Many providers, including myself, are dealing with the “I need a Xanax” epidemic. It’s tiring! I’ve lost track of how many times I had the NO BZD chat. So far, I haven’t gotten cussed out too badly, but a threat of not returning is sometimes a major win. Anywho, I just wanted to share a few pointers that are helping me:
Step 1: Listen to the Xanax Story
In the initial assessment, let the patient talk even if it’s not true, crazy, weird…let them build up to how Xanax did it all like never before! Trust me, it’s how they will get caught in their own words. This is not to be evil, but how the provider won’t get the brunt of the anger. Here’s a simple example based on a recent conversation:
Patient: (insert the life story here)….I don’t enjoy things anymore, I don’t feel like doing things and only Xanax helped me.
Provider: How did the Xanax help?
Patient: I was more relaxed
Provider: What’s helping you now?
Patient: nothing
Provider: Can you describe your anxiety?
Patient: not being able to do things
Provider: What exactly are you not able to do?
Patient: Well I like to cook and be around family
Provider: It sounds like you need energy and motivation, are you sleeping okay?
Patient: yes I’m sleeping fine….
-> At this point, I’m not asking questions to order the BZD since this is NOT a panic disorder but I’m actually asking questions to target the anxiety under the impression of asking about the BZD. I emphasized that she’ll be more at risk for a fall-related to a BZD (pt. was in her 70s) and ultimately said “Let’s discuss some safer options…”
How to Engage the Conversation? Show Empathy and Educate.
Pretty straightforward but some providers will immediately say NO, without listening to the story and no questions asked. Some people place a sign outside the door with a list of meds they will not order to strongly avoid the conversation. Don’t do this. Even if the provider is justified, poor communication will make YOUR job more difficult.
In the past, BZD had providers especially well-intention/educated doctors ordering them on everyone for everything since it was assumed they were safe. Plus, in many situations, they are such as with surgical procedures. However, when they became known to be super addictive, many patients felt like they were cut off without considerations, alternatives, or hope.
Healthcare providers know there are better ways to manage anxiety but sometimes patients are not aware or need to be educated. Try to build a solid therapeutic relationship so they can TRUST you to help them use other medications and lessen the anxiety. Patients will not get mad at you for trying to avoid injuries or harm, but they will get mad if they lack understanding.
Therefore, also educate about the lifestyle, -if a patient drinks caffeine all the time, uses illegal substances, or has a history of drug/alcohol addictions, then more than likely, this person is not a good candidate for BZD. If the person has a sedentary lifestyle, is elderly, and has other mental conditions, again BZD may exacerbate the situation so you have to STRESS the alternatives.
Educating is also part of the documentation. I write my notes in a way, that whoever will read them will understand what’s safe and appropriate care. If they see that I didn’t order a BZD for “Kim having a bad day” hopefully my colleague can also see the importance of not writing a prescription to shut the patient up or to make them happy. However, if they chose to write it then it’s on them because at least you know YOUR actions will be justified.
Target the Symptoms of Anxiety
I 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
I apologize for all the wordiness (and typos/grammar) because honestly, it’s not an easy subject to tackle. These tips overall shouldn’t take long to incorporate and usually the biggest pain is in the initial assessment but it will get easier. If the patient still gets irate or threatening –continue to stand firm on the importance of keeping the patient safe and offer to follow-up when they are calmer or d/c services. They will either move on, find another supplier, or be less apprehensive to try other ways to deal with the panic/anxiety.
When to Order a BZD??
My personal rule of thumb is really just one question I ask myself; is it debilitating? You cannot die from too much anxiety or panic, however, it can be debilitating or lead to suicidal thoughts. Remember in the initial assessment about how the BZD was the only thing that ever worked? also notice (in the patient’s story) things that are not debilitating or even recent, if anything a patient can just be venting. Don’t ask patients, “…Is it debilitating?” 10/10 times they will say yes.
I had another patient that said she couldn’t get along with people, I told her –stop hanging around people that you don’t like, so then she said I don’t like to get on the bus, and then I said but you’ve been getting on the bus all these years so how can a pill fix that? In other words, the problem was not debilitating, just an inconvenience. Use their own words to stand firm by letting them know that it’s not how medications work and not a safe practice.
Nevertheless, anxiety/panic can be debilitating and with the patient’s own words you would want to hear situations that have proven ramifications; a loss of employment, unable to leave the house, syncope episodes, arrests, school dropout, ER visits… things that have physical evidence or a paper trail as opposed to someone telling you about their feelings. If the person came with a recent prescription, I would inquire about returning to the original prescriber. If the incidents occurred a long time ago -it’s probably just venting, which is very often.
However, if they are requesting your services at the moment and everything is legit, I would suggest how drug screens will be mandatory and discuss tapering. I would discuss tapering as soon as possible so they can use the BZD to just deal with the conversation and future visits, especially if they were on the dose for a long time. If there are safer options for the chronic user or you are concerned about diversion, falls, or other risks please seek assistance for support and management. It’s NOT easy. If the BZD is being prescribed for the first time, start very low and also educate about the dependence and serious withdrawal symptoms.
They will not be happy! but continue to stand firm with safe practices and target the anxiety. Emphasize therapy. I would also tell someone who’s not on a BZD, that it’s simply not my practice if they don’t qualify for it. Get used to saying NO but understand the reasoning and process to make it easier for yourself and the patient.
Okay now I’m done venting lol hopefully this was clear and not offensive to the provider or a person actually taking it, it’s truly all love! BZD can be a temporary fix or a chronic condition for a lifelong problem of anxiety and panic. Good luck in practice and in the community! Read about how a Psych NP was Held Liable As Patient’s Suicide Results in $12 Million Verdict. Please you can’t just abruptly stop these medications (about tapering). The above post suggests people who are inquiring about a BZD. 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.
