Thursday, February 28, 2008

For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)


Alison Cummins said...

“And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail.”

Interesting — I had the impression it was that she doesn’t have the luxury of getting to know people the way she does in private practice, so she’s more cautious!

Anonymous said...

abuse and dependance are one thing but to not prescribe a med for fear of diversion (pot smoking son will help himself) is dumb.

ClinkShrink said...

Anon: I had hoped for a better argument than name-calling. Chevy Chase from Saturday Night Live said it better: "Jane, you ignorant slut..."

From what I see in prison there are doctors out there who aren't being responsible (or careful) about prescribing controlled substances. That's the point of this post and what I'm trying to call awareness to.

Anonymous said...

dumb? tell that to Heath Ledger's dad

Dinah said...

Okay, so I agreed with the fear that giving an addictive medication can trigger an addiction.

The pot smoking son will get his benzos on the street-- not prescribing for fear of diversion is ridiculous.

What do you say to someone, I'm sorry you have to live with your pain from those multiple fractures because you might be lying to me, or you might have a drug addicted relative or visitor who might steal them??

Alison, I don't start people on benzos in a public clinic for all the reasons Clink mentioned, I don't know them as well, their care is harder to track, and I'm not sure I've ever seen anyone who Doesn't have a family history of addiction (if not a personal history).

Really, if someone wants to go to all the effort of multiple pharmacies, doctor shopping, lying in regular therapy sessions, to get 5 tablets of Ativan out of me, then more power to them.

Clink: I haven't figured out what makes your cutoff for justifying

I wouldn't prescribe benzos in jail either-- my feeling (and this may make me unpopular amongst the correctional folk) is that you're supposed to be uncomfortable in jail.

And people do call Prozac a "happy pill".....

Anonymous said...

I didn't call anyone dumb. said it was a dumb idea. Dinah agreed it was ridiculous.That proves she is smart too. Go dinah go. People take klonopin for epilepsy. Do we stop prescribing for fear of diversion? People who take any drug should be smarter about where they store it.It is not the doc's job to withhold a medication because someone might break into the medicine cabinet.That is a little too much social control for my taste.
Geez, i once said maybe Tony Soprano should feel uncomfortable and everyone jumped on me. He should have been in jail so if that is the case, why should he not have had to feel discomfort? Never mind.
As for SNL, Clink, I believe it was Dan Aykroyd not Chase who called Jane Curtin an ignorant slut. But you're a nun , so we'll let it go.

Anonymous said...

It's just taken a long, long time to really figure out the benzo problem.
I think about one in four people who get more than one prescription will become dependent in some fashion, and that's a whole lot of people. Now that we have the Z drugs for sleep, perhaps benzos should be dispensed only in packs of twos (one for the flight there, and one for the flight back), no more than one per month (and if you fly more than that you certainly need to do CBT for your fear).a

Midwife with a Knife said...

I do like the analogy with pain. I certainly don't give out narcs like candy, but if someone has severe pain (say a separated pubic symphysis, which can be extremely painful), I have no problem giving some vicodin (or T#3s, but they seem to be bad for constipation, and most pregnant women are prone to constipation) to get someone through the last few weeks of pregnancy. I'd certainly prefer that to an elective induction before 39 weeks.

I don't see the addiction potential with benzos being any worse than that with narcotics (although I may be wrong), and so it seems like the same prudent prescribing practices should be implemented.

Only enough until the next visit. Only if there seems to be an objective reason. (i.e. panic disorder, etc.)
If you need chronic narcs, you need them from a special doctor (chronic pain specialist)
There are the same warning signs.. lost prescriptions, increasing dosages over time, etc.

And I don't really know, but it does seem like for some people anxiety is as uncomfortable as moderate-severe pain.

ClinkShrink said...

Dinah: The pot-smoking son isn't going to get his benzos from the street if he can get them from the medicine cabinet. And now you're changing your example---you make the clinical hypothetical more severe when you're countering my argument and less severe when justifying your own. Your post used the example of an MRI or fear of flying. No, I would not give benzos for that. It's ironic that I "only" have a medication management practice yet here's a good situation where I wouldn't prescribe. Simple phobias can be managed with therapy, and you're a therapist.

So distress is OK if you're a prisoner, but not if you're a free society patient? Should people in free society never have to experience discomfort? Is elimination of all anxieties and discomfort a realistic treatment goal?

DK said...

I'm not sure I agree with the "prisoners should be uncomfortable" argument. Although I would argue that prisoners are more likely to cheek and sell/trade their benzos then, say, the pot-smoking son, which might be a good reason to curb their prescription. Eh, may or may not be true.

I do agree, though, that there's risk in anything we prescribe, whether it's physical dependency, psychological addiction, discontinuation symptoms, metabolic syndrome, etc. And I also think that addicts are probably going to be addicts, regardless. There are plenty of substances that legal and widely available for abuse. It may be something I consider when I write for potentially addictive substances, but ultimately it's not because I pick up my pen. It's unfortunate, but, it's brain chemistry.

Anonymous said...

Bottom line, we are a drug addicted society. The pharmacuetical industry controls us, and has a lot of power. Watch televison and see it. To expect people not to take drugs (and thier teenagers or relatives not to find them in the medicine cabinet) is naive.

Alison Cummins said...

I'm with Clink that the risk of diversion needs to be taken into account. Medications that are not for a specific disease tend to be treated like aspirin and shared, especially if the prescription is prn. If I take it myself when I judge that I need it, then it's just natural that I would think I could give it to a family member when I judge that they need it. Or that they would think that they could take it when they judged that they needed it.

But I can't go with Clink's refusal to prescribe benzos for extraordinary situations. Flying and MRIs are outside the range of most people's everyday experience. If I need an MRI after being dropped on the head, I don't have the luxury of six weeks of CBT to teach me to deal with the claustrophobia that barely affects my normal day-to-day existence and only becomes a real handicap in this extraordinary situation.

I could compare this a little to giving birth: most people can deal with some pain, almost everyone can deal with pain better when they've had training, some women have so much training that they can use auto-hypnosis to give birth without pain. We could conclude that all women should be able to learn auto-hypnosis, therefore epidurals are not worth the risk, therefore they should never be used. And we might even be right to reach that conclusion. In practice, we judge that given that most women never give birth more than three times in a lifetime, that learning the degree of self-mastery necessary to give birth comfortably without pain relief, while laudable, is an unrealistic expectation for most women. And that pain relief in labour is a good thing in itself, that needs to be balanced against risk.

If someone flies as often as I do for a living, then it makes sense for them to learn to cope with any fears they might have. CBT, absolutely. If their generalised anxiety is so high that they cannot benefit enough from CBT then they probably need something like an SSRI that they take every day, and then they can work from there.

If someone never flies because they are terrified of the idea but needs to fly right now to Hong Kong because their wife just had a stroke there and is in hospital - that's not something that happens very often, and flying to Hong Kong is an ordeal for almost anyone. Never mind those circumstances. If someone could overcome their claustrophobia to do it anyway, they would be justifiably proud of themselves. They would be a better person. Well, not everyone is a better person or is motivated to become one. They might still need to get to Hong Kong.

This is like the old joke:

Man: Would you sleep with me for a million dollars?
Woman: A million dollars you say? Sure, why not?
Man: (looks in his wallet) Shoot! I've only got $5. Would you sleep with me for five dollars?
Woman: (in total disgust) What kind of woman do you think I am!?
Man: Miss, you already determined what kind of woman you are. I'm just bargaining the price of your service.

In my case I wouldn't sleep with him for a million dollars. But I wouldn't judge someone else for making a different decision. And if I were in a situation that I needed a benzodiazepene to enable me to do something extraordinary but necessary, I would hope that I could find someone to work with me compassionately.

Alison Cummins said...

Dinah, I thought Clink said that benzos were not often prescribed in a clinic setting because clinic patients are known better - that is, their addictions are visible. That the patients you see in private practice function well enough that they can hide their addictions, giving prescribers a false sense of security.

Anonymous said...

I used to be afraid to fly. It's receded in recent years, but for awhile an impending flight caused me to be very anxious. It manifested itself with me running back and forth to the bathroom all the time in the day or so before.

I would have considered some kind of drug to take but I only flew 3-4 times a year and I was too lazy to take off work to go see a doctor about it.

Then there was some plane problem, I think a fire in a bathroom, and I read an article that said the people who were injured or died were drugged or drunk.

At that point I wasn't going in search of a tranquilizing drug because I decided if something bad did happen I would want to have my wits about me!

In recent years I've been flying more, even across large oceans, and while I don't sit next to the window I have managed to get there and back without creating a scene.

That said, when they offer coffee on a plane I usually pass.

Roy said...

As for prescribing (or not) to someone with an addicted relative at home who might take the pills you are prescribing, this is a risk that docs think about. I tell the patient to get a good combination lockbox and keep the pills in there. Don't use a box with a key, because that starts the get-the-key game.

And I've seen lots of little old ladies on [insert drug of abuse here] who are too embarrassed or ashamed to admit to the doc that little Johnnie (who may be more like 43yo) steals her pills.

There is a current advertising campaign by FDA or CDC or someone about keeping medicine cabinet drugs away from teens... pharming.

Aqua said...

In my case the problems I have had with benzodiazepines are not problems at all, but lessons for me about myself.

I have had trouble with depression, anxiety and alcohol addictions and coming off benzodiazepines now and in the past. I also have a strong family history of alcohol addiction, depression, panic disorders, anxiety disorders.

My pdoc knows all this yet he regularily prescribes me Diazepam whenever I need it, because our relationship is such that I am honest with him when I begin to have trouble with it.

His non-judgemental attitude about my anxiety difficulties, and his willingness to help me with medication (Diazepam) when I ask for it when I feel I cannot cope in any other way with my anxiety, allows me to be 100% honest with him about how I use it, how much I use, and if I am taking more than I think I should be taking.

His non-paternal and personal responsibility focused approach to these medications have allowed me to recognize when I need to stop the benzodiazepines and when continuing them is in my best interest.

In turn I take the lessons I learn when I take Diazepam and apply them to my difficulties with alcohol. I am beginning to approach my alcohol use in the same way. Sometimes a little alcohol can be a good thing, but I need to recognize for myself, and take responsibility for myself, when too much of a good thing becomes a bad thing. At this point, as with the Diazepam, I take steps to reduce and stop each of them.

My Pdoc's approach allows me to trust he will help with medication if I need it. It reinforces my beliefs that he trusts and respects my judgement, and it supports my rights, as an individual, to care for myself in a way I believe I need to take care of myself.

My point being, there is value in a allowing the patient to express what they need, to trust they know what is best for them, and to allow them to make their own decisions. My pdoc's approach has helped me grow and learn in a safe environment.

However, in order for this to work the trust has to go both ways. My pdoc has to trust me to either make good judgements, or to be honest with him about what I am taking, and I have to trust him to tell me if I might be headed in the wrong direction and to help me stop when I need to stop.

Anonymous said...

Should people in free society never have to experience discomfort? Is elimination of all anxieties and discomfort a realistic treatment goal?

As a CSA survivor, I experience discomfort every single day. I live with anxiety every single day. I am currently in therapy and have been for a few years now. I am learning to cope with and lessen the discomfort and anxiety but I am not very good at it yet. When my anxiety takes off into a panic attack, I am extremely greatful that my psychiatrist is one that will prescribe benzos! They are the only thing that helps once the panic mode has been activated. And before anyone says that I'm addicted because I said it's the only thing that helps, consider psychiatrist prescribes 10 ativan at a time, I last filled on 9/12 (checked my bottle) and I have 4 left. So I am pretty sure I'm not addicted. Panic attacks are not a little uncomfortable... they are HELL!! If you think that isn't true, talk with the patient who arrives in the ER by ambulance hooked up to an EKG and getting oxygen who's convinced he/she is having a heart attack/dying. Better yet, talk with the ER doc that figured out it was "just a panic attack". Is eliminating all anxiety and discomfort realistic? Probably not. Not any more realistic than eliminating all physical pain. However, it is perfectly reasonable to lessen severe pain to allow a person to why not the same with anxiety/panic?

Anonymous said...

Season one episode four, i believe it was.The Sopranos.Tony is on Prozac for his panic attacks but he is anxious about lots of stuff not least of which some mob biz. This he doesn't share with the good doc upon he he is spying, stalking via a cop he pays offs who also happens to beat the crap out of her boyfriend of the time while getting the dirt on her for Tony. Despite being on Prozac Tony has one more 30 second panic attack and Melfi tells him she is going to prescribe Xanax to help get him over this rough spot. Too ironic.

Anonymous said...

I still have yet to see anyone talk about behavioral therapies as a viable alternative to prescriptions. Why?? Dinah is a therapist. Surely she is aware of the very real, scientifically validated benefits of therapy for treating anxiety and panic attacks. Why constantly be putting a bandaid on the problem when you can actually be treating it at its root? There are many, many people who could benefit a significant amount from such therapies in the long run.

Anonymous said...

Those therapies would put a lot of talk therpists out of business.

DK said...

Behavioral therapy takes a while to see results. Sometimes, you don't have "a while" when your patient (or, depending on your vantage point, you) is in considerable distress. And sometimes the investment isn't worth the payout (as the above occasional fliers commented on).

And, no, behavioral therapies will not put talk therapists out of business. Nor will any of the above put the med maintenance folks out of business, or vice versa. Because we all know that these things are best used in conjunction, not as a single "alternative" or "band-aid".

I'm just sayin'.

Anonymous said...

I believe a standard course of CBT is 9 sessions, which really isn't all that long if you consider how long it takes to see results on some medications for anxiety (ie: Paxil, Zoloft, Buspar). The patient does have plenty of time to try therapy since the anxiety/panic is just going to keep coming back unless you treat it with something other than a short acting benzo. And not to put it callously, but anxiety is not a life-threatening condition in the way that a heart attack is. It may be uncomfortable, but therapy is a viable option for many patients. I'm sure there are instances where the distress is severe, but there's no reason why therapy can't be started immediately so the benzos can (hopefully) be tapered off.

Sometimes meds aren't worth the investment either. Especially when they have side effects, potential for addiction, and possibly require a lifetime commitment. Behavioral therapy may be more costly on the front end, but the argument is that it is more cost-effective in the longrun because the need for constant medication will be reduced or eliminated. It can also be more cost-effective in terms of quality of life (ie: greater sense of self-efficacy? ability to deal with other situations better because of improved coping skills?).

There's something real to be said about behavioral therapy.

Anonymous said...

CBT is a joke, unless you are well enough actually set goals and do the activities in the first place. Medications can help us get to the point where we can begin these things.

CBT worked well for my first MDE, but after that my MDE's began getting so bad I couldn't motivate myself to even get out of bed sometimes.

I believe that for some people, those with mild or mild moderate depression, or those in their first few episodes CBT can help. I do not however, believe that a course of 9-15 sessions will even touch the surface for someone with severe depression and I am reluctant to even believe it can help the milder forms of depression unless it is continued on a very much longer term basis. It is just to easy to slip into depression again and longer term support is needed.

Roy said...

Cost-effectiveness of CBT...

I ran a PubMed search (this one) on this area and came up with a few notable findings. As Anon and DK allude to, this can be challenging to quantify, depending on how you define your timeframes and things like lost productivity ("presenteeism") and diminished quality of life. But here are a few:

Byford 2007: Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive behavioural therapy in adolescents with major depression. RESULTS: The trial comprised 208 adolescents, aged 11-17 years, with major or probable major depression who had not responded to a brief initial psychosocial intervention. There were no significant differences in outcome between the groups with and without CBT. Costs were higher in the group with CBT, although not significantly so (P=0.057). Cost-effectiveness analysis and exploration of the associated uncertainty suggest there is less than a 30% probability that CBT plus SSRIs is more cost-effective than SSRIs alone. CONCLUSIONS: A combination of CBT plus SSRIs is not more cost-effective in the short-term than SSRIs alone for treating adolescents with major depression in receipt of routine specialist clinical care.

McHugh 2007: Cost-efficacy of individual and combined treatments for panic disorder. RESULTS: Results demonstrated consistently greater cost-efficacy for individual over combined treatments, with imipramine representing the most cost-efficacious treatment option at the completion of the acute phase (cost-efficacy ratio = $972) and CBT representing the most cost-efficacious option at the end of maintenance treatment (cost efficacy ratio = $1449) and 6 months after treatment termination (cost-efficacy ratio = $1227). CONCLUSION: In the context of similar efficacy for combined treatments, but poorer cost-efficacy, current monotherapies should be considered the first-line treatment of choice for panic disorder. Additionally, CBT emerged as the most durable and cost-effective monotherapy and, hence, should be considered as a particularly valuable treatment from the perspective of cost accountability.

Note that McHugh's study finds CBT most cost-effective when a longer timeframe is chosen.

Myhr 2006: Cost-effectiveness of cognitive-behavioural therapy for mental disorders: implications for public health care funding policy in Canada. RESULTS: We identified 22 health economic studies involving CBT for mood, anxiety, psychotic, and somatoform disorders. Across health care settings and patient populations, CBT alone or in combination with pharmacotherapy represented acceptable value for health dollars spent, with CBT costs offset by reduced health care use. CONCLUSIONS: International evidence suggests CBT is cost-effective. Greater access to CBT would likely improve outcomes and result in cost savings. Future research is warranted to evaluate the economic impact of CBT in Canada.

Dinah said...
This comment has been removed by a blog administrator.
ClinkShrink said...
This comment has been removed by the author.
Anonymous said...

Can I make a comment about psychotropics for flight anxiety??? There is a cheap, easy, and legal way to medicate for this, obvious to all, and those same GABA receptors are at the crux of the therapy. Every airport terminal has something called a bar in it where anyone over the age of 21 can have a stiff one before the flight. Does the same thing as that coveted ativan that might be stolen by the pothead son, only more calories.
And if that isn't enough, there's the in-flight beverage selection. Same effect, no prescription needed, quicker and without all the hassle of CBT.....

Anonymous said...

As an aside to my question about why CBT (or other equivalent behavioral therapies) aren't being talked about:

When medication + therapy is a necessity (and sometimes it really is), what are the non-potentially-addictive alternatives to benzos? I know there's some of the SSRI's like Paxil and Zoloft. There's also Buspar. I've heard some talk about Seroquel even (this one always confuses me though). What medication alternatives do you (shrinks) suggest to patients needing medication management who walk in requesting benzos to control anxiety/panic? And do you ever recommend it in combination with a behavioral therapy?

Anonymous said...

And thank you Roy for your PubMed search, it was very informative!

Assrot said...

Lord knows I have no medical qualifications at all other than a brief stint as an EMT back in the early 70s for a couple of years but I always thought that if a medication is deemed necessary and prescribed by a licensed physician that practices in the field he or she is treating the patient for that a patient could take anything and not violate probation or parole.

Do you mean to tell me (not that I condone it, although it does cause me some concern) that if a person on probation or parole is prescribed narcotics for a medically necessary reason by a licensed medical doctor and said person takes this medication that they are in violation of their probation or parole?

What if the person is say dying of cancer or some such other terminal condition that is excruciatingly painful? Do I understand correctly that you are saying this person is violating probation / parole by taking a legally prescribed narcotic pain relief and will be taken back to prison and possibly allowed to die in pain without the benefit of such medicine just because its a narcotic?

I know there are many fakers and scam artists out there with a thousand excuses and ways to make you believe they need narcotics just so they can get high on them or sell them but what about the person that truly needs them for pain relief and not to get high?

Has our system become so jaded against narcotics that it will allow a person to die in agony, in jail because of societal prejudice against certain medications?

I'm just asking. It seems rather barbaric to me if this is allowed to happen.

Anonymous said...

The drug companies and doctors are working in tandem to ensure that everyone ends up on Seroquel or some variant. Ear infection? Seroquel works. Psychotic break? Seroquel? Fever, flu, aching joints? Seroquel or whatever else you see advertised these days. It even works as a morning after pill because if taken the night before, who the hell will be in the mood? Ain't gonna be no morning after, so give it to your sons and daughters as a form of birth control and never worry about teen pregnancy again. Got a leak in the caulking? Well, crush some handy dandy Seroquel, mix with a bit of water and fill the hole, wait five minutes, swallow, 600 mg fo Seroquel, wait an hour and presto, who give a damn if you Poseideon adventure 15 is being filmed in your bathroom? It takes away all pain, anxiety, fear, delusions, pesky neighbors and stubborn stains.

DK said...

I had no idea Seroquel could be used for caulking. Must be an off-label indication....

Anonymous said...

isn't everything off label, under the table and on the qt?

ClinkShrink said...

A$$rot: No, that's not what happens. Terminally ill folks with chronic pain do get pain management in prison. We've even had a small hospice ward with family visits for those end-of-life cases. I've yet to see someone's parole violated solely for positive urines. It's usually positive urine plus failing to report plus changing address without notice plus etc etc. If they can provide documentation of medical care then that factor isn't an issue.

Anonymous said...

Clink, an ass is an ass by any other name, whether there is evidence of rot or not. You are way proper, but how come you didn't type "ignorant slut" that way?

Assrot said...

Clink, thanks for the clarification. I thought I asked an honest question and was not trying to be an ass in any way.

I think the punk that hides behind "anonymous" is the greatest ass of all and I suspect there is evidence of rot between the ears.

I can't stand low brow people that avoid the issue being discussed yet attack others asking an honest question because of their username.

Come on anonymous. Grow a pair.

ClinkShrink said...

A$$: You weren't being unh...a jerk. It was a good question.

Anonymous said...

hey, assrot, i was not suggesting that you were being an ass in any way but since you call yourself assrot i wanted to know why clink had trouble typing out the word ass if she could type out the word slut without using a dollar sign, that's all. i wasn't attacking you i was saying that ass is ass whether you type it with letters or with dollar signs.
grow a pair of what? donkey ears, balls, or higher brows?
i like that you called me punk. makes me feel young.