Friday, October 9, 2009

Saying no to drugs

I remember when I was a kid hearing Nancy Reagan saying "Say No to Drugs." I deal with this every day in clinic. I'm not even talking about ice, smack, weed, crack, bumpin' a rail, etc. I mean the honest to goodness, legal prescription stuff. Every day I have to talk with patients who are abusing there benzos. Residency training programs are a great place for benzo abusers, because the residents cycle in and out, and nobody takes ownership of bad situations, therefore problems just get passed along. Even though our patients sign medication contracts, they still try to abuse the system.

Since I have recently begun clinical rotations, I have been stuck in numerous predicaments such as this. Patients abusing their priviledges. Psych Doc draws a line in the sand. Patient retaliates. Some examples.

Patient #1 presents for refill on her valium. She was fired from another clinic in our system for repeatedly overusing valium, calling for early refills, and on one occasion, showing up totally stoned on weed. My attending physician told me that I got to be "the bad guy" and take her off valium. We had a fairly pleasant discussion, however she did inform me that if I didn't prescribe it, she would send her grandpa to Mexico or Canada to get it. She also told me she should be able to smoke weed whenever she wants. On the way out of clinic, she screamed "Psych Doc is a Demon from Hell!" That didn't exactly brighten my day, but it did provide the name for my fantasy football team this year.

Patient #2 I inherited on Klonopin 1mg TID. She insists that it is QID, though it's been prescribed TID for > 6months. She ran out early. She could barely stay awake during the nursing assessment. Once again, I get to be the bad guy, cuz nobody else wants to set limits. I tell her we're going to taper her off Klonopin over 4 months because she's been abusing it. She asked, "Is there a higher authority than you?"

I resisted the urge to answer, "Maybe God would qualify" but decided I would leave that to my surgical colleagues. Instead I replied, "Do you mean like a patient advocate?" to which she answered in the affirmative. As she wrote down the advocate's name and phone number that I provided, she was so stoned that she couldn't operate a standard ballpoint pen. She then slammed the door on the way out, went into the waiting room and told the other patients, "Good luck with Dr. Asshole."

I am so frustrated with the users. As one of my attendings used to say to these patients, "Excuse me, but do I look like a vending machine?" I really try to do what's in the patients' best interests. Use the lowest possible dose (all meds, not just benzos). Avoid polypharmacy. Prescribe high risk meds when appropriate.

Some days I wonder why I went to med school.

Say "Thank you" to your doctor today.

Dr. Asshole aka Demon from Hell aka Psych Doc


Doctor D said...

Some days I wish narcotics and benzoes hadn't been invented.

I can do a lot of good with them, but the constantly trying to figure out who needs them and who is manipulating me wears on my love for the human race.

Crazed Mom said...

Hell of a snappy new nickname!!

HugeMD said...

Doctor D--You said that so well!

Psych Doc--You're doing all that you can--trying your best not to take it personally, even though that's not really possible, then blogging and laughing about them later. Hang in there!

Anonymous said...

Like others said, dont take it personally. If I had a nickel for every time I have damned into the depths of hell I wouldnt need to work. Being the nurse of these patients isnt any easier- nurses try to buffer the crap they spew only to get told "I hate you and your mama". Yes, they crossed the mama line. lol. Dont forget the ever favorite of C U next which nurses laugh at. I cant deal with that but dont mess with mama. lol

Anonymous said...

I know some people/families whose lives have been wrecked by prescription drug abuse. Your a great doctor for not giving in to drug seekers.

08armydoc said...

I feel for you. These people are such a drain to deal with. I'm exhausted after a 30 minute visit and feel like years have been taken off my life.

I had a patient ask if I would write a prescription for vicodin and MS contin for HIS WIFE.

Trust us....we're doctors said...
This comment has been removed by the author.
Trust us....we're doctors said...

Reminds me of a patient yesterday. Morbidly obese male on dialysis. wanted a new schedule, so he was missing dialysis on purpose to get kicked out so he would have to start over and get a new dialysis schedule. came in and his sugar was >500. I kept trying to correct it, and he would keep leaving to get fried chicken, baked potatoes, candy bars, etc. i could never bring it down b/c of his behavior, so I discharged him. when i discharged him he wanted to know if i could "hook him up with some lorcet 10s for his knee problems." i told him no, and he threw a shit fit. told me he would "buy some cocaine if i didn't give him lorcet's" i told him I dont take threats from patients and kept with the discharge.

-ER Doc

Ladyk73 said...

ugh.... I've been on klonopin before. (I have issues) I am not sure what people get out of it recreationally. There were times I needed it to stop my limbs from shaking. I've taken it like three times in the last year, so it is really not my choice.

Anyways...Getting off the crap is tough, I've seen some patients go through hell.

My own experience, I found seroquel was good "replacement"
for the anxious coming off of benzos.

Do you offer these seekers the atypicals as an alternative?

Trust us....we're doctors said...

Usually not atypicals. They have their own risks. I have had some success with Seroquel, but try to avoid it unless there is a definite bipolar or schizophrenia diagnosis. Lyrica probably is better and safer for treatment of anxiety in those patients with risks for dependence/abuse.

Keep in mind, this is not any type of medical advice and both would be off-label for treatment of anxiety disorders.

-Psych Doc

Anonymous said...

Had fun with this yesterday. Had a patient with chronic back pain MS contin TID, and PRN ativan 05. mg q6h for anxiety. "Can I have my tranquilizer now?"

"Are you feeling anxious?" "Yes!"

um, ok. 6 hours later, sound asleep, "O" sign - tip-toe into room, she wakes up, "I need my tranquilizer."

Trying to explain the difference between scheduled meds and PRN's.

"You have no idea what I had to go through to be able to have that medicine! I really need it!"

If I try to not give it, because she was just sound asleep, and didn't appear anxious at all, then the patient ends up complaining, making our 'customer service' look bad.

Maha said...

I just had a long LONG day in which I dealt mostly with drug seekers. A particularly memorable patient was on oxycodone and methadone at home for 'back pain'. Because the pharmacy was closed, he couldn't have his methadone so he was ordered some other narcotics. Bastard sent different members of his family every hour ON THE HOUR to the nursing station to not so gently remind me that his next dose was due. Meanwhile, the patient himself was sound asleep and his resps dropped from 15 to 7/minute. I absolutely refused and they wanted to get the doctor to fire me! Joke was on them - I'm not hired by doctors! And the docs refused to let him have anymore. Again, throughout the entire kurfluffle, the patient himself was asleep. Today was a day that really made me hate drug seekers and wish they'd all just OD at home and be done with it.

Anonymous said...

In my experience, physicians are far too quick to prescribe narcotics and benzos!

I had surgery last year. I informed the anesthesiologist that I did NOT want a benzo pre-med, and both the anesthesiologist and the surgeon that I did NOT want any narcotics. Both argued with me, but I prevailed.

I was just fine with NSAIDs and no pre-med - actually, everyone involved in my care told me that I had a faster, more complete recovery that virtually any patient they'd seen for the same condition in recent memory.

(I'm a veterinarian. If I wanted to obtain drugs to abuse, they're as close as the locked cabinet in my office.)

So, physicians... educate your many of these drugs are really necessary in the first place?

Anonymous said...

I'm just your average, run-of-the-mill gal who LOVES working in the nursing home (certified bum wiper). Love our elderly! I do in-home care now.

Anyway to my point... I have social anixety/tad of depression. I've been on Klonopin for 3 years. I've only re-filled my med maybe 4 x's.

I just don't get the whole abuse/addict thing. When I take a Klonopin, I take it because I'm shaky & I need to walk out the door to go to my job. I usually only take a 1/2 one & that does the trick. I'm much calmer by the time I arrive to my client.

Sorry for the ramble.

Anonymous said...

However, those of us who are getting our carefully titrated meds from our PCP's for legimate problems and so that we can contnue to drag our fannies to work every day rarely if ever show up in ER's for early refills.

Susie Nurse

Chris said...

Susie Nurse, that's me too. I've had panic attacks forever - I take the absolute minimum dose to be able to get myself to work every day and support my family. I don't get the whole thing with benzo/narcotic addiction - you WANT to be sleepy/comatose? Sorry, I'm missing the fun part there....

Chris said...

Sorry, that should have been "minimum dose of Xanax".

ERP said...

Luckily, I can turf those refil requests back to you! I tell them "The ER is not a place for psychiatric drug refil", best tell your psychiatrist about that....

Anonymous said...

I live on the border and the Border Patrol is NOT letting granny and grams back across from Mexico with drugs, they scan your ID, write the names of the drugs and will confiscate whatever they want.
Sounds like people yell idle threats to intimidate you and try to make you comply. I think its left over tactics from bad parenting where their parents always caved when they had fits.

DHS said...

I really try to do what's in the patients' best interests. Use the lowest possible dose (all meds, not just benzos).

I've found that I do the opposite: use the highest possible dose, at least for some things:

- antibiotics
- statins
- beta blockers

Mary said...

People don't abuse drugs because they are stupid.

They abuse them to escape pain.

They abuse them due to genetic propensity for addiction, or wounds that will not heal (survivors of sexual assault are scores of times more likely to abuse drugs than non-survivors) or because they are more affordable than the medications or therapy that they actually need.

They are not manipulating you. It's not about you. It's about the patient. If you don't recognize that at some point you will burn out and start harming them on purpose.

I've never abused a drug in my life. I have been a psychiatric social worker for a couple of decades though. And I've had depression since age seven, and PTSD since before that.

I know compassion is probably harder when you don't sit on both sides of that desk, but these patients need your compassion. And I KNOW you want to be healers and relieve pain, or you wouldn't be at a county hospital! Bless you for the work you do. :)

Me said...

My GYN prescribes me one dozen Vics per year for my god-awful periods. Some people would say I'm abusing drugs. Especially since I only get a period every 45 to 60 days. Or because I like to drink a glass or two of wine with my pill. But I think that I'm just avoiding a little discomfort and there's nothin wrong with that.

PJ said...

"you WANT to be sleepy/comatose? Sorry, I'm missing the fun part there...."

The first few days after I lost my job, I slept about 16 hours a day, and the only reason I got out of bed was because I couldn't sleep anymore. Did I want to be sleepy/comatose? Not really, but since life wasn't aligning itself to what I ACTUALLY wanted, I would take being sleepy/comatose if it would make the whole damn thing go away for a while.

I've never been prescribed any of the sedative-type drugs, though, so I had nothing to abuse for the few days that lasted. I've been in therapy for five years, but since I haven't heard of any drugs that make life go the way I want it to I don't see how drug abuse could improve my situation.

Anonymous said...

How I hate Hate HATE benzos.

My PCP put me on 1 mg of Klonipin at night for anxiety and sleep issues. It messed with my memory -- badly -- so I dropped it to 1/2 mg at night. Then I got tolerant, so I started taking it in the morning to let me get out the door and go to work. But that lasted only so long before the anxiety progressed to agoraphobia, which cost me my job.

Damn benzos. I am off them now and have even quit carrying two 1/2 mg Klonipins to quell panic attacks -- which I had used for that reason while I was at work. The panic attacks have come before, but when they went away I was still here; I will still be here when the next one comes. And yes they have come and I have stood and faced them down without the benzos.

Anonymous said...

As a bipolar whose med doctor (not sure what his tilte is, but he perscribes my meds) took her off a drug cold turkey (seroquel, which i did NOT need) and put her through horrible withdrawl... Thanks You.

In all seriousness, thank you all for being the bad guys. I hated my doctor for the time it took me to detox, but now I'm on a much milder pill that works a billion times better, and I am eternally grateful to my doc for being kind enough to put his foot down.

I hope you continue to be the "mean one" and do what's best for all us paitents who don;t know whats best for ourselves.

-sincerly, me.