANY kind of change despite the imminent danger that is right in front of us. 15+ years of nightly 10 mg Ambien, Soma tid, Xanax 1 mg up to tid prn, Hydrocodone 7.5/325 up to tid, gabapentin 300 mg QID AND this patient is 67 yrs old, drinks a "highball" with dinner and can't for the life of them figure out why they always feel tired with no energy...................... BUT - it CANNOT possibly be my medications - those are what keep me going...................... Dx: "back pain", no MRI, no PT, no nothing..................................... "my back pain makes me anxious" and I can't sleep without my meds A sharp rock for my head sounds good after that 40 minute interaction. I am trying - heaven help me - I am trying Link to comment Share on other sites More sharing options...
taotaox1 Posted August 19, 2016 Share Posted August 19, 2016 I am convinced the only reason soma has not been taken off the market is to make it easier for the DEA to figure out who to bust. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 19, 2016 Share Posted August 19, 2016 I am convinced the only reason soma has not been taken off the market is to make it easier for the DEA to figure out who to bust. Have you seen the references to Soma in Blade Runner?................................. Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 19, 2016 Moderator Share Posted August 19, 2016 one doc I worked with came up with this simple solution... before his time ONE agent #60 MAX in one month thats it.... no multiple controlled no numerous psych choice was find a new PCP, or referred out to specialty level care - who would advise taking them off.... Call and office got WAY better after this change... Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 20, 2016 Share Posted August 20, 2016 Patient this afternoon - Switched 67 yr guy from Ambien to Belsomra samples and he is ok with Belsomra for the most part. He misses his ambien................. he took it nightly for over 17 years. He doesn't sleep as "deep" (read stoned) on Belsomra as ambien. He has crap for sleep hygiene and no real interest in changing it. I suggested hypnosis and he actually bit. Not that insurance will pay for it but if he can make a single behavior change - he will be better for it. Another 70 yr lady with migraines mixing trazodone with elavil that the UC gave her and out and out yelled at me when I advised that they not get mixed. She said I was mean and not helping her. I read her the UC note that said to REPLACE the one med with the other. Still didn't believe me. The full moon was just yesterday I think - there is still funk in the air Happy Friday Link to comment Share on other sites More sharing options...
ColoradoIMCardsPA Posted August 20, 2016 Share Posted August 20, 2016 OP, this is a very tough and common situation that I never found a solution to other than leaving outpatient primary care. My observation was this standard combination: - 1-3 benzos (often Restoril plus up to two others), plus - Ambien, plus - Opioid (e.g. Percocet), plus - 1-2 muscle relaxants. I saw some gruesome overdose stories among these patients, and was motivated to fight against this type of polypharmacy - but the fight with even just one patient was very emotionally draining to me. So I got out of the business, to greener pastures where I could tell patients to follow up with their PCP (a saintly, long-suffering figure). Best of luck fighting the good fight. Link to comment Share on other sites More sharing options...
cinntsp Posted August 20, 2016 Share Posted August 20, 2016 My hospital is a revolving door for the little old ladies who come in altered with these combinations on board. They are the most annoying patients and insist on leaving the hospital as soon as they are awake and alert enough to function. I guess they can't wait to get back home and restart their meds. Link to comment Share on other sites More sharing options...
gcox87 Posted August 21, 2016 Share Posted August 21, 2016 Have you seen the references to Soma in Blade Runner?................................. Off topic..but explain. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 21, 2016 Share Posted August 21, 2016 Off topic..but explain. Sent you a PM. Not going to hijack for my nerd sci fi weirdness..... Link to comment Share on other sites More sharing options...
CAAdmission Posted August 21, 2016 Share Posted August 21, 2016 The sad part is most of these poly pharmacy patients were started on these meds by physicians! We just inherit them. You're too generous. Every single mess in American healthcare from drug abuse to funding occurred on the doctors' watch. They had a chance to run things well. They did not and corporate medicine stepped in. Link to comment Share on other sites More sharing options...
jcash Posted August 21, 2016 Share Posted August 21, 2016 Our next door neighbor at work is the Seattle Pain Clinic that just got shut down for narcotic issues including patient deaths. We never really referred to them because of some issues and suspicions about folks on greater than 120 MED of pain meds and some really creepy combinations. Our pain mgmt options are pretty limited on our side of the state and the few that exist don't want to take Medicaid or state ins patients. Unfortunately, a lot of folks on chronic pain meds don't work and are on state insurance..................... A lot of mine are older and long addicted or overmedicated. I know folks get busy and life has challenges - it just gets to me when they won't open to ANY kind of change despite the imminent danger that is right in front of us. 15+ years of nightly 10 mg Ambien, Soma tid, Xanax 1 mg up to tid prn, Hydrocodone 7.5/325 up to tid, gabapentin 300 mg QID AND this patient is 67 yrs old, drinks a "highball" with dinner and can't for the life of them figure out why they always feel tired with no energy...................... BUT - it CANNOT possibly be my medications - those are what keep me going...................... Dx: "back pain", no MRI, no PT, no nothing..................................... "my back pain makes me anxious" and I can't sleep without my meds A sharp rock for my head sounds good after that 40 minute interaction. I am trying - heaven help me - I am trying Wow this is so sad! I feel sorry for this pt that he was started on all of these drugs and is now dependent on them. Shame on that physician for using all these meds. And NO MRI that's just bad medicine. I worked for a doc like this for a short time she gave crazy doses of pain meds to pts she knew were also using marijuana. I refused to give the same pt anything. Sorry you're cleaning this up. Send to pain management!!! Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 22, 2016 Moderator Share Posted August 22, 2016 New one the other day from a seriously hard drug and ETOH user Shooting straight vodka - so no ETOH on breath, but still drunk..... Yikes Link to comment Share on other sites More sharing options...
sk732 Posted August 22, 2016 Share Posted August 22, 2016 New one the other day from a seriously hard drug and ETOH user Shooting straight vodka - so no ETOH on breath, but still drunk..... Yikes Respiratory techs used to tell us to nebulize the stuff - fast hit into the blood stream and no hangover...shooting it though hurts just thinking of it. That's one desperate alcoholic. SK Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 22, 2016 Share Posted August 22, 2016 My county hospital days - I got a lesson on how to soak bread in anti-freeze - put it out in the sun and then eat the bread after the polyethylene evaporates. EEEWWWW!! Also, real vanilla extract is a certain percent alcohol and so is Listerine and Nyquil. Just in case you run out of access to distilled alcohol................. Link to comment Share on other sites More sharing options...
sk732 Posted August 22, 2016 Share Posted August 22, 2016 Also, real vanilla extract is a certain percent alcohol and so is Listerine and Nyquil. Just in case you run out of access to distilled alcohol................. I used to live in Yellowknife in the Northwest Territories as a kid - was a bit of a shanty town then - and if you wanted vanilla extract, you had to go to the pharmacy and ask the pharmacist for it from behind the counter, people were that hard up to get a fix. When we moved back south, the quick fix became shotgunning cans of Lysol, even before whippets came into vogue. SK Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 25, 2016 Moderator Share Posted August 25, 2016 Just had a heavy addict come in who decribed his intake 1/2 gallons of vodka As much heroin as he could get 1-4 bundles/day Any benzos available But the best 2-4 bottles of nyquill per day as well - for the ETOH and the buzz o pushing through the antihistamine - course I have no idea how he could pee with that much antihistamine in him..... HAve seen a few patients in the past resort to cough syrup as a last resort, but never where that was on of the drugs of choice... Link to comment Share on other sites More sharing options...
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