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I'm posting this because Roy fell asleep at the wheel and missed the Xanax article on the front page of yesterday's New York Times. In "Abuse of Xanax Leads a Clinic to Halt Supply," Abby Goodnough writes about a clinic where they've stopped prescribing Xanax because to many people are abusing it. Goodnough writes:
“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”
Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.
If you want to know how the Shrink Rappers feel about Xanax, do read Roy's post on Why Docs Don't like Xanax (Some of Us). It's been our all-time most popular post.
So I was a little (not a lot) surprised that this was "news." I've worked in four public clinics-- I've never seen a prescription written for Xanax, and for the most part, the clinics where I've worked have had a sort of non-stated ban on prescribing controlled substances. It's not that benzodiepines and stimulants are never helpful, but in the clinics, the issues concerning abuse, and the drain on the system gets to be very hard, plus we worry that the harm these medicines can do will be worse than the problems they 'cure.' It's very rare that I've written for controlled substances, and I've never written for Xanax in a clinic, or seen a chart from another patient where Xanax was prescribed. I'd be shocked by the article, but during the two weeks I was in Louisiana after Katrina, I did see many patients who had been on high doses of long-standing Xanax that were prescribed by docs at community clinics, so I know it's done. But you know, ClinkShrink doesn't like benzos at all, ever (per The Benzo Wars, if you'd like to hear us shriek at each other), and the rest of us Shrink Rappers don't like Xanax in particular.
Time to wake up, Roy.
In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing. The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life.
Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage. It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me). What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy. He had a secret life.
There's not really much to do about this. One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website. Oh, and I am so glad.
When it comes to hiding medications, or treatments, then perhaps that's different. Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax? If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't prescribe to someone doing such things. Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his psychiatrist? We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.
So where is the line? Is it okay to hide manic behaviors from a psychiatrist---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings! Is the psychiatrist entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink? That mom thinks he's getting sick again? Every fantasy that pops into his head? Is it okay to withhold your dreams from your psychoanalyst?
I won't go on. You tell me where the exact line is. I have no idea.
