Stay Awake

Thank you all so much for your feedback on our survey. I'm still thinking about it, but your suggestions have been excellent!

Please join our Facebook page. Again. I'm taking down the original as I didn't realize when I put it up that it would be one more thing to check and maintain and "Shrink Rap" has been a lousy Facebook friend without reciprocating. Roy put up another page, and his twitter feed populates it so that something actually happens-- on a good day, it announces new blog posts, on a bad day, Roy tweets out funny little incomprehensible tidbits. We're our own fans, so we can post to the wall, and there are some pics of real people. And the duck is there. Our page URL is: http://www.facebook.com/shrinkrapbook
Some day, we'll get it right.

We have a new post up on our Psychology Today blog. A bit more of the same, but check it out if you can stand it.

Okay, so here's the real post in honor of ClinkShrink, our caffeine addict.
It's a century since Coca-Cola went on trial for sticking that caffeine stuff in their drink. 80mg, back then. There was a trial, there was research, and here's the article in today's New York Times: A Century Later, Jury's Still Out on Caffeine Limits and Murray Carpenter writes:

Coca-Cola hired a Barnard College psychology instructor named Harry Levi Hollingworth. He mustered 16 subjects aged 19 to 39, including occasional, moderate and regular caffeine users, along with abstainers. In a Manhattan apartment rented for the research, he tested their mental and motor skills under varying levels of caffeine use and abstinence. They took caffeine capsules and placebos — double blinded, so neither they nor the researcher knew which was which — and “soda fountain” drinks with and without caffeine. The trial looming, Hollingworth did it all in just 40 days.

The subjects kept good notes. On Feb. 22, a regular user was caffeine-free: “Felt like a ‘bone head’ all day. My head was dull more than usual.” On Feb. 25, an abstainer was dosed with four grains of caffeine (260 milligrams, the approximate equivalent of a 12-ounce cup of Starbucks coffee): “Gradual rise of spirits till 4:00. Then a period of exuberance, of good feeling. Fanciful ideas rampant.”

Hollingworth found that moderate doses of caffeine stimulated his subjects’ performance on an array of tests, though some slept poorly after the highest doses. His appearance on March 27, 1911, was a high point in a four-week trial dominated by anecdotal, contradictory or sloppy testimony.

The point of the article? 100 years later and we're still asking all the same questions. Go figure.

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.

My Three Shrinks Podcast 50: More About Geeks

In this show we continue with our guest Dr. Pat Barta of the Adventures in Telepsychiatry blog.

We talk about electronic health information systems and Clink continues her rant which she started in her post Rage Against The Machine. Roy mentions the Certification Commission for Health Information Technology and the American Recovery and Reinvestment Act which provides funding incentives for doctors who use health information technology. We cover developing standards for behavioral health information technology, including personal health records which allow patients to store their own information voluntarily "in the cloud", on a server. Dr. Pat Barta talks Open source health record systems and information security.

Health Data Rights is an organization that developed a proposed declaration of rights for patient data. Another organization addressing this is SpeakerFlower, of which Roy is the spokesperson.

Dinah talks about her blog postWhat's An Emergency? and wonders how flexible psychiatrists should be when a patient says they need to be seen right away. Which situations are truly emergencies? What should you do if a patient turns down multiple appointments offered for that same day? Should your office voicemail tell people to call 911?

Finally, Dinah wonders what has happened in states with medical marijuana laws. She mentions KevinMD's blog post Medical Marijuana Has Doctors Asking Questions. Should marijuana be prescribed for attention deficit disorder? How do you do clinical research on a controlled substance?

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