Nursing · politics

A B*&$H About Benzo’s

I watched Xanax on Netflix. It’s a documentary about anxiety and Xanax.

I had a lot of feelings come up as a prescriber.

I think the commentary on the mental health system and race was good and certainly accurate. I think the commentary on why we as a society are anxious is also good/accurate. But it misses why Xanax is a problem.

Benzodiazepines are meant to be used short term. The psychiatrist does say this. She does not go into why though people end up on them long term.

There are a number of reasons; starting with there is a shortage of mental health prescribers. Primary care physicians and APRNs end up bridging this gap. They are comfortable starting some one on Xanax because they are actually taught to do this in school. The line they give is “I’m going to prescribe you a 7 day supply, and give you time to find a mental health prescriber.” Now, it takes more than a week to get an appointment. At my practice we are booking out 2-6 weeks depending on provider. The prescriptions then may get extended and by the time a patient lands in front of me they have been taking Xanax daily for six weeks. As prescribed by their primary.

This is not meant to knock PCPs. They are doing the best they can in the system we exist in. But there is no education about it. There is likely no discussion about what will happen when they see a mental health provider- aka we are not going to continue it daily and we are going to recommend a daily antidepressant medication. And once you’ve had xanax- well Prozac just does not feel as nice. Thus begins a person chasing the “calm” aka “high” that Xanax induces and being really angry at the mental health prescriber who won’t give it to them.

The documentary then spent less than ten seconds on the pressure on prescribers to do what the patient wants. And at the end of the day- that’s what matters- because without that pressure prescribers would have the balls to prescribe safely and ethically. I had to leave a top hospital in our country system to prescribe safely and ethically. Let that sink in. I had to leave a top hospital in the country to be a good and ethical prescriber.

Here’s why.

You ever hear about Press Ganey? It’s a company that puts out those nice little surveys all patients get after a hospital stay. My raise and reimbursement and ability to advance in the corporation was dependent on my Press Ganey scores. Yes, much of my present and future career at the hospital was based on feedback from patients. I worked on an inpatient psychiatric unit and usually half my caseload were hospitalized involuntarily. Then about 1/8 of those people had to be medicated involuntarily through a hearing with a probate judge.

Guess how many of my patients gave me and my team good reviews? Potentially half. The other half, well I was lucky to not be sued by them; which was threatened daily.

Let me tell you a story. Patient X is on Methadone 120 mg, Xanax 1 mg TID, Quetiapine 800 mg nightly, and Lithium 450 mg ER BID. Patient X is admitted on this regimen for depression and suicidal ideation. They are noted at the table in the morning eating breakfast falling asleep. Legitimately falling asleep. Food falling out of their mouth mid-chew.

They are now a choking risk. And within six months of me starting I had some one on Methadone choke, and need to be resuscitated due to their airway being completely blocked. It’s a real thing that happens.

Me being the responsible APRN I am, consult with my Attending MD, they agree, we need to lower their sedating medication especially AM dosing when they are eating right after. We also review the EKG, shows significantly prolonged QT interval- due to Methadone/Quetiapine combination- prolonged QT interval can lead to Torsades which leads to sudden cardiac death. Again- kind of a big deal.

We go sit with the sedated patient, who barely responds to us verbally, and tell them we are going to start tapering their Xanax and Methadone. VERY SLOWLY. We will not put patient into withdrawal but it is unsafe how incredibly sedated they are. Patient mumbles as food falls out of their mouth.

Next day. I walk onto unit. Patient screaming about doses being lowered. Thus begins a very unhappy week for myself and our team and our patient. But. They did not die, they did not have any observable or measurable withdrawal symptoms. And they were able to actually be awake for mental health treatment by 10 AM and engage in groups and therapy. They left on lowered doses of Methadone and Xanax with a lower QT interval and not a choking risk. But they gave me a complete crap review and wrote a novel about how we sucked.

I had to have a sit down with my manager about that case not because of the inappropriate prescribing done by their outpatient team, or the good job in looking out for their respiratory and cardiac health- and preventing another preventable choking potentially fatal situation on our unit- but because I got a bad review. I had to review the chart with my manager and go over the case step by step defending my actions along the way. Amen for my stellar documentation, the withdrawal measures (which were all negative), and the objective data provided by group leaders, EKGs, vital signs, etc. that showed patient had a decrease in depression, decrease in SI, and increase in attentiveness, concentration, and ability to engage in treatment.

My manager wanted me to sign a form saying that basically we had spoken about my negative review. I declined. I requested a meeting with HR. So the cycle began. I provide safe care in conjunction with the treatment team including an MD. I get a negative review. I have a meeting with my manager then with HR. This is not unique to me. This is common among any prescriber working for a corporation that favors patient satisfaction over safe and ethical treatment.

This is not the only reason hospitals cannot retain good doctors and APRN’s. But is definitely in the top three reasons. At least it was for me, and for many of my colleagues.

It is not safe to be a competent and ethical prescriber when working for a healthcare corporation that measures my present and future success by patient reviews- especially when working in psychiatry and addiction medicine.

This does not just apply to inpatient work. It applies to outpatient centers also. My pay being directly linked to patient satisfaction is a problem and the reason I do not work for a hospital corporation any longer. Because working with patients who ran out of their Xanax early, their outpatient prescriber says they are going to be cut off, now I have to forcibly taper them off of it- doesn’t go well for me in my reviews. But that’s part of the work inpatient, and it’s part of being a prescriber. Making tough calls, and especially inpatient working within a team of clinicians to do right by the patient.

So me being ethical and legal…didn’t go so well. And that’s what the documentary failed to expound on. Not only are there these patient reviews- but these patient reviews dictate how much money we make, our performance reviews, and how and if we can advance…and that, my friends, is a fucked up system that invites prescribers to make bad decisions to advance their pay and their careers.

I still get negative reviews on Google for my practice. And they still irk me. But they do not impact my ability to advance my practice or myself. I also can look at them objectively and say, well that patient didn’t get the 3 mg of Xanax they wanted, and got mad, pulled a knife on me- and then wrote a Google review. True story. The google reviews don’t bother me because they do not impact my career and to date they have all been reactive to me setting boundaries and prescribing ethically and legally.

I still have a full caseload, a growing practice, and rock solid clinicians who work for me who know I have their back to be good, ethical, competent clinicians and that I will not let a bad review by an angry patient who we held a boundary with impact their pay or merit or my respect for them.

I agree with the psychiatrist in the documentary when she says benzodiazepines have a place and a time and I am incredibly grateful for these drugs to have been invented and utilized by clients who need them. Because I do prescribe them when appropriate with a lot of education, a urine drug screen, an informed consent form with risks/benefits that the client must sign, and what the expectation will be going forward in terms of treatment.

I have full control over my caseload whereas before I did not. Until our healthcare system changes from a for profit, patient satisfaction oriented system- there will be more irresponsible prescribing and irresponsible treatment. There will also be a lack of retention of prescribers in areas they are needed most such as mental health and addiction psychiatry. The two are linked and need to be addressed nationwide.

*****This blog post covers a very small portion of the issues and dangers of benzodiazepines and is not meant to be fully comprehensive of every issue prescribers face in relation to benzodiazepine prescribing.

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