Is this unethical behavior?

[uhmocksuhsillen]

Have a patient who has a history of AUD. Has had relative sobriety over the last 4-5 months, only a handful of heavy drinking days. Says they went to detox (obviously not medically indicated) earlier this month following two days of moderate drinking. They frequently goes to detox for "fluids and a taper" when they are pushed to do so by family despite no medical indication. I also suspect there is an element of dependency which is met by the detox environment.

At this most recent detox, they were placed on a benzo taper over a period of three days. Today the patient is asking me for benzos which I declined to provide. I checked drug monitoring and see the doc who detoxed this patient sent them out the door with two prescriptions, one for 1mg ativan and another 1mg klonopin (roughly 4x equivalent doses). These were filled only days ago and are now gone. Patient then admits to this and states these weren't prescribed in any particular extended taper fashion, just to take as needed.

So in my mind, not only is this place detoxing patients without medical necessity, but they are sending patients with severe substance use disorders out the door with multiple prescriptions of benzos. Is this something worth reporting to a medical board?

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[littlefred]

Welcome to the jungle!

In all seriousness though, many patients without complicated withdrawals don't need benzos. Once a patient recieves a benzo taper then they chronically tend to keep getting them.

The chronicity and continued benzo taper prescriptions speak more about the patient not being on the right meds, appropriate level of care or just unmotivated to stop (or a combination)

I don't think this is reportable to the board. What I would report for example is a patient with recurrent hospital admissions for alcohol use/benzo use disorder and complications related to it(e.g. seizures) and a prescriber continuing them on Xanax 2 mg TID, Ambien 10 mg HS etc.

 

[comp1]

Whoa there, buddy. Why in the world are you jumping to medical boards and questions about ethics? You've got a couple of carts several miles ahead of a horse there. What you're seeing is bad, but it's not in any way uncommon. It's a near every day situation in EDs around the country. How do you know what the patient is telling these facilities? How do you even know what the patient is telling you now is the truth? Trust, but verify every word that comes from a patient. Substance abuse almost definitionally involves deceit. You've got the prescription and thus you know the prescriber. If somehow not, check in your state's controlled substance database. As with most substance use disorders, you have to collaborate intensely here with all involved providers to effectively treat and avoid splitting. Call the prescribing doctor and discuss your concerns. Discuss the case overall. Then, come up with a treatment plan together that will work for your (joint) patient. No medical or ethics boards needed.

 

[birchswing]

The CMHC where I used to live would have homeless patients feign suicidal ideation to get admitted, and when the stays got too short had them start feigning heavy daily alcohol use which they would then claim to have abruptly stopped so that they would need detox and then inpatient for a while and then a halfway house you could stay for I think two weeks. This was done by the homelessness director. She had no bad intentions. She paid out of her own pocket for homeless people to stay in motels as her finances allowed when she could. I have a friend who went as far as to continue going to AA because while they were inpatient they met an actual alcoholic who offered her to stay with her after she was discharged as long as she went to meetings. So she had to keep up the ruse that she had been a drinker. She finally got section 8 housing now, but it was a long wait. My friend who did quite a few feigned stints for feigned suicidal ideation and the one time for alcohol withdrawal was never questioned on the veracity, but from how she describes it she barely interacted with a psychiatrist ever.

 

[Sushirolls]

Get the records from the facility...

 

[TexasPhysician]

When someone admits to a detox center, they can display symptoms of withdrawal that could be things like agitation, sweating, etc. They could just be agitated about going to detox and sweaty from tiring to run away. They could be telling me a fake story about how much they drink and for how long. I’m not going to play detective over this. A short “detox” of benzos is cya medicine, and it probably helps patients adjust to being in rehab.

I do not understand discharging patients on benzos from rehab. This would be worth getting records. If records are poor, I would consider reporting this to the board. I get discharging on Suboxone but benzos is weird.

 

[jbomba]

Whoa there, buddy. Why in the world are you jumping to medical boards and questions about ethics? You've got a couple of carts several miles ahead of a horse there. What you're seeing is bad, but it's not in any way uncommon. It's a near every day situation in EDs around the country. How do you know what the patient is telling these facilities? How do you even know what the patient is telling you now is the truth? Trust, but verify every word that comes from a patient. Substance abuse almost definitionally involves deceit. You've got the prescription and thus you know the prescriber. If somehow not, check in your state's controlled substance database. As with most substance use disorders, you have to collaborate intensely here with all involved providers to effectively treat and avoid splitting. Call the prescribing doctor and discuss your concerns. Discuss the case overall. Then, come up with a treatment plan together that will work for your (joint) patient. No medical or ethics boards needed.

Hard to know what's typical when you're fresh out of residency. What happens in an academic environment is often very different than the community.

 

[comp1]

I completely agree that there are ivory tower residencies where you might not be experiencing the real world, but a really good residency, even an ivory tower one, will make a good attempt at showing you how things actually work. Patients lie, often and repeatedly. They may have good reasons or bad reasons, but you shouldn't necessarily assume what the patient says happened, happened.

 

[annoyedpsychiatrist]

I mean its stupid, but this par for the course from what ive seen. I feel like stuff similar to this happens all the time. Giving someone with severe AUD a benzo prescription upon discharge makes about zero sense.

 

[whopper]

It's shady, and if they were doing this with every patient it's wrong, but without more information...can't answer.

 

[mistafab]

Honestly this is not great medicine but doesnt seem ethically wrong or egregiously bad. A short term stint at an etoh use program and the get a 3 day supply of as needed benzos that have long half lives... So what?

Whatever the patient's story just look at the facts. Recent substance use program, short supply of med that could potentially treat withdrawal from said substance. Nothing here to report ethically or morally. Also not the kind of practice you'd want to emulate but oh well.

 

[littlefred]

I mean its stupid, but this par for the course from what ive seen. I feel like stuff similar to this happens all the time. Giving someone with severe AUD a benzo prescription upon discharge makes about zero sense.

It's usually a short term taper, 6 or 8 tablets.

 

[ObsequiousAplomb]

You didn't mention how many pills, unless the 4x in your post is about four doses. If it's fewer than 10 tablets, it's clearly meant to prevent that person from re-presenting when they have withdrawal symptoms. Plenty of people continue to have some symptoms and want to have a little more buffer from those symptoms. The symptoms certainly wouldn't be life-threatening, but they may still be there and they will likely respond very well to a benzodiazepine.

That being said, I certainly never have done this and don't intend to. I would rather keep them an extra day or two after the taper was completed with comfort meds while we complete whatever other indication for hospitalization they have. Thankfully, nobody gets on me about the LOS in those situations.

As other people have said, serial prescriptions for less than 14 days of a benzodiazepine usually indicate multiple attempts at outpatient MAW. There's a risk of diversion, sure. There's a small increase in the risk of fatal overdose, sure. It is still considered common practice for PCPs, OP psychiatrists, or ERs to prescribe these tapers (and considerably less common for it to be from a facility that does MAW, unless they have seen him so many times they really do have a longitudinal relationship).

And as others have said, you do really have no idea what is being told or what the presentation looks like at this facility. Requesting records is a good first step. Reporting people to the board based solely on what a patient (who you know is dishonest) tells you is extreme in most situations.

 

[whopper]

I have a 1 patient on Alprazolam and Buprenorphine. We're weaning him off of Alprazolam. Another doctor in the community who no longer practices put all of his patients on ridiculous med combinations. It was either that or terminate him cause some idiot doctor put him on a bad medication in the first place.

If I were judged only on the metric that I gave him Alprazolam and Buprenorphine people would think I'm a bad doctor. You can't judge a doctor based on 1 patient.

 

[mcatqueen]

I wouldn't jump to reporting the other MD/DO. You don't know the specifics and what they were (or weren't) told by the patient or their family. You should, however, get consent from the patient to talk to the other MD/DO and obtain copies of the records to further understand what happened and coordinate care for the patient. Chances are, your patient might go to the detox facility again and ultimately it's in the best interest of the patient for you and the other psychiatrist to collaborate to best help the pt.

 

[comp1]

Assuming this is in the US, you do not need consent to reach out to the patient's other providers and I would argue in this case it would be strongly contraindicated to wait to contact the other provider while such consent was obtained. This idea that multiple providers of a given patient need consent to speak with each other about their joint patient is a huge misconception and can be extremely dangerous, particularly around substance abuse, where again, deceit is the norm and a core part of the illness. The OP actually has an ethical and legal obligation to obtain that information if they continue to treat this patient.

 

[jbomba]

Assuming this is in the US, you do not need consent to reach out to the patient's other providers and I would argue in this case it would be strongly contraindicated to wait to contact the other provider while such consent was obtained. This idea that multiple providers of a given patient need consent to speak with each other about their joint patient is a huge misconception and can be extremely dangerous, particularly around substance abuse, where again, deceit is the norm and a core part of the illness. The OP actually has an ethical and legal obligation to obtain that information if they continue to treat this patient.

I can't tell you how many therapists, PCPs etc refuse to talk to me unless the patient signs an ROI. Hell even if residency our attendings wouldn't let us call unless an ROI was on file.

 

[Asklepian]

I find this an ethical quandary, too. Where is the limit?
For example, this past week I admitted a patient who is seen by a Mental Health Nurse Practitioner.
Checked her recent controlled Rxs and saw all of the following prescribed by this same midlevel within 1 week:

1. Alprazolam 1mg TID
2. Temazepam 30mg PO qHS
3. Triazolam 0.25mg PO qHS
4. and of course, Amphetamine/Dextroamphetamine Salts 30mg PO qd

Part of me is tempted to call them and talk directly to them about the risks. Part of me wants to report it. I have a hard time seeing where the line is given how many egregious prescriptive practices are out there (generally not as much from board-certified psychiatrists, however).

 

[whopper]

 

[Candidate2017]

Whoa there, buddy. Why in the world are you jumping to medical boards and questions about ethics? You've got a couple of carts several miles ahead of a horse there.

There's jumping to conclusions. And then there's being taken for a ride. OP is going all in, buying a one way ticket from the patient, and hopping aboard the patient's splitting train.

OP, listen. Stop it. Pull the emergency brake and get off that train. Everyone likes to blame the psychiatrist. Don't be one of those people. You're not a surgeon, an internist, politician, plantiff's lawyer, or patient's enabling family member. You're a psychiatrist. You should know better. There are many egregious things out there, but this is not one of them.

Hard to know what's typical when you're fresh out of residency. What happens in an academic environment is often very different than the community.

What happens in an actual academic residency is you spend hours and hours in supervision and didactics discussing splitting. The fact OP doesn't recognize this is splitting points to a community residency.

OP if you want to learn more about splitting, read your patients' records from other doctors. Then you can read all about the juicy, erroneous, and sometimes patently false things they tell other doctors about you.

 

[ObsequiousAplomb]

What happens in an actual academic residency is you spend hours and hours in supervision and didactics discussing splitting. The fact OP doesn't recognize this is splitting points to a community residency.

As a community residency graduate, I take offense that you think we didn't also spend 6 hours in psychotherapy supervision per week for 12 hours of psychotherapy in addition to all the other banal atrocities of community programs. Plenty of academic graduates miss the boat on it despite all the pomp and flair of academia.

 

[jbomba]

As a community residency graduate, I take offense that you think we didn't also spend 6 hours in psychotherapy supervision per week for 12 hours of psychotherapy in addition to all the other banal atrocities of community programs. Plenty of academic graduates miss the boat on it despite all the pomp and flair of academia.

Plenty of academic programs are very biologically oriented...looking at you UCSD.

 

[Ceke2002]

Have a patient who has a history of AUD. Has had relative sobriety over the last 4-5 months, only a handful of heavy drinking days. Says they went to detox (obviously not medically indicated) earlier this month following two days of moderate drinking. They frequently goes to detox for "fluids and a taper" when they are pushed to do so by family despite no medical indication. I also suspect there is an element of dependency which is met by the detox environment.

At this most recent detox, they were placed on a benzo taper over a period of three days. Today the patient is asking me for benzos which I declined to provide. I checked drug monitoring and see the doc who detoxed this patient sent them out the door with two prescriptions, one for 1mg ativan and another 1mg klonopin (roughly 4x equivalent doses). These were filled only days ago and are now gone. Patient then admits to this and states these weren't prescribed in any particular extended taper fashion, just to take as needed.

So in my mind, not only is this place detoxing patients without medical necessity, but they are sending patients with severe substance use disorders out the door with multiple prescriptions of benzos. Is this something worth reporting to a medical board?

Ah yes, the good old 'here, have some benzos' approach to dealing with addiction, I remember it like it was 22 years ago. Sadly this isn't something that's hugely surprising to me. A lot of places either just don't want to deal with addicts, even those who are genuinely wanting to quit whatever substance(s) they're on, or you get shonksters that get people in for a few days 'detox' and then send them out the door with a bunch of pills. Not sure about reporting, although coming from a Doctor a medical board report probably holds more weight.

 

[vanfanal]

Assuming this is in the US, you do not need consent to reach out to the patient's other providers and I would argue in this case it would be strongly contraindicated to wait to contact the other provider while such consent was obtained. This idea that multiple providers of a given patient need consent to speak with each other about their joint patient is a huge misconception and can be extremely dangerous, particularly around substance abuse, where again, deceit is the norm and a core part of the illness. The OP actually has an ethical and legal obligation to obtain that information if they continue to treat this patient.

Side track….aren’t there special rules for consent and ROI for matters related to addictions and HIV for which we would need an ROI to speak with another physician in the pts circle of care?

 

[littlefred]

Side track….aren’t there special rules for consent and ROI for matters related to addictions and HIV for which we would need an ROI to speak with another physician in the pts circle of care?

Are you referring to this law?

 

[annoyedpsychiatrist]

I have a 1 patient on Alprazolam and Buprenorphine. We're weaning him off of Alprazolam. Another doctor in the community who no longer practices put all of his patients on ridiculous med combinations. It was either that or terminate him cause some idiot doctor put him on a bad medication in the first place.

If I were judged only on the metric that I gave him Alprazolam and Buprenorphine people would think I'm a bad doctor. You can't judge a doctor based on 1 patient.

similiar situation, i have a patient on suboxone and klonopin .5mg bid. However when I first saw her, she was already on 6mg of klonopin and i worked hard with her and shes down to .5mg bid. Tbh i call that a win. Shes had a tough life to say the least and now shes actually functional, has a great job, taking care of her kids, etc. Shes started to use the klonopin now as more PRN. She also has no comorbid OSA or respiratory issues, or other respiratory depressants, and is in good overall health. I could have been aggressive and said "ok now lets just take off the klonopin completely" but by making it a collaborative process, she was able to to trust me more and work with me.

I have some people on benzos and stimulants. Usually this wasnt by my choice, i inherited them. I could just refuse to treat them but the practice I work for is about access to care ultimately and I want to give everyone a chance. Honestly people have really surprised me, a lot of people, when given the chance will surprise you, and it has taught me that in some situations countertransference happens and I should always reserve judgement. I think at the start of my career, I was too harsh and had the mentality of "if you want benzos, go to the other clinic". Now its become more of "you want benzos, why? what are you getting out of it? is it really helping you? if so, then why are you anxious? if you have been on it for 10 years and dont remember how you feel off it, how do you know you really need it?".


Anywho, im surprised some of you are shocked at these med combos. Every month i get stuff like this. Hell, two weeks ago I had a patient come to me on seroquel 1200, zyprexa 20mg, geodone 80mg bid, phenobarb 60mg bid, klonopin 1mg qid, effexor 300mg xr, and zoloft 100mg. Not even lying. That was probably one of the worst ones ive seen lately, but i see lots of crazy stuff like this in my clinic.

 

[comp1]

Even with 3 benzos, you still call the provider first to discuss the patient care. Hopefully you are able to provide some education and develop an actual joint working relationship instead of just, wow, look at this horrible regimen. In all my years of practice and training, I only ever saw a medical board complaint once. It was for a pill mill doctor who was contacted a full three times for separate admissions (at least) and told to please stop prescribing sedating medications to a patient who had repeatedly overdosed after each contact. Yet, the prescriber continued even after saying they would stop. It's that kind of thing that should warrant a medical board complaint, not a less than ideal medication regimen.

 

[vanfanal]

Are you referring to this law?

Yes indeed. My understanding is that “federally assisted” is defined quite broadly including just having a DEA number; and that concern for potential medication interactions does qualify as a medical emergency to disclose without consent.

 

[littlefred]

Fine line and a bit of a stretch. But I'm no lawyer.

 

[Merovinge]

Fine line and a bit of a stretch. But I'm no lawyer.

It's a stretch to discuss medications that have clear risks of death with another doctor without an ROI? I think this is about as straightforward as it comes for discussing care through an intentionally legal pathway.

 

[whopper]

When I took new patients and for whatever reason it's a lot less now, about 25% of them were on Zolpidem 10 mg daily, had been for years, and their prescribing physician never warned them it's not for long term use nor the risks including not to mix it with alcohol.

I haven't had one of these types for several months and I still take new patients. Hopefully this flippant overprescribing of Zolpidem is at least starting to die off.

 

[whopper]

Oz states his voicing his quack recommendations are "a fundamental right as Americans." Quack treatment recommendations is not political discourse.

Dude-1) The criticizing doctors weren't calling on government censorship-hence no rights are being taken away, 2-private institutions and individuals have every right to criticize a quack, 3-private institution have every right to take away one's titles and honors with that organization.

Not only did Oz sell quack treatments, but then used the McCarthy fear card to defend himself. I've seen idiots confuse First Amendment rights with consequences for irresponsible speech, but when a Columbia professor does it? No it's not that he didn't know better. He knew full well he was intentionally trying to make his critics look like they were against the First Amendment.

 

[Merovinge]

Oz states his voicing his quack recommendations are "a fundamental right as Americans." Quack treatment recommendations is not political discourse.

Dude-1) The criticizing doctors weren't calling on government censorship-hence no rights are being taken away, 2-private institutions and individuals have every right to criticize a quack, 3-private institution have every right to take away one's titles and honors with that organization.

Not only did Oz sell quack treatments, but then used the McCarthy fear card to defend himself. I've seen idiots confuse First Amendment rights with consequences for irresponsible speech, but when a Columbia professor does it? No it's not that he didn't know better. He knew full well he was intentionally trying to make his critics look like they were against the First Amendment.

Of course he did, there is a literal playbook on this technique, it has been essentially perfected. The capabilities of propaganda/manipulation have far outpaced our ability to combat them.