Patient Prescribed High-Doses of Controlled Medications Seeking Admission to Psychiatric Unit

[Stagg737]

They don’t want to stop the Xanax hypothetically, you want to force someone into withdrawal even though they will be discharged and get back on it?

That wasn't part of the case given, but if they really want a benzo I'd still stop the Xanax and either treat withdrawal with the plan to restart them on a lower dose of Klonopin or Ativan, or just switch and decrease the dose inpatient. High dose opiate + moderately high dose benzo in a patient with SI is a terrible combo, and I'm absolutely not d/c'ing this person on a 6mg dose of Xanax daily. I should add that I'd also be calling their outpatient doc and asking how tf they got to this medication regimen. If that prescriber isn't actively trying to get them on more reasonable doses, I'm likely reporting to the board. If they're getting meds from multiple docs, I'm asking if they're aware of the full med list and trying to coordinate care.

I definitely get calling the outpatient provider, but (hypothetically), what if they don't want to talk turkey and work with you, say if they're committed to the med regimen as described for XYZ reason? I suppose beyond reporting to the board as @TexasPhysician said, what options do you have?

You let them know that you'll be happy to report them to the board for prescribing a dangerous mix of higher dose medications to a patient with SI. An opiate + benzo is already increasing risk in patients without co-morbid substance issues or stimulants. You can make a solid argument that prescribing all 3 in higher doses, especially to patients who report even occasional SI, is malpractice in many if not most cases. If I had a patient on that med combo I'd certainly feel the need to justify it if another doc called asking questions and I'd expect the same if I'm the one making the call.

Good thought, and they have been tried, but in my experience, gabapentin/pregabalin don't work well for "anxiety" and "insomnia" (typically trauma-related) in benzo taper.

The bolded is interesting. I've had some decent luck with gabapentin (mixed results) but haven't really differentiated based on past traumas. That actually seems like an interesting area to study.

I'm also surprised how commonly adult adhd is diagnosed and people put on stimulants.. At least in my residency clinic these cases were few and far in between. Maybe it's underdiagnosed. Would be interesting to see prevalence in comparison to more common psych diagnoses. It's also such a tricky dx to make.

I've actually been very surprised by how many of my new intakes in clinic are for ADHD in adults. I'm probably a bit more liberal with stimulants than others, but I still need some pretty strong evidence of a h/o ADHD with current symptoms to start an adult on it. I've started most of these patients on Wellbutrin, but am not against a stimulant if I believe the evidence is strong enough. Mostly, it's when a parent whose kid was recently diagnosed comes in and is asking for treatment.

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[comp1]

Inpatient is an excellent safe place and time to taper off contradictory controlled meds. You do need to get the NP on board with any plans and preferably there should be a new contract in place on the controlled substance website for the state to limit the seeking of new prescribers.

 

[clausewitz2]

I've actually been very surprised by how many of my new intakes in clinic are for ADHD in adults.

Russell Barkley estimates that 4-5% of American adults have ADHD. Even if you want to cut that in half, throw in the fact that people presenting to a psychiatrist are going to be an enriched sample and you quickly end up with a large percentage of a typical panel if you are actually looking for/treating it.

 

[Stagg737]

Russell Barkley estimates that 4-5% of American adults have ADHD. Even if you want to cut that in half, throw in the fact that people presenting to a psychiatrist are going to be an enriched sample and you quickly end up with a large percentage of a typical panel if you are actually looking for/treating it.

Fair, but I think for me it's still disproportional. At the VA I'm at over half my intakes are for ADHD or ADHD + something else. If I did 10 intakes in a week (which I don't), I'd estimate 5-6 would have ADHD as part of their reason for initial eval. That just seems so high to me even considering the sample demographic I'm seeing.

 

[calvnandhobbs68]

Fair, but I think for me it's still disproportional. At the VA I'm at over half my intakes are for ADHD or ADHD + something else. If I did 10 intakes in a week (which I don't), I'd estimate 5-6 would have ADHD as part of their reason for initial eval. That just seems so high to me even considering the sample demographic I'm seeing.

I would rephrase that and say half your intakes are for patient perceived problems with inattention/focus/etc. People just perceive that as "ADHD" but diagnoses don't present, patients present with symptoms. That's like saying half of GI's intakes are for stomach pain or reflux...probably wouldn't bat an eye at that.