My NO Xanax Pep Talk

The Challenging Epidemic

Many healthcare providers are dealing with patients requesting benzodiazepines (BZDs) like alprazolam, often without appropriate indications. Managing these requests can be frustrating, but a considered approach helps reduce conflict. Let’s  start!

Step 1: Listen to the Patient’s Story

• Let the patient share their story fully, even if it sounds exaggerated or implausible.
• Use open-ended questions to guide the conversation toward understanding their true concerns and symptoms.
• Open dialogues illustrate how to identify underlying issues (e.g., lack of energy or motivation) instead of automatically addressing the request for a BZD.

Engaging with Empathy and Education:

• Avoid outright rejection of requests without listening; this approach fosters poor communication and escalates tensions.
• Explain the risks of BZDs (e.g., addiction, falls in elderly patients) and suggest safer, evidence-based alternatives.
• Address patient misconceptions by educating them about anxiety management and the historical misuse of BZDs.

Building Trust and a Therapeutic Relationship:

• Patients are more receptive to alternative treatments when they trust the provider and understand the rationale.
• Emphasize non-medication strategies and lifestyle changes (e.g., reducing caffeine, avoiding substance use, staying active).
• Tailor education to the patient’s specific circumstances to ensure they feel heard and supported.

Documentation and Collaboration:

• Document patient conversations and decisions carefully to justify clinical actions and provide continuity of care.
• Notes should reflect appropriate care decisions, ensuring clarity for colleagues who may review or take over the case.
• Emphasize the importance of avoiding BZDs for inappropriate situations while supporting colleagues in making informed choices.

Step 2: Target the Symptoms of Anxiety

Focus on the symptoms of anxiety because it’s like prophylactically treating the blood pressure to avoid a stroke or a panic attack in terms of mental health:

• Lack of sleep: suggest good sleep medications
• Shakiness/Jitters: discuss the use of beta-blockers and stress management
• Worry/Fears/Irritability: propose an antidepressant 
• Need Energy/Motivation/Focus: target norepinephrine or non-stimulant medications 
• Promote a healthy lifestyle: encourage physical activity, therapy, healthy eating, self-care, and non-pharmacological methods
• Rule out medical causes and other etiologies  

Addressing this sensitive topic may feel challenging, but the suggested strategies are quick to implement once the initial assessment is complete. If a patient becomes irate or threatening, prioritize their safety by standing firm and emphasizing its importance. Offer to follow up when they are calmer or consider discontinuing services if necessary. Over time, they may either move on, find another provider, or become more open to alternative ways of managing their anxiety or panic.

Step 3: How to Start?

General Principles

1. Key Question: Ask yourself, “Is it debilitating?” Consider if the issue significantly impacts the patient’s functionality or quality of life.
2. Avoid Direct Questions: Don’t ask patients if their condition is debilitating—they are likely to say yes regardless.

Assessment Guidelines

3. Differentiate Between Debilitating and Non-Debilitating Issues:
   • Look for tangible impacts (e.g., job loss, inability to leave the house, syncope, arrests, ER visits, school dropout).
   • Avoid prescribing for inconveniences or venting (e.g., interpersonal conflicts, discomfort with routine activities).
4. Seek Evidence: Use the patient’s own words and look for a paper trail or documented consequences of anxiety/panic.
5. Revisit Original Prescribers: If the patient has a recent BZD prescription, encourage them to return to their original provider.

When to Prescribe

6. For Legitimate, Debilitating Cases:
   • Discuss mandatory drug screens and tapering early on.
   • Prescribe the lowest effective dose if it’s the first prescription.
   • Educate the patient about dependence and withdrawal risks.
7. Chronic Use Cases:
   • Consider tapering and transitioning to safer alternatives.
   • Address concerns about risks like diversion or falls.

Communicating with Patients

8. Set Boundaries: Be firm about not prescribing BZDs for non-qualifying issues or unsafe practices.
9. Educate on Safe Practices: Emphasize therapy and other non-pharmacological interventions.
10. Prepare for Resistance: Patients may not be happy with decisions, but consistent communication and reasoning can ease the process.
11. Maintain protocols: Always prioritize safety over patient satisfaction and seek support when faced with complex or risky cases.

Read about how a Psych NP was Held Liable As Patient’s Suicide Results in $12 Million Verdict. Warning! You can’t just abruptly stop these medications (read about tapering). The management and taper require at least months with tons of support. Read about Xanax Drug Abuse and Why is Xanax so Addictive? Updated 9/23/20: F.D.A. Requires Stronger Warning Label for Xanax and Similar Drugs.