Recognizing and Avoiding Common Pitfalls in Clinical Psychopharmacology

This article examines the risks involved in prescribing psychotropic medication and offers suggestions for managing those risks to ensure the best possibility for a favorable outcome. The major areas covered include:

• Prescribing a medication that has the potential for abuse or addiction.
• Anticipating and managing adverse effects.
• Properly obtaining and effectively documenting informed consent.
• Off-label use, particularly in the pediatric population.
• Appropriate disclosure of acknowledged errors.

Psychotropic medications of major concern primarily include benzodiaze- pines, psychostimulants, and narcotic analgesics,¹ although common adjuncts such as benztropine can also have moderate abuse potential.² Two common pitfalls in prescribing these medications are supplying too much or supplying too little. It is the former that concerns us most, but the latter presents an equal risk to the prescribing physician.

Managing the risk of overprescribing or underprescribing psychotropic medication is dependent on the physician having a clear understanding of the terms "overuse," "abuse," and "addiction."³ It is not always easy to identify problem patients. As pointed out by Kirsh and Passik,⁴ "Traditional definitions of addiction that include phenomena related to physical dependence or tolerance cannot be the model terminology for medically [or psychiatrically] ill populations that receive potentially abusable drugs for legitimate medical purposes."

Empirical studies have shown the value of increased success in both psychotherapy and pharmacotherapy when there is a stronger therapeutic alliance.⁵ Without adequate medication, a patient may lose faith in his or her physician, thereby uncoupling a therapeutic alliance or eliminating the chance of building one. Moreover, the patient may be made to feel guilty or ashamed that he needs to entreat his doctor for more medication—producing the very emotions that we so often seek to diminish.

Misinformation about this class of medication abounds in the lay press and on the Internet.^6-9 One reader's comment on the book by Gadsby⁹ states, "[H]alfway through the book the author started citing evidence how benzodiazepines cause permanent brain damage. Some of the evidence she presents states that benzodiazepines actually shrink the human brain." Because of these widespread misgivings about benzodiazepines, effective management of the actual risks compels clarification.

When it was observed that diazepam(Drug information on diazepam) was the most widely prescribed drug in the United States in the early 1970s, we began to question how we became "a nation of addicts."¹⁰ The more accurate question was, "Why is anxiety so prevalent in our society?" Physicians began to eschew prescribing this class of drug and attempted to substitute other medications for anxiety and panic disorder, such as antihistamines, b-blockers, and antidepressants.

Both doxepin(Drug information on doxepin) and diazepam were sought-after medications in the prison setting for facilitating sleep. Yet, even though doxepin could be far more lethal than diazepam, one federal prison in New York began automatically substituting doxepin whenever an inmate arrived with a prescription for diazepam.¹¹

Another example of medical misconception about benzodiazepines is illustrated in a 2005 research study, wherein illicit drug users taking prescribed diazepam were to undergo mandatory reductions of 10% per month.¹² After 6 months, the initial mean daily dose of 29 mg was reduced by approximately 6%. The researchers concluded that it is possible to reduce prescribed diazepam among illicit drug users—but not at the rate of 10% per month set by the study. Moreover, the therapeutic dosage range for diazepam is up to 40 mg/d, so why attempt to reduce doses that are already less than three fourths of the maximum allowable dose?

The risk posed by the compelling desire to reduce or discontinue benzodiazepines is perhaps best illustrated by the following case vignette.

A 60-year-old woman had been taking 5 mg of diazepam 4 times a day, prescribed by her general practitioner for an anxiety disorder, for more than 30 years. When her doctor died, a young family practitioner took over the practice. He was aghast that the woman was "addicted" to diazepam and scheduled a withdrawal regimen. Within a few weeks the woman was nearly psychotic and required hospitalization. Nonbenzodiazepine substitutions were tried, to no avail. When her 2 adult children brought her in to see me, I restarted diazepam, and she was back to a functioning baseline within a couple of weeks.

The safety and efficacy of benzodiazepines is unsurpassed for treating anxiety and panic disorders, and the abuse potential is much lower than widely believed.¹³ Newer drugs that are touted to have no abuse or dependence potential can eventually reveal the opposite, as shown in a 2003 review of zolpidem and zopiclone(Drug information on zopiclone).¹⁴ In extreme cases, dose increases reached a factor of 30 to 120 times the recommended doses. The majority of patients in these cases had a history of former drug or alcohol(Drug information on alcohol) abuse and/or other psychiatric conditions. The risk of inadequately prescribing benzodiazepines stems from exaggerating their potential adverse effects and minimizing their beneficial effects. Be evenhanded when informing patients about these medications.

Psychotropic medications are designed to help patientsthink and feel better. It is the latter goal that becomes problematic. "We have this Calvinistic view about treating pain in the long-term care setting: we must not give them too much analgesia because—you never know—grandma might become addicted."¹⁵ The media-reinforced mindset that one should not need medication to feel better is an attitude that unfairly stigmatizes anxiolytics and antidepressants in particular. The other extreme is promoted by patients who label their illicit drug and alcohol use as "self-medication," a term that has even gained acceptance in some medical circles.¹⁶

The psychiatrist's role is limited to the evaluation and diagnosis of psychological contributions to pain, rather than to treating the pain itself: "Psychotropic medications, psychotherapy, behaviour therapy, biofeedback, and distractional methods are the tools available to the psychiatrist."¹⁷ Therefore, psychiatrists who do prescribe pain medication are shouldering a heavier potential risk. Yet we have all seen patients who have been denied pain medication or who have been so limited in their analgesic prescriptions by their physician that it is useless to try to treat their depression without addressing this aspect of their treatment.¹⁸

The reticence to prescribe adequate analgesia is in large part due to the difficulty in defining "aberrant behavior" that can distinguish abuse and addiction from physical dependence and tolerance: "The differential diagnosis for aberrant drug-taking attitudes and behavior includes (1) addiction, (2) pseudoaddiction (inadequate analgesic), (3) other neurologic and psychiatric diagnoses, and (4) criminal intent."¹⁹

Reduced analgesic efficacy because of tolerance—loss of a drug's therapeutic effect over time—makes the treatment of chronic pain with opioids more difficult. However, the clinician should not avoid prescribing opioids just because it may eventually be necessary to increase the dose. "Unlike the chemically dependent patient whose level of function is impaired by substance use, the chronic pain patient's level of function may improve with adequate, judicious use of . . . opioids."²⁰

Diversion and abuse of prescription drugs is costly in terms of addiction, overdose, death, and related criminal activity, but chronic pain carries significant economic, social, and health impact as well.²¹ Criminal commerce can actually be fostered and promoted as a result of physicians' common reluctance to prescribe analgesics for patients who experience severe chronic pain. Turning to illicit substances and alcohol can be the result of receiving inadequate doses of pain medication.