Every now and then, a physician in a group practice or clinic setting disappears abruptly. Sometimes this is due to illness or a family problem; occasionally, the doctor has encountered a professional difficulty of one sort or another that precludes them from continuing to practice. The abruptly disappearing physician’s patients must be cared for by covering colleagues. This is especially important for patients who are being treated with controlled substances like opioid painkillers and benzodiazepine anti-anxiety medications. When a patient’s brain has grown accustomed to receiving either type of medication, or both of them, sudden discontinuation can be extremely unpleasant and dangerous.
I once stepped up to cover for an abruptly departed psychiatrist with a large and “complex” practice. I had no idea what kind of a mess I was getting myself into. A high percentage of this psychiatrist’s patients carried diagnoses of chronic pain, anxiety disorder, and attention deficit disorder. Most of them were receiving hefty doses of three or more controlled substances: painkillers, tranquilizers, and stimulants. Some critically-minded observers might assert that the psychiatrist for whom I was covering had attracted a following of “controlled-substance seeking patients.” Sometimes physicians of this ilk are given the worrisome nickname of “Dr. Feel Good.”
These days, I am sometimes sought out as a coach by physicians, nurse practitioners, and physician assistants looking for help in artfully saying “no” to patients who are intent upon receiving prescriptions for controlled substances. Unfortunately, medical training did not adequately prepare most of us to walk the tightrope that presents itself in these situations. How do we collaborate effectively with a patient who insists that what they need and want is a course of treatment that you, the prescribing clinician, deem to be problematic or downright harmful?
The world of adult primary care can be particularly thankless, with its large patient panels, seemingly infinite workload, and high burnout rates. Recruiting and retaining high-quality professionals is especially challenging when a departed Dr. Feel Good has left their mark on a large and demanding panel of patients. I published this piece in Psychiatric Times to assist clinicians in their quest to get things right in these challenging and stressful circumstances.
The focus of the article is how to effectively address controlled substance use and misuse in patients with a presumptive diagnosis of attention deficit disorder. The principles developed are generalizable to other situations. This clinically-focused piece includes guidelines to help you do no harm while practicing patient-centered medicine, even when you are caring for individuals who developed bad habits while working with a Dr. Feel Good who is no longer available to them. We need to be helpful to patients who became dependent on prescriptive practices that deviate from acceptable standards of care, as they are at high risk of experiencing bad outcomes when frustrated clinicians inherit them and replace their predecessors’ permissiveness with unrealistically draconian limit-setting.
Steve Adelman is a coaching and consulting psychiatrist and can be reached at his self-titled site, AdelMED.
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