Recently, I posted a case that involved an older woman who presented to me for the first time and had been on a long-term benzodiazepine. Although she was not happy with me when I began the discussion about deprescribing her sleep medication, I chose to educate her on risks of this medication and begin a slow taper.
This case seemed to resonate with many readers, as evidenced by the fact that over 100 of you elected to write a comment. Collectively, this level of interest highlights the high-wire act that is clinical practice when the patient and treating healthcare professional (HCP) fail to see eye-to-eye. As one savvy physician noted, “You just can’t condense a case like this into choosing between four check boxes.” Thank goodness this is never the case in clinical practice.
The confrontation with this patient escalated quickly when I brought up the subject of her long-term use of alprazolam. Thus, my first goal was to at least attempt to deescalate the emotions involved. Has there ever been a situation in which a clinical decision was improved by fear, anger, or frustration in either the patient or the professional?
Some of you pointed out that the therapeutic alliance was broken the moment that the patient started making threats. I would argue that is not true and that this patient encounter can be salvaged. Doing so, however, would require a step back on the part of the HCP and some open and clarifying questions as to what happened during her previous efforts to discontinue alprazolam.
I guessed that her previous attempts featured more abrupt discontinuation and no attempt to couple the weaning of alprazolam with other tools to promote better sleep hygiene. Addressing these previous episodes with empathy not only will assist me in my attempt to develop patient trust, but it will also likely help me to chart a precise therapeutic plan with my new patient. Most important, it enlisted her to play a large role in establishing this plan, investing her in the plan of care and increasing the likelihood of adherence.
Therefore, I respectfully disagree with the concept of firing or discharging this patient from practice that was suggested by some readers. I think that we can work together to improve her overall well-being. Just look at that nice example with the aspirin! She heard my concerns about the potential downside of her daily baby aspirin and was willing to discontinue it.
As for her threats to write letters to my superiors and the medical board, I would be happy to defend practicing evidence-based medicine in an empathic way. But the scenario does provide a good reminder to always document counseling and shared decision-making in these encounters.
Several readers were absolutely right in stating that this patient may have multiple reasons for insomnia, such as pain and anxiety. Those reasons need to be better elucidated and treated. But I also believe in the data that benzodiazepines truly are harmful for older adults. So to assume that everything will be fine over the next several years as she approaches 80 years of age on chronic treatment with alprazolam is dangerous.
Having this conversation at the very first visit is an important and necessary step in trying to reduce her dependence on alprazolam. But it is not going to be the only time we discuss the management of insomnia. She should be reassured that I would like to continue the alprazolam for the next couple of visits as we pursue a tapering dose.
In addition, I would strongly recommend talk therapy to provide her with tools to combat chronic insomnia. And I would make sure to emphasize that all of this effort is designed to help her live longer and happier.
Will this be successful? My experience is yes, more often than not. Regardless, the effort is worth it, no matter who is screaming.
Charles P. Vega, MD, is a clinical professor of family medicine at UC Irvine and also serves as the UCI School of Medicine assistant dean for culture and community education. He focuses on medical education with an intent to resolve health disparities.
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