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.)