Pt on several controlled substances

[BayPAC]

I’m permanently replacing a NP who was heavy on prescribing controlled substances. For instance, I saw one of her patients who is on Adderall, Hydrocodone, Gabapentin, Temazepam, and Klonopin (two of the meds given by outside providers). Patient is on these meds for more than a year and “very happy” with this combination, refuses any change. This situation is not to fair me, the practitioner, or to the patient. Now I have the pressure over my shoulders and the patient, the addiction. How do you handle cases like this?

[thinkertdm]

Easy.  Don't go in with the attitude you are going to take anything away.  Take each problem, asses it, then discuss with the patient the best- safest and most effective course (which may be opiates).

Discuss that being on various combinations can increase side effects, including death.  Don't be scared to say death.  The patient will probably cross their arms and reply "well, I haven't died yet".  Don't fall for that- don't get into an argument match with a three year old.

Don't forget you many times you can't discontinue cold turkey, and be prepared for well thought out replacements.  Refer to pain management for weaning ideas.

People die on these things.  Period.  They worry so much about myalgias with statins but have no problem with the sleep of death by temazepam AND Clonazepam? Please.

Hold fast to your belief, but sometimes these Are useful tools, if used right.

Ps- there's a difference between addiction and dependence.

[Marinejiujitsu]

I’m permanently replacing a NP who was heavy on prescribing controlled substances. For instance, I saw one of her patients who is on Adderall, Hydrocodone, Gabapentin, Temazepam, and Klonopin (two of the meds given by outside providers). Patient is on these meds for more than a year and “very happy” with this combination, refuses any change. This situation is not to fair me, the practitioner, or to the patient. Now I have the pressure over my shoulders and the patient, the addiction. How do you handle cases like this?

Just tell them they have a 15% chance of dying on that combination.

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[thinkertdm]

35 minutes ago, Marinejiujitsu said:

Just tell them they have a 15% chance of dying on that combination.

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That's 85% chance of living.  Not going to change anyone's mind.  Remember, work with them but don't argue.

[rev ronin]

I somewhat disagree with the "not going to take anything away" approach--at least, as I think I understand it.  Yes, something needs to get taken away, because that is a deadly combination, but yes, we need to be building community with our patients.

One goal might be to get the patient to order his or her prescriptions in "I absolutely need this" order, and end up taking off or tapering one at a time.

Another would be to correct the level of scrutiny: No pot, monthly visits, monthly UA WITH confirmation, monthly pill counts, monthly symptom inventories, monthly PMP checks, etc.  That can end up costing them thousands of dollars more, and might provide the financial incentive to get down from three to one class of controlled substances.

You can also enforce specialist consultation as a requirement to prescribing? No CBTi visit this month? No Temazepam, sorry.

The bottom line is that you are not there to cater to the patient's whim, you are there to help them.  You are not willing to have them die on medications you're prescribing.

[thinkertdm]

I don't think my initial comment was clear- yes, ultimately, things will be taken away.  But don't come to the table with that attitude, because people have been trying to take their goodies away for years, and they ain't having any of it.  Instead, convince them to give it it away.  It was their idea. That's the goal.  

We know it's dangerous, and deadly- they may too.  The art of medicine is to listen and work with them. Lots of options for ambien- trazodone, melatonin, warm milk.  If they counter "it doesn't work", and they will, be frank.  Be clear.  This combination could kill you.  Why hasn't it yet?  Luck.

[Marinejiujitsu]

That's 85% chance of living.  Not going to change anyone's mind.  Remember, work with them but don't argue.

I am a pro at this. Blame medicine and how we practiced for years. Then state how Trump is trying to end this and blaming the providers. People losing licenses left and right. All true. Usually, it goes like this, "Yeah, Trump is no joke. You see what he's doing to the Mexicans? " lol. That was a real response from a patient. Lol.

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[rev ronin]

5 hours ago, thinkertdm said:

I don't think my initial comment was clear- yes, ultimately, things will be taken away.  But don't come to the table with that attitude, because people have been trying to take their goodies away for years, and they ain't having any of it.  Instead, convince them to give it it away.  It was their idea. That's the goal.  

We know it's dangerous, and deadly- they may too.  The art of medicine is to listen and work with them. Lots of options for ambien- trazodone, melatonin, warm milk.  If they counter "it doesn't work", and they will, be frank.  Be clear.  This combination could kill you.  Why hasn't it yet?  Luck.

Yeah, I thought that's what you were trying to say. So many apparent disagreements are just alternatives in vocabulary and perspective.

[sas5814]

It is a bit passive aggressive but I always take the "you need very close monitoring on these meds" approach. Never more than a 30 day prescription, always have to have a visit every month to get your refills. When they begin to get exasperated I open the door for some changes that would ease the visit requirements. Its a slow process. Oftimes they get tired of it and move on to someone else which, for me at least, solves the problem.  We aren't shoe salesmen. While this is a participatory process it often puts us at odds with what the patient wants. What is medically best is always the best path.

[BayPAC]

Thanks everyone! Very helpful ideas here. Today I used the "death card" with my patient. Her response: "nobody never told me this." She gladly agreed to cutting her benzo in half. 

[ventana]

On 5/11/2018 at 6:54 PM, BayPAC said:

  Adderall, Hydrocodone, Gabapentin, Temazepam, and Klonopin  

Having just come back from a ASAM conference...

 

here is my thoughts

 

never use two types of benzos.... never never never (and that is the only absolute I have)  Let a Boarded Psychiatrist take on this but more on this later

 

your patient is on a roller coaster of meds, uppers, downers, chillers, and even some w/d blunters when (if) they run out early....

 

 

So what to do???

Do not cut them off - benzo's need long tapers

Do educate them as you have done and follow the above suggestions on pill counts, utox screens, monthly follow up and the like - this is now what medicine should be - you are not being a jerk, you are managing a very high risk patient.

there is some interesting data coming out on Benzo's that state they keep patients on MAT longer then with out - I honestly do not know how to interpret this data as it seems we are leveraging a benzo dependency into compliance.  But the point is there is still un answered questions.

 

The Adderall might well be needed, but you might try wellbutrin in it's place - helps with ADHDH/ADD s/s and is not a controlled (but it is subject to abuse) 

 

GABA - well that just really doesn't do much (recent studies show that it is NOT effective for neuropathy, is know to only cover partial seizures poorly, and yet psych and pcp are writing it like it is water.    It likely can be d/c with out much issue

 

Hydrocodone - has opioid effect, up regulation, dependency, mood stabilizing effect, and temp relieves pain(but gives you more pain in the long run due to up-regulation) and likely should be attempted to be removed.  Might consider a long slow taper, ie over 6 months or more to help get off.  Usually I don like Tramadol but in this case might be helpful as a step down

 

Finally - as stated before  - no way two benzo's -nope nada

 

 

Overall I would likely bring them up to speed on some of these issues - change nothing the first month, refer out to a baord addiction specialist, psych provider whom can give the clear answer on the benzo's (and even ask them to take over prescribing if they do not want to get down to one agent)

At month 2 see how it is going, check Utox and results, review psych consult, explain again the risks and maybe go for the removal of the GABA over  a month or so - okay to go down by 300mg every 2 days till they are off.  Sometimes I leave 100mg po qhs for a week just to let them step off it slowly.

At month 3 you have them off one of the benzo's, off Gaba, and maybe on wellbutrin - leaving only hydrocodone and maybe a benzo (still REALLLY dislike  and I would be honest with them that this is unlikely to continue in the long run)

 

In the preceeding 3 months do a few extra Utox screens and some unannounced pill counts

 

 

They will likely tire of you trying to manage them "to the best of your ability" and find another prescriber.  but if they do not you are on the way to a more manageable situation.

 

 

Me personally, if chronic opioids are going to be used it will be to the methadone clinic (SUD hx) or office Suboxone - nothing else - I see ZERO evidence for any other long term chronic opioids in non cancer issues.  period..... (and BUP does work well for chronic pain and is volumes safer WRT death and overdose)

Check your PMP and make sure the person does not have an incarceration hx (if so strongly recommend MAT)

 

Sounds crazy, but make sure you CP is on board or they will sink you in the long run - they have to have an awareness of what you are doing, have faith in it, and NEVER overrule you to the patient.....

 

 

 

The X number training is FREE and is lik 24 hours of CME....  worth doing..

[sas5814]

GABA gets prescribed because insurance companies will pay for it without a prior auth and , in cash patients, because it is cheap. I never had any luck with it in neuropathy even in very high doses but try and start someone on something else as a first line choice and see what hell the insurance company puts you and the patient through.

Once again money over good medicine.

[sk732]

I'm looking at some of the stuff and wondering how much is being diverted - gabapentin is a drug of abuse here where I work, as well as all benzos, all opioids/opiates of course, and Adderall.  I remember having to examine someone brought in  by coppers  - he was a dial a dealer that had a box of every known dose of gabapentin in the car, all in bottles with other people's names on them...people here snort the stuff.

SK

[mgriffiths]

A patient on this combination of medications, the first visit would start something like the following: "I understand other providers have started these and prescribed them.  It's an unsafe combination, therefore I'm not comfortable keeping you on this combination.  We will be immediately starting to wean _________, with plans to continue to wean and discontinue medications until the combination is safe."

Not every controlled substance patient gets this introduction, but someone on ridiculous combinations gets this every time from me.  Their response is always incredulous and some anger, but it gets the point across that it is my DEA and medical license and I will NOT prescribe this.  They can whine all they want, I don't care.  It doesn't need to be their idea, they are in my office because they "want" (more likely require) my idea.

Yes, many patients on crazy combos don't return to my clinic, but if all of us stood up to patients and did what was clearly in their best interest there would be no point in hopping providers.

[kargiver]

I hope you didn't cut the benzos in half... this will precipitate a benzo withdrawal. 

If you are intent on weaning patients of this nature, you need to understand, cold, the pathways involved, what interacts with what, the timeframes for proper weans, what is "en vogue" in the FP/IM community to "replace" narcotics, and the best way to get from point A to point B.  If the PATIENT is the focus - treat them as such... or you do a disservice to both of you. 

There is a stigmata emerging (already has emerged) about "controlled substances" and the people who take them.  I see this in new grads as they come into our group and with students who rotate through with us.  Everything we prescribe is "controlled."  The only difference is where it works and its potential to cause harm.  The reality is the most dangerous drugs do not fall on the DEAs controlled substances list at all - the idea of pulling people off of regimens they have been on for years, their body is now physiologically dependent upon, causes a lot of strife unless done carefully, methodically, and with buy-in from a patient.  You wouldn't abruptly stop someone on high dose beta-blockers... why would you abruptly stop their clonazepam?

Food for thought...

G

 

[Guest JMPA]

GABA can work well for neuropathic pain, it is better tolerated with less side effects than pregab, with that said do not stop high doses, wean do to potential for seizure. I do not allow my patients on a combo of opiods and benzos, i do not do it, it is a game of sudden death.