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As a physician, I know the solution to physiologically impossible tasks doesn't lie in a prescription bottle. I'm having a hard time getting that message across to patients, however.
When I’m prescribing certain types of medications, I try to remind myself to focus on a patient’s function. This is most true when managing high-risk medications like chronic narcotics, stimulants, and benzodiazepines. Recently, though, I’ve started to wonder if I’m promoting the ability to continue an adaptive dys-function in some of my patients.
I recently saw a man that I’ve known for several years. He’s struggling with a toxic work environment, which is not an uncommon complaint among my patients. As a result, he’s anxious. On weekends and days away from work, he’s fine but at work, he’s a mess. Through the magic of pharmacology, he’s better. He’s well enough that he can continue to drive himself through a job that appears to be sucking the life out of him.
Another female patient with multiple medical problems asked for a refill of her anxiolytic. As I went to enter the order in the computerized medical record, I realized that in the challenge of controlling her other medical issues, I’d allowed her to treat her anxiety with thrice daily doses of benzodiazepines. This is not first line for anxiety disorders, and I’m not in favor of continuing this treatment without exploring other options. We had a focused discussion about the risks of long-term use of this type of medication. She can’t function without it, she confesses. Her workplace stress is through the roof, and this medication cocktail allows her to function.
One of my patients brought up the possibility that she has attention deficit disorder (ADD). She works full time and goes to school. She’s experiencing a difficult time retaining information she’s read or paying attention to lectures. I was careful with my words, but I explained that we’d all do a little better with a stimulant. Hence, the widespread abuse of stimulants on college campuses during finals week. Maybe she meets clinical criteria for ADD, but I can’t help but feel that I’m being asked to medicate something other than a true disease process.
These stories, of course, are balanced by numerous successes - my patient who advanced far enough in his career that his untreated ADD was getting in the way of a promotion. Treatment for him has been life-changing. Many of my patients have workplace stress but don’t have the luxury of searching for another job in a risky economic climate.
I stand amazed at times when patients seemingly are requesting that I alter the laws of physiology so that they don’t have to sleep for days on end in order to work more hours, drive across a half-dozen states and back in 48 hours, or fall asleep easily and sleep well despite massive amounts of caffeine and abysmal sleep habits. I understand the pressure they are under, having been asked to do physiologically impossible activities during my residency training. However, I know that the solution isn’t found in a prescription bottle. I’m just having a difficult time convincing my patients.
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