If you haven’t seen the trailers for “World War Z”, try to avoid it as best possible.  This scene of the zombies trying to scale this huge wall is so disturbing to watch!

But, I do feel it worthy of using for this post.  My concerns with the escalating DEMANDS, not requests or simple interests mind you, for controlled substance prescriptions (CSRx), should be of concern to every single physician, not just psychiatrists.  But, in this third and final post about substance abuse and what to do to minimize it, I focus on what I feel patients should, and shouldn’t be doing in expecting doctors to foster either quick fix seeking, self medicating, or just frank abuse.

PATIENTS MUST:

1.  be wary, if not outright rejecting of being offered CSRx if with a history or actively abusing substances, illicit or CSRx at the time coming into treatment with a new provider.  Also if coming in on a CSRX to a new provider, need to be ready and willing to sign releases of information for the new provider to contact the old one(s) to document and clarify the intent of such Rx use.  To delay or refuse, well, be ready to be denied further CSRxs.

2.  never lie to a provider.  Lying can and should be interpreted as everything being claimed is NOT true until proven otherwise, and could quickly end the treatment alliance.  If dealing with addiction/dependency, honest and directness is the mainstay of recovery, new or established.  

3.  never self medicate, even if with medications with no overt potential for physical abuse.  And, it is important to realize that just because one does NOT have a history of addiction or dependency coming into care does not mean one won’t develop such problem if given a CSRx.  The problems that brought one into treatment almost always did not develop overnight, so to expect instant relief of symptoms is NOT realistic.

4.  not knowingly give other people your medications or letting others easily steal it, especially knowing these others have addiction problems.  If you are not willing to confront, much less report those who are disrupting your care if on medication, especially CSRX meds, you are only enabling and encouraging their abuse, and putting yourself at risk for running out of meds earlier than expected.  And, be prepared providers may not be sympathetic; your early request for a refill could be denied, even if you are not personally misusing the CSRx.  Road to hell adage applies to all, not just providers.

5.  never stop any Rx abruptly without consulting the prescribing physician first.  Abrupt discontinuation of any medication puts you at physical and mental health risk.   If you want other Rxs if realizing being on a CSRx is too risky, it will be important to taper the use over some period of time, perhaps a couple of months even.  But, if one is not comfortable with the use of a Rx, it should be addressed, because not having faith and hope in a treatment intervention itself could lessen any positive impact.

6.  accept you should not refuse the request to be drug tested, especially if noting a history of substance abuse coming into care with a new provider.  Technically, you have the right to refuse, but what does that say to a provider if you will not be tested?  Denial = admission of abuse in 95% of situations.  But, you do have the right to ask why being requested to be drug tested.  If a misunderstanding, won’t a negative test support your position if being honest and direct?

7.  be prepared to be asked why asking for another CSRx if already on one actively.  As noted in the Provider post, the provider should be wary of being asked to medicate a side effect Drug A might be causing to induce the patient to think a need for another medication.  Also, if in recovery and already taking a risk being on one CSRX, is it worth the logarithmic risk for relapse by adding a second?  And why is it not worthy of looking for non pharmacological interventions for problems like insomnia or anxiety as first treatments?  Finally, asking for CSRxs to treat insomnia is almost always going to lead to further consequences until proven otherwise, remember Ambien and Lunesta are CSRxs and NOT meant to be used indefinitely.

8.  remember that most pharmacies do not like taking requests for CSRxs by phone or by fax, and you cannot do so for CSRx 2′s like stimulants and opiates.  Presenting a CSRx in person will hopefully have the pharmacy be an ally if legitimate problems do arise that need a premature refill or new RX filled.  Also, fill Rxs at the same pharmacy unless circumstances dictate no choice otherwise; using multiple pharmacies is a red flag to both providers and pharmacists.

9.  give thought every 6 months or so to reevaluate what you are doing with your medication use, especially with CSRxs.  If stable and making progress with mental health issues, it only benefits you to attempt to lower the dose, if not taper to a trial discontinuation and see if the medication is no longer needed.  Just remember this one point I have learned with benzo use long term:  for every 6 months on a sizeable dose, it will take at least 6-8 weeks to taper and minimize withdrawal symptoms, and it is possible if on benzos for years that it may take up to 6 months to successfully discontinue after a slow taper.  As per stimulants, they can be d/c’d rather quickly, but should be tapered a bit for psychological withdrawal features.

10.  be willing to begin or resume psychotherapy if put on or being continued on larger dosages of CSRxs.  Meds alone will not control all the symptoms these meds are indicated, AND, if asking and expecting for dosage increases with a new provider, why do you think more will help if the only intervention being used to now?

I am seeing more people coming into psychiatric care, regardless if private practice or community mental health sites, who either are innocently being mislead, or, actively seeking CSRxs for less than honorable reasons, and not accepting appropriate limits such medications deserve.  And, I have met people with no honest addiction/dependency history prior to going on these meds who have become addicts and are hopelessly dependent as presenting.

I finish with this to sum up my position on addiction and dependency, and note those terms are separate to some degree per the issues each has uniquely:  abusing CSRx and denying it is a problem just because one does not abuse pot, cocaine, heroin, even alcohol, that denial is without foundation.  Remember that opiates = heroin, stimulants = cocaine, benzos = alcohol, and these “synthetic” products allegedly sold over the counter to mimic pot, well, even more dangerous and unpredictable in response.

I know that getting into recovery is a lifelong process, that people will relapse until proven otherwise, and that people should try to be as supportive and understanding to the recovery work, but, to use a CSRx is as risky as going to a street dealer and asking for illicit substances, even if to self medicate a true problem like anxiety or depression.

Look at it this way, if you are struggling with chest pain, shortness of breath, persistent nausea or vomiting, recurrent headaches, do you go to the street to have those issues treated by a dealer?  God, I hope not!

Hope this three part posting about addiction, from my point of view mind you, is of value and interest.  Sorry this third part took longer to present, busy last few days.

BE WELL AND BE SAFE!

this is my best choice as a picture for a road to paradise.  If not yours, find one and put it in a place you see with regularity: