Piper Posted June 25, 2011 Share Posted June 25, 2011 Busy urgent care center having a very busy day…… Recent college graduate comes to clinic for evaluation of some anxiety and insomnia x 1 week. Patient states she is moving out of state in 3 weeks to begin a new job. Describes the anxiety as a feeling of restlessness more than anything else. Insomnia is a mix of difficulty falling asleep and/or early awakening. No chest pain, palpitations, abdominal pain, N/V, diarrhea, shakiness, sweating. Two days ago, she took one of her boyfriend’s low dose diazepam tablets for the anxiety and states it helped tremendously. Yesterday, received pre-employment package from company that requires her to have a urine drug screen collected within 24 hours. She realizes her drug screen may well test positive for benzos and is requesting Rx for 2-3 diazapam tablets since it helped her symptoms. This is a robust, healthy appearing young woman who exercises regularly, uses minimal caffeine, does not smoke, and denies recreational drug use. No significant past medical or family history. I felt that the main problem was one of insomnia related to situational anxiety, so I elected instead to prescribe a limited number of Ambien CR and did not prescribe the diazepam. Since my own insomnia woke me up at 3 a.m. this morning, this patient has been stuck in my head. We have a tough economy right now, I have low suspicion this patient is a drug seeker, and the results of the drug screen may put her new job in jeopardy. I feel that, medically, I treated her appropriately and did the correct thing. My question now is: Did I do the RIGHT thing? Any insight would be appreciated. Link to comment Share on other sites More sharing options...
rcdavis Posted June 25, 2011 Share Posted June 25, 2011 You did not do a WRONG thing. But, as you surmise, you may not have done the best RIGHT thing. Right thing being defined as treating her symptoms with a benzo which would treat her primary complaint and symptoms, and " give her cover" for the secondary agenda she had.. A prescription covering the probably pos benzo preemployment drug screen she was facing. Sometimes it takes several hours of processing to see the RIGHT thing.. It requires time for all the variables to shift and align and re-align for us to end up with a more thoughtful response than the one we initially had. You know this patient. And you are at the bedside. Sometimes we have to make choices based on our gut. IF everything is equal, then amben is a wonderful choice.. For the insomnia. But a less great choice for the anxiety.. In which case a more directed anxiolytic might be more beneficial. I think, as you are sensitive to this patient's quandary and your ability to "kill two birds" by prescribing a couple days of a benzo, perhaps a quick call to her and telling her that you have been thinking about her case, and that you do feel that a benzo might be more helpful for her complaints than the ambien, would settle your uncertainty, and would probably earn you a devoted patient. Even if you are wrong, and she is scamming you.. Have you really done any harm giving her the benzo and the implicit excuse for the positive test? If you are not doing any harm, as best you can see, and if there is a greater good to serve by giving one drug over another, chose the drug with the greatest "good" effects. I think you did a right thing, and your reasoning is good. I also think that you could do a "more right" thing, with less harm, by giving her the benzo. Treatingthe situational anxiety preferentially over the resultant insomnia.. And reaping the test result benefit. I would call her You sound like a wonderful clinician.. Most would have simply made the benzo or not decision and moved on. Your introspection and self reflection speak volumes about your character. vr Davis But, what do I know... Urgent care is a strange thing. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 25, 2011 Moderator Share Posted June 25, 2011 tough position remember that the patient reports what prescription meds she/he has PRIOR to the drug screen - all that she would have to do it report that she has a script for benzo's and the drug test would come up appropriately positive - no harm, no foul.... IF you are an occ health clinic and the visit was paid for by the employer then you have likely done a less then good thing (|bad|). The whole point of a company spending money on pre-employment physicals is to screen out this exact type of person - taking someone else meds.....your responsibility is to the company not to the patient - her PCP can make the call to say she is on a benzo not you think of it this way - she tests positive for benzo's - you covered for her - 3 months later when driving a company vehicle she falls alseep, crosses yellow line and head on's a family of 4 on vacation - killing one of the kids and paralyzing the other - - long court case and you are deposed..... how do you answer the plantif attorney when asked about the positive benzo test? Granted this is long long shot but it is important to think of who your responsiblity is to - if you are getting paid by the company you are representing them, not the patient..... I would have explained to her that she should document on the drug screening form that she has taken an benzo, then document that she is on a benzo - leaving out rather it is specifically prescribed to her. I would NOT give her a script for a controlled substance (benzo's) under any circumstance -- if this was a visit paid for by the company. As well I am not sure that there is any way possible to get to know a patient enough to prescribe controlled substance in an overbusy occ health clinic - even in the primary care world I would get a f/u visit and utox results prior to prescribing a benzo's for only short term use to help but would insist on counseling (DBT or CBT) and then next step is SSRI - sorry but benzo's just do not work for long term anxiety management in my mind - course if this visit was not paid for by the company, but instead the patients insurance, you did fine - you avoided the benzo's (good) while addressing her s/s. however the concern of f/u is very real as you started a new medical treatment plan and should f/u with patient.... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted June 25, 2011 Administrator Share Posted June 25, 2011 Two days ago, she took one of her boyfriend’s low dose diazepam tablets for the anxiety and states it helped tremendously. [...] denies recreational drug use. So either you're tacitly acknowledging her right to self-presctibe, or you're using too narrow a mental description of "recreational" for my view. There are drugs prescribed to a patient, and NOT prescribed to a patient. Of those NOT prescribed to a patient, many are non-controlled substances, and many others are. "Recreational" is a value statement in this context, that says some non-prescribed, controlled substances may be OK while others are not. The thing to remember, in my mind, about helping someone avoid consequences is that you did not make the choice that led to the undesirable consequence--she did. I wouldn't lose sleep over the probable withdrawal of her job offer; those are the consequences of her own choices. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 25, 2011 Moderator Share Posted June 25, 2011 I don't know your specific pt but am leery of anyone who says " I tried a friend's xyz and it worked great, can I get some more?" my feeling is that in an er/urgent care setting in general we shouldn't be starting folks on psychotropic drugs in including ssri's or benzos without a real good reason or a consult. she had no f/u plan in place and for all you know she peddles that story all over town and has been using benzos for years. I may be a cold hearted bastard but I probably would have given her some vistaril to tx her insomnia and a referral to a local pcp and/or mental health provider. trying a friends rx antihistamine is one thing. trying a friend's controlled substance is another. trying a friend's valium counts as "recreational drug use" in my book. Link to comment Share on other sites More sharing options...
medic25 Posted June 25, 2011 Share Posted June 25, 2011 Agree with EMED; I don't see too many occasions when we should be prescribing meds for anxiety from an ED/urgent care setting. This is much better treated by a PCP or a psychiatrist. I would also make sure to check this patient on the state controlled substance monitoring website if you have that option. It's always nice to know a patient's prescription history when they come in requesting controlled substances. Link to comment Share on other sites More sharing options...
bradtPA Posted June 25, 2011 Share Posted June 25, 2011 I would haves checked the state-wide controlled substance data base to see if there was a pattern of drug seeking before making any decision. If there was no data base issues such as doctor shopping, I would have given her a two day supply until she could have been seen by her PCP. An example I had yesterday was a patient with chronic back pain asking to switch providers. Last fill for percocet was 04/23/2011. Last stated dose taken was 9 days ago. point of care testing showed he was positive for THC, cocaine, oxy, and opiates. No controlled meds were given, offer to help with rehab was rebuffed. Link to comment Share on other sites More sharing options...
winterallsummer Posted June 25, 2011 Share Posted June 25, 2011 Your job was to treat her symptoms, which you did, not give her a get out of jail card for her future employer. She's a college educated adult who must've known she had a drug screen coming up and she took the pill knowing the consequences. Plus what if her story is bogus and she just wants more pills since she enjoyed her boyfriend's? What she was asking you to do was unethical IMO. Besides, she can go to her employer and explain the situation just like she did to you, telling her employer "look I even went for a consult right after" and then it is up to THEM if they fault her for it or not. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted June 25, 2011 Administrator Share Posted June 25, 2011 Your job was to treat her symptoms, which you did [...] Really? You have a patient who tells a story of anxiety and insomnia, which may well be true, and of needing to pass a drug test, which is probably true because it is an admission against her interest. Which one of these two reasons is her chief complaint? The drug screen: it's the reason she's in the office today, as opposed to any other day of her reported symptoms. Now, when a patient presents with a CC of needing a prescription to pass a drug screen, which of you thinks it's ethical to comply with that request? (I can't say that I ever anticipated that a security background which included interrogations classes and an academic background which includes game theory studies would combine to help me deal with ethical conflicts in medicine, but stranger things have happened...) Link to comment Share on other sites More sharing options...
dpc511 Posted June 25, 2011 Share Posted June 25, 2011 I would haves checked the state-wide controlled substance data base to see if there was a pattern of drug seeking before making any decision. If there was no data base issues such as doctor shopping, I would have given her a two day supply until she could have been seen by her PCP. I agree with this post. I have one question for the OP. Would you have considered prescribing a benzo if she never mentioned the drug screen? Link to comment Share on other sites More sharing options...
Contrarian Posted June 26, 2011 Share Posted June 26, 2011 .....your responsibility is to the company not to the patient -. Maybe in your alternate universe... but this very notion is the antithesis of medical "CARE"... I guess they are teaching "Patient Focused and Centered Care" a bit different now-a-days... :sad: Personally, I couldn't give two $hits what "company" signs the checks... I work for and my responsibility is to THE PATIENT...!!!! Your job was to treat her symptoms, which you did, not give her a get out of jail card for her future employer. Really...?? Lets come back and try again after a few days/months/yrs without the "Pre" as a prefix to the PA... BEFORE you start spouting off to someone who is where YOU are trying to get to... what THEIR job is. Simply put... Lets get a license to practice medicine before telling those with one... how to do so..! Thanks ____________________________________ Other than that... I pretty much agree with most of whats been written above by everyone. The "Practice of Medicine isn't "black & white"... there is beucoup "gray." There are LOTS of contextual "rights"... and a few concrete "wrongs" when dealing with real live people and there are some... but few ABSOLUTES when tasked with non-judgementally dealing/directing/mitigating human bio-psycho-social pathophysiology. Personally, I might have used a Beta Blocker (referral to PCP/Psych) for short term TX of the reported anxiety and she would have been on her own as far as accounting for the "self-prescribed" Benzo. YMMV Contrarian Link to comment Share on other sites More sharing options...
Piper Posted June 26, 2011 Author Share Posted June 26, 2011 Thank you, thank you, thank you all for your thoughts and inputs. I did check the state controlled substance database and no activity was showing on this patient. Follow up in the short time frame available was definitely an issue since the patient has no local PCP. One option would have been to have her recheck at urgent care, but she would, in all likelihood, end up seeing another provider who would then inherit the problem of follow-up, possible refills, etc. From dpc511: “I have one question for the OP. Would you have considered prescribing a benzo if she never mentioned the drug screen?” Good question and I really think you are pointing to the crux of the issue. Although my gut feels like this is a young person who made a one-time bad decision, the primary purpose of the visit definitely was to obtain a prescription that would justify a positive urine tox screen. Without that variable, I absolutely would not have considered starting this patient on benzos due to the history I was getting from her plus her lack of a PCP for follow-up. I don’t know why I am choosing to lug this particular patient home with me. Yep, she screwed up and I do believe that screw-ups can be pivotal learning moments and one should deal with ensuing consequences. As medical providers, we all want to “make things better” for our patients. The voice whispering in my ear tells me I could have done that if I had just …given…diazepam. But the head on my shoulders disagrees. As Contrarian said, “The "Practice of Medicine isn't "black & white"... there is beucoup "gray." My pre-PA work life was very algorithmically driven and as I (hopefully) mature as a provider, I am learning that patients are not algorithms. The art of medicine has turned out to be a more challenging mountain to climb than the science of medicine. Thank god for this forum and craft beer is all I have to say. Link to comment Share on other sites More sharing options...
Contrarian Posted June 26, 2011 Share Posted June 26, 2011 Similar situation: Had a young lady show-up to the clinic for expedited induction into our Suboxone program. Due to the 100 patient limitation, the waiting list is about 3wks - 2 months long and always has about 25 people on it. So when she showed up I thought it was a bit odd since she was nowhere on the waiting list. While she was in the lobby completing the paperwork (demographics and several ROIs for court, LE, Primary Care, social services, etc) I asked the clerk about her and the clerk told me that my SP recieved several phone calls from the Tribal Elders over the last 24-48hrs about her and so under pressure, he let her "jump the line." I walk into the exam room to see her and my "Spidey Sense" starts tingling... She was a well dressed, well groomed, well kept, well nourished, attractive young lady who didn't "fit the mold" of the typical Native American Opioid Addict that we see everyday. Her answers to the induction questions weren't "right" and the amount of Suboxone needed was miniscule but overwhelming for her. I walked out of that exam room and told my SP that "something just ain't right with this one"... I also told him that there were 25 folks in front of her who REALLY needed to be in the clinic, but he told me that he was pressured politically into allowing her to move to the front of the que... because her familiy was one of the strongest influentially in the tribe. This young lady was gone about 12min total when the phone rings. Its the Sherriff who is asking to speak to a prescriber. I get the call and find that the young lady I just induced was stopped 2 days ago by LE and found with 40 orange hexegonal tablets. She was booked and charged with distribution, but told them that she was a Suboxone patient and the pills were prescribed to her by us. Since I had ROIs, I simply told the sheriff that we JUST induced her, and she became a Suboxone Patient TODAY. I also informed him that in the future, "don't believe the hype" because we ONLY send 1 days dose home with patients on Saturday evening only. The patients in our clinic MUST come to the clinic and take their (crushed) dose in front of us Monday-Sat... they only get to take home their sunday dose on saturday night. So there is NO legitemate reason that a patient of ours would have 3-40 pills. (average dose 16mg -2 tabs) The young lady showed up for two visits then disappeared. Basically, as soon as she realized that she would still be prosecuted for distribution, she saw no need to continue to come to the clinic. Just how it happened... Contrarian Link to comment Share on other sites More sharing options...
WTEngel Posted June 26, 2011 Share Posted June 26, 2011 It is always tough to decide how to help our patients. I am not a PA yet, so please don't think I am trying to tell anyone the best way to do things, but being a paramedic, I also run into drug seekers, and potential drug seekers more often than I would like. Trying to decide if the patient made a one time mistake and self prescribed her BF's medication for "genuine" medical reasons (in her own mind) or if she took the valium recreationally for more untoward purposes is tough to say the least. If I had treated this patient, the thing that would have bothered me most about the case is that the patient was seeking a prescription for a benzo to cover up her mistake, and not being up front about it. I am not saying it makes up for her lapse in judgement, but some up front honesty would have made me feel a little bit more comfortable when making my decision about how to best serve this patient. When patients are not fully up front and honest it makes it so much harder to know what is right for them (I know I am preaching to the choir on this one.) What this patient did also makes it hard to prescribe a benzo even if it does meet her needs, as it would make me feel almost complicit in her being less than honest on her drug screen. In the end, if you feel like you treated her appropriately and did not punitively withhold the valium prescription because of her admitted self medicating, then you are not in the wrong. If she does not get the job because of a positive urine drug screen, there should not be any guilt on your conscience, as you best served the patient by giving her the right treatment. Ultimately it is not your decision to withhold a benzo prescription that might cost her the job, but her decision to take the benzo without a prescription in the first place. These are the situations that no amount of education can fully prepare you to handle, IMHO. This is where treating the patient begins to be more from the heart than from the head. Link to comment Share on other sites More sharing options...
Hemegroup Posted June 26, 2011 Share Posted June 26, 2011 Doesn't Ambien affect a benzo sub-receptor anyhow? Maybe it'll show up as a benzo. You COULD have tried trazadone ... hmmmm, why didn't you ... ;) Link to comment Share on other sites More sharing options...
just_me Posted June 27, 2011 Share Posted June 27, 2011 I have one question for the OP. Would you have considered prescribing a benzo if she never mentioned the drug screen? This is what I was thinking...or she could have simply lied and said she was on it before but stopped because of xyz and would like to start again Link to comment Share on other sites More sharing options...
cinntsp Posted June 27, 2011 Share Posted June 27, 2011 Doesn't Ambien affect a benzo sub-receptor anyhow? Maybe it'll show up as a benzo. Nope. There's no cross-reactivity. Link to comment Share on other sites More sharing options...
Hemegroup Posted June 27, 2011 Share Posted June 27, 2011 Nope. There's no cross-reactivity. http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=5875 Pharmacodynamics Subunit modulation of the GABAA receptor chloride channel macromolecular complex is hypothesized to be responsible for sedative, anticonvulsant, anxiolytic, and myorelaxant drug properties. The major modulatory site of the GABAA receptor complex is located on its alpha (α) subunit and is referred to as the benzodiazepine (BZ) receptor. Zolpidem, the active moiety of zolpidem tartrate, is a hypnotic agent with a chemical structure unrelated to benzodiazepines, barbiturates, pyrrolopyrazines, pyrazolopyrimidines, or other drugs with known hypnotic properties. In contrast to the benzodiazepines, which nonselectively bind to and activate all BZ receptor subtypes, zolpidem in vitro binds the BZ1 receptor preferentially with a high affinity ratio of the alpha1/alpha5 subunits. The BZ1 receptor is found primarily on the Lamina IV of the sensorimotor cortical regions, substantia nigra (pars reticulata), cerebellum molecular layer, olfactory bulb, ventral thalamic complex, pons, inferior colliculus, and globus pallidus. This selective binding of zolpidem on the BZ1 receptor is not absolute, but it may explain the relative absence of myorelaxant and anticonvulsant effects in animal studies as well as the preservation of deep sleep (stages 3 and 4) in human studies of zolpidem at hypnotic doses. Verrrrrry interesting, so I suppose the test would have to be BZ1 specific ... oh well, I was trying to cheer the OP up a bit ;) Link to comment Share on other sites More sharing options...
lightbearer06 Posted June 27, 2011 Share Posted June 27, 2011 Sometimes the best thing we can do for our patients is say no. There are reasons why benzos and narcs are scheduled medications. From ED/UC, I rarely if ever (I can't think of a specific time) when I have given anyone a script for benzos. Narcs are given a little more freely in the Department but there has to be a specific reason/legitimate cause of pain before I send someone home with them. I recently read an article talking about "Pharmageddon," and there are legitimate dangers with these medications. Link to comment Share on other sites More sharing options...
Hemegroup Posted June 27, 2011 Share Posted June 27, 2011 I'll give benzos as they're to be used, temporary crutches for the tough points in life. However, if someone has chronic anxiety, I'll start them on a two-week benzo course along with Buspar for the long haul ... these people who feel they are entitled to long-term benzos are whacked. We had a woman throw a complete temper tantrum at the nurses desk, because she wasn't getting the Klonopin she had been receiving for years. Waaa. That being said, remember that people who've been on benzos long-term need to be weaned off so they don't go into withdrawals (which can include seizure). I'll also sometimes prescribe Valium to be used as an occasional muscle relaxant, for patients who have bad results from the others (such as Flexeril or Baclofen). Soma would probably be best for those patients, but we see a lot of patients covered under our county insurance and our county pharmacy doesn't include Soma on their formulary. For the patients who can afford it, I'll send that prescription to another pharmacy for them to pay out of pocket. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 27, 2011 Moderator Share Posted June 27, 2011 This is what I was thinking...or she could have simply lied and said she was on it before but stopped because of xyz and would like to start again that's even easier. "sorry, we don't refill narcotics in the er, you need to get these from your regular dr". Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 27, 2011 Moderator Share Posted June 27, 2011 Heme- soma is the devil. highly addictive. try to never get folks started on this. please. I agree valium as a muscle relaxant has its place and I do write it for that indication. Link to comment Share on other sites More sharing options...
Contrarian Posted June 27, 2011 Share Posted June 27, 2011 valium as a muscle relaxant has its place. Yep... emergently for procedural medicine, but NOT to be taken home. Use Robaxin.... Flexeril... or Baclofen for outpatient muscle relaxation. Tooo easy to get into trouble with Benzos and Opioids individually and in combo. Also wouldn't want to contribute to the "entreprenurial exploits" of the Rx drug diverter/dealer. Lots of addicts trade Benzos for Opioids and also use them together since they have synergistic effects. Just something I learned from my time in Addiction Medicine Contrarian Link to comment Share on other sites More sharing options...
Hemegroup Posted June 27, 2011 Share Posted June 27, 2011 Yep... emergently for procedural medicine, but NOT to be taken home. Use Robaxin.... Flexeril... or Baclofen for outpatient muscle relaxation. Tooo easy to get into trouble with Benzos and Opioids individually and in combo. Also wouldn't want to contribute to the "entreprenurial exploits" of the Rx drug diverter/dealer. Lots of addicts trade Benzos for Opioids and also use them together since they have synergistic effects. Just something I learned from my time in Addiction Medicine Contrarian I understand what you're saying (and don't think the others aren't my first-line of treatment), but as I stated ... I feel they have their place, yes, in outpatient medicine. I have a patient with severe scoliosis who experiences rebound muscle tension with the others, Valium works well for him when it's severe and I have absolutely NO problem with that. EMED, I understand what you're saying about Soma, and there are wayy too many people on it TID all day every day. But it works very well as a muscle relaxant and I have no problem prescribing it to certain patients just as I have no problem prescribing Norco to certain patients. And don't go thinking I'm Mr. Free For All, I'm not. When I prescribe these meds, it's for very specific cases and we have a thorough discussion about how these meds are to be used ... not every day all day, but only when, and if, necessary. As someone with a bad back (protruding disc and degenerated couple of other discs, gee, where is my construction boss now??), I can say that personally, Flexeril does zilch for me. Amrix, however, the ER formula of Flexeril (cyclobenzaprine), works great at 30mg, usually (rebound has occurred a couple of times, which is hell the next day, absolute hell), but you have to take that 4 hours before it really takes effect. It's also terribly expensive (about 600 bucks). Soma, on the other hand, works fast, is affordable, and when you are in serious pain from being on your feet all day, it does the job. Baclofen works well also, but it knocks me on my ***. My point is, I understand what it means to have a bad back, and I work with my patients to find a regimen that works best for them. Some people get great results with Flexeril, Baclofen or Robaxin, it just all depends on the individual and situation. Link to comment Share on other sites More sharing options...
Hemegroup Posted June 27, 2011 Share Posted June 27, 2011 Incidentally ... http://www.amrix.com/Patient/Instant-Savings-Coupon.html 10 bucks definitely beats 600! Link to comment Share on other sites More sharing options...
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