Harmful Deprescribing Practices

[[Li...]]

Dr. David Healy is raising awareness about potentially inappropriate/harmful deprescribing practices in the articles linked below. He gives several examples, including a man accused of doctor shopping when he tried to get a liquid form of the benzodiazepine he was being forced to taper.  Another man was informed via an automated e-mail that his long-standing benzodiazepine was being deprescribed.

Dr. Healy has asked for more examples of inappropriate/harmful deprescribing (see note below).

Do you or someone you know have one to share?  If so, please post below! 

Note: Examples of potentially inappropriate/harmful deprescribing practices include abrupt cessation (cold turkey), forced tapers, algorithmic rapid tapers, ‘skipping doses’ tapers, and refusals to write prescriptions (on the part of clinicians) or fill prescriptions (on the part of pharmacists). Other examples involve treating taken-as-prescribed benzodiazepine patients as addicts (substance abusers) by forcing them into detox/rehab or ‘monitoring’ their medication use via urine drug testing and on-demand pill counts.

Links:

Potentially Inappropriate Deprescribing

Deprescribing – Where does Responsibility Lie?

 

 

[[Md...]]

Unfortunately, I have had to deal with this myself. Here's my testimony.

It all began when I was having interdose withdrawals from Xanax. My GP wanted me to do a straight swap to Klonopin, but the idea of not doing a gradual cross over made me hesitate, she also suggested that I space my doses apart. For whatever reason, I didn't feel comfortable with this either. She was also not familiar with the Ashton Manual, and so had no idea how to safely and slowly cross me over to Valium. Ultimately, my GP did not know how to handle the situation, so she cut me off as a patient, cut my dose in half, and told me to go to a detox center. 

This is when I reached out to Dr Josef, and they transferred me to Valium, which eliminated the interdose withdrawals.

When I decided to start tapering, Dr Josef put me on liquid Valium, instead of the pills. The liquid hit me much harder. It felt like I was taking twice the dose. So I requested that I did half pills and half liquid. Dr Josef had no problem with this, but multiple pharmacists either didn't always have the liquid in stock, or they flat out refused to give out both liquid and pills, even though it was the exact same dose as the pills. Pharmacists treated me like a drug seeker, and did not want anything at all to do with accommodation. It simply made them feel uncomfortable. I was even hung up on by multiple pharmacists.

I do want to add that Dr Josef tried very hard and made several phone calls to different pharmacies to meet this request of mine, but it made no difference. 

Thankfully, I was eventually able to find a local pharmacy that had zero issues with this simple accommodation. 

When I asked Dr Josef if I was his only patient that has faced this issue, he said no, and that he's had to deal with this with other patients of his. 

I think many doctors are in a state of hysteria when it comes to benzos due to the opioid epidemic, as well as the benzo FDA black box warnings that came out in 2020.

This won't end well if doctors aren't properly educated about these complications and unsafe deprescribing practices. 

Edited May 6 by [Md...]

[[Li...]]

Thank you so much for sharing your experiences @[Md...].   

Like you, I sense we are on the cusp of a ‘benzodiazepine withdrawal crisis’ and agree wholeheartedly that doctors (and pharmacists) need to be better educated about safe (and unsafe) deprescribing practices. 

[[Li...]]

A member sent this to me via PM and asked me to post it on her behalf.

My Mother’s Story

Several years ago, my frail elderly mother in her late 80s was discharged from a UK NHS hospital having been diagnosed, amongst other things, with vascular dementia. She was transferred to a nursing home that seemed good, well staffed and compassionate. She was in a new area and there was a local GP surgery to whom resident’s care was assigned. It was a lot to take in and she was naturally very confused. She was also part sighted/registered blind. I feared for her well-being, visited everyday & hoped she would adjust and settle into new surroundings. 

After a few days she became angry, this escalated into what I can only describe as rage/agitation/a different persona. After a week, it was discovered that the local GP had abruptly stopped her medication - a benzodiazepine*.  He apparently thought she didn’t need it. Whilst I understand the risks, especially regarding falls, to stop a benzodiazepine without discussion at all with her family or follow any taper plan to cease this medication seems wholly unnecessary, given that she was already confused by dementia and by being somewhere entirely new. This caused her and her family immense distress. She was placed back on her medication and reverted to her ‘self’. 

This experience was both dreadful to witness and for her extremely upsetting. I cannot imagine what she went through. Suffice to say older vulnerable and precious family members deserve better.

 

* I am unsure what benzodiazepine it was but she had been taking it for several years.  She also had taken Librium and Mogodan in the past.

 

 

[[kn...]]

My unrequested and unexpected taper was steep and devastating to my health. Each appt. resulted in 15-20% drops in my Diazepam Rx.  Unable to proceed and too sick to function , I appealed to the agency administration and after two years of agony was granted a new provider. We had three nonproductive appts before he abandoned his patients and resigned. Left to my own devices, I requested and was denied another Dr. Following no action by the agency, I discovered that no one would accept me due to the vindictive history left by my original doctor in my med file. At a loss, I up dosed to gain functionality and was labeled medically noncompliant and a drug seeker. Denied med refills, I sought help and a script for oral solution with my PC. I was subsequently told I was violating state laws by Dr. shopping.  Repeat requests for medical care by behavioral health were denied per my past record and I was put on a waiting list for new hire who failed to appear after three months time. Desperate, suffering WD, and out of medication, I again sought help from hospital admin. I was granted a one time telemedicine appt with a NP. She favored my situation and granted a new Rx. Repeated calls to hospital reception resulted in my being added to her patient profile. Our first f 2 f appt resulted in compassion, agreement to help me with dry micro taper and an add on med that has enabled me to get back on my feet. I’m living my life, able to eat and exercise a bit.  After almost three hellish years, at last some reprieve. 

[[ns...]]

6 hours ago, [[L...] said:

Dr. David Healy is raising awareness about potentially inappropriate/harmful deprescribing practices in the articles linked below. He gives several examples, including a man accused of doctor shopping when he tried to get a liquid form of the benzodiazepine he was being forced to taper.  Another man was informed via an automated e-mail that his long-standing benzodiazepine was being deprescribed.

Dr. Healy has asked for more examples of inappropriate/harmful deprescribing (see note below).

Do you or someone you know have one to share?  If so, please post below! 

Note: Examples of potentially inappropriate/harmful deprescribing practices include abrupt cessation (cold turkey), forced tapers, algorithmic rapid tapers, ‘skipping doses’ tapers, and refusals to write prescriptions (on the part of clinicians) or fill prescriptions (on the part of pharmacists). Other examples involve treating taken-as-prescribed benzodiazepine patients as addicts (substance abusers) by forcing them into detox/rehab or ‘monitoring’ their medication use via urine drug testing and on-demand pill counts.

Links:

Potentially Inappropriate Deprescribing

Deprescribing – Where does Responsibility Lie?

I was accused of this when my PA took me off of lorazepam in 6 weeks. I ended up at the er several times. Had no idea what was wrong with me.

Told the PA I was going to er that day, she accused me of doctor shopping! Insane!

I found an local attorney that sued for these kinds of issues but thankfully I never needed them.

This is typical.  She was trying to protect her own butt! She played the innocent little PA game, I dint know what's wrong with you crap!

Once she knew the er told me what was up with me, she literally deleted my records from the online portal and I was unable to see my medical records and visits with her! 

I'm not looking back, just moving forward to healing now!

Ns

[[Li...]]

Thank you so much for sharing your deprescribing experiences, @[kn...].

After reading your post and picking my jaw off the floor, the title of a children’s book came to mind  — “Alexander and the Terrible, Horrible, No Good, Very Bad Day.”  Your version would be “Knackered and the Terrible, Horrible, No Good, Very Bad Three Years.”

I’m so very sorry for what you’ve had to endure but delighted you’ve finally found a clinician who is willing to support safe tapering. What a relief that must be for you!

[[Li...]]

Thank you for sharing your experiences, @[ns...].  Being rapid tapered in just 6 weeks must have been awful.  Am I remembering correctly that you are an older adult who took your benzodiazepine exactly as prescribed long term?  If so, it’s no wonder you ended up in the ER.  I hope you’ve found a more supportive prescriber.  You are very wise to be looking forward to healing not backward!

[[re...]]

Think of all the money saved in hospital/er and specialists visits if ONLY these ego maniacs would taper their patients correctly. They really are sheeple. Doctors (most) are very monkey see monkey do. And very concerned over what their peers think. 

Extremely book smart, but lack common sense. 

[[Li...]]

 

Sending a shout out to @[Md...], @[kn...], @[ns...], and the author of “My Mother’s Story” for responding to this request.  Your help is much appreciated!

If other members have experiences to share, please do so.  (If you are uncomfortable posting to the open forum under your BB username, please feel free to send me your story in a PM and I will post it for you.)

The experiences shared thus far inspired me to begin looking through past posts for other examples of potentially inappropriate/harmful/unsafe prescribing and deprescribing practices.  Here’s what I’ve discovered so far:

• Refusal to prescribe Valium for crossover (especially in the US)
• Refusal to write or fill prescriptions for two different benzos during crossover
• Too rapid crossovers (insufficient or no time allowed for the longer-acting benzo to achieve steady state)
• Refusals to write or fill prescriptions for dosage strengths and forms needed to make ‘small enough’ reductions in dose (e.g. more tablets but at lower strength; liquids)
• Time-limited fills (e.g. only 2 weeks worth of medicine dispensed at a time)
• No refills (patient must get new prescription each month)
• Accusations of drug-seeking behavior (e.g. patient calls multiple pharmacies trying to find one that can fill prescription with preferred generic)

 

[[An...]]

18 hours ago, [[L...] said:

A member sent this to me via PM and asked me to post it on her behalf.

My Mother’s Story

Several years ago, my frail elderly mother in her late 80s was discharged from a UK NHS hospital having been diagnosed, amongst other things, with vascular dementia. She was transferred to a nursing home that seemed good, well staffed and compassionate. She was in a new area and there was a local GP surgery to whom resident’s care was assigned. It was a lot to take in and she was naturally very confused. She was also part sighted/registered blind. I feared for her well-being, visited everyday & hoped she would adjust and settle into new surroundings. 

After a few days she became angry, this escalated into what I can only describe as rage/agitation/a different persona. After a week, it was discovered that the local GP had abruptly stopped her medication - a benzodiazepine*.  He apparently thought she didn’t need it. Whilst I understand the risks, especially regarding falls, to stop a benzodiazepine without discussion at all with her family or follow any taper plan to cease this medication seems wholly unnecessary, given that she was already confused by dementia and by being somewhere entirely new. This caused her and her family immense distress. She was placed back on her medication and reverted to her ‘self’. 

This experience was both dreadful to witness and for her extremely upsetting. I cannot imagine what she went through. Suffice to say older vulnerable and precious family members deserve better.

* I am unsure what benzodiazepine it was but she had been taking it for several years.  She also had taken Librium and Mogodan in the past.

Doing this to older geriatric patients is unconscionable w/o careful analysis of the medical history and consultation with close family members. If abrupt cessation is necessary, the patient has to be monitored very closely, IMO.

[[Li...]]

I agree @[An...].  We have another older member who was hospitalized for a non-benzo issue.  During his stay, his ‘care team’ decided to deprescribe his benzodiazepine via abrupt cessation*. They did this without obtaining informed consent.  When he began showing classic symptoms of benzodiazepine withdrawal including hallucinations, they were clueless as to what was going on. After a week or so, someone finally thought to reinstate the benzodiazepine. The last we heard from the member, he was in dire straights several months after this experience.

*As you may already know, benzodiazepines are flagged as Potentially Inappropriate Medications (PIMs) for older adults per the Beers Criteria. Consequently, they are viewed as prime targets for deprescribing.

[[An...]]

Thanks Libertas.

Post a link to the Beers Criteria. I would like to read about it.

[[Li...]]

You’re welcome @[An...].  Here’s the link:

American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults

Given that you’re a long-time member and know your way around the community, might I ask a favor?  If you’ve read about examples of inappropriate/harmful/unsafe deprescribing practices shared by past or current members, would you please call them to my attention either on this thread or via a PM?

 

[[Co...]]

Hi @[Li...]. It is late for me, but I'll add a banner alert tomorrow to bring this better to the attention of members. If I have failed to do this within about 18 hours, please (you or anyone) remind me.

[[re...]]

Nsindy:

Truly appalling you would have to deal with that. It angers me so much. 

It is amazing how ONE mistake from a health professional(s) can have dire consequences on someone's health and well being. 

[[An...]]

1 hour ago, [[L...] said:

You’re welcome @[An...].  Here’s the link:

American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults

Given that you’re a long-time member and know your way around the community, might I ask a favor?  If you’ve read about examples of inappropriate/harmful/unsafe deprescribing practices shared by past or current members, would you please call them to my attention either on this thread or via a PM?

Ok, will do.👍

[[Ca...]]

My NP will only prescribe a week's supply so every week I have to have a telehealth visit at 300 dollars a pop!

[[An...]]

5 hours ago, [[C...] said:

My NP will only prescribe a week's supply so every week I have to have a telehealth visit at 300 dollars a pop!

Wow! Are you serious, Carol? Are you in a financial position where you can easily afford this? Why the telehealth? Would it not be cheaper to just see someone in person?

[[Co...]]

I've added an alert, @[Li...]. Please let me know if you would like it edited.

[[Le...]]

Given clonazepam at ever increasing amounts as told to quit cold turkey multiple times then told the withdrawal was a new GAD illness. the final withdrawal when a doctor just started ignoring me was so horrendous and long lasting that I am in awe that I survived. I was told to use them in basically the worst way and exactly opposite of what is reccommended. I went through the final withdrawal without anyone ever telling me what was happening. 

[[Li...]]

10 hours ago, [[C...] said:

My NP will only prescribe a week's supply so every week I have to have a telehealth visit at 300 dollars a pop!

Ouch!  I’m sorry you’re having to pay so much to get the medication you need to taper, @[Ca...].  

[[Li...]]

Thank you for sharing your experience, @[Le...].  As I’m sure you know, far too few doctors know how to safely deprescribe benzodiazepines.  Even fewer know how to distinguish between withdrawal effects, relapse of an underlying condition, or emergence of a new condition.

 

 

[[Le...]]

4 minutes ago, [[L...] said:

Thank you for sharing your experience, @[Le...].  As I’m sure you know, far too few doctors know how to safely deprescribe benzodiazepines.  Even fewer know how to distinguish between withdrawal effects, relapse of an underlying condition, or emergence of a new condition.

yea I know. That helps a little but I have yet to meet one that will even read an article. Even the warning in the dsm i was told only prevents them from helping more people. 

I think what many doctors have to face to accept this is too much for them. 

[[re...]]

 

 

yea I know. That helps a little but I have yet to meet one that will even read an article. Even the warning in the dsm i was told only prevents them from helping more people. 

I think what many doctors have to face to accept this is too much for them. 

 

 

OH THE COGNITIVE DISSONANCE IS REMARKABLE WITH THESE PEOPLE!!!!!!!!!!!!!!!!!!!!