When protocols harm patients

She called in tears. Beyond tears, actually. She was so upset that it was impossible to get a coherent history and the triage nurse was only able to ascertain that her psychiatrist was no longer willing to prescribe her long-term clonazepam, she couldn’t function, and that she couldn’t afford the urine drug test. She insisted she wasn’t suicidal and didn’t need to go to the ED Crisis Unit, but begged me to prescribe the clonazepam that her psychiatrist had discontinued. With considerable misgivings, I found a way to see her for an extended appointment later that week.

 

Her psychiatrist had weaned her from her anti-anxiety medication, clonazepam, which she had been taking in a dose of 1 mg three times daily for more than 5 years without dose escalation, side effects, or other problems. Over a period of several months her anxiety had steadily worsened, and she was now unable to sleep,  struggling with nausea and emesis, and had lost 17 pounds by our scale. She was unable to leave the house and had had to stop her local volunteer work and had missed a family funeral. Her grown son was concerned enough that he was calling daily from college.

 

What had happened to precipitate this?

She has several major and interdependent medical problems, and they had all been relatively stable for at least 3 years:

  • Multiple sclerosis (MS) which is followed by a local neurologist, stable but symptomatic with paresthesias, balance problems, and muscle spasms.
  • Chronic pain related to back disease stemming from vertebral fractures in a MVA, coupled with fibromyalgia (FM). For this she was followed by a rheumatologist as well as a physiatrist specializing in pain management, and was on stable and slowly tapering oxycontin, NSAIDs (naproxen), a muscle relaxant, trazodone for sleep, lyrica for mood and as an adjunct for her FM.
  • Chronic depression and severe anxiety, managed by her psychiatrist, with a history of two hospitalizations but no suicide attempts. She was currently on an Lyrica and until recently had been on clonazepam. She also saw a counsellor once or twice a month.
  • Severe multifactorial insomnia, partly from back pain and FM, partly from depression, and partly from anxiety. Multiple medical treatments over 5 years had been minimally successful but she had managed 4-6 hours of sleep a night on clonazepam, trazodone, and melatonin.

Then, because of side effects (daytime sedation) from one of her MS medications (cyclobenzaprine) the dose had been decreased and her muscle spasms and insomnia worsened. She had asked me about the possibility of a trial of medical marijuana. We had discussed it at length, covering the poorly understood risks and benefits, and had agreed to a six month trial focused on sleep and muscle spasm. She had found it quite helpful and had been using it at bedtime 2-3 times a week. She had been able to decrease both her narcotic and muscle-relaxant use, and had increased her social interactions. At our follow-up visits, we agreed that she was benefitting and was having no problematic side effects.

In good faith, as she cycled through her various providers, she told them that she was using medical marijuana 2-3 times weekly at bedtime. Her neurologist had been supportive,  while her rheumatologist and physiatrist were neutral but had no objections. Her psychiatrist immediately told her he would no longer prescribe her any clonazepam or other benzos, and began a taper. After two months off the clonazepam, with increasing anxiety and insomnia making her miserable, she returned to the psychiatrist who agreed to restart the clonazepam only if she stopped the marijuana and agreed to regular monthly visits for urine drug screens (at $400 and not covered by her insurance) in order to get her next month’s prescription. His reason: their office protocol was that marijuana was a contraindication to the use of medications like clonazepam. When the patient asked him to call me and discuss it, he refused, saying it wouldn’t matter because he would not stray from the protocol.

There is certainly good reason to be concerned about the simultaneous use of marijuana along with any psychoactive medications and in the setting of psychiatric disease. I completely understand why this made the psychiatrist uneasy. However, he was putting adherence to the protocol (which arguably is there to protect him rather than his patients) above individualized patient-centered care. 

Denouement: I am prescribing the clonazepam and we are working to find her a new psychiatrist. Preferably one who is more flexible, because I would hate to be in the position of suggesting to a patient that she lie to her psychiatrist.

 


 

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