We take our job as clinicians quite seriously. When a patient hires us for their primary care needs, it is our mission to provide excellent, evidence-based care. We use our expertise, training, and latest resources to provide guidance and management plans that are tailored to your health and wellbeing in the long term. We do not offer quick fixes or band-aids just to move on to the next patient; our entire philosophy is about a long-term view of health.
Many controlled medications, when used for prolonged periods, are not compatible with long-term health. In the same way that we hope to help someone with type two diabetes eventually make lifestyle and dietary modifications so as to discontinue their insulin and other medicines, it is our goal to taper individuals off of many of the following medicines.
As we’re all well aware, there has been an explosion in the use of opioids and narcotics over the last several decades. Unfortunately, as time has gone on, we’ve come to realize that the harms of narcotics/opioids vastly outweigh the benefits, and — as such — should be used in limited, controlled settings (largely in the hospital setting and in the context of end-of-life, terminal pain). These medicines — codeine (T3), fentanyl (Duragesic), hydrocodone (Vicodin, Lorcet), hydromorphone (Dilaudid), morphine (MSContin), oxycodone (Percocet, OxyContin), tramadol, etc. — have serious side effects, including inability to have a bowel movement/constipation, slowness of reaction time, bone fractures, sleeping problems, sexual problems, hormone problems, breathing problems, addiction, respiratory depression and even death.
Paradoxically, people often get used to the effects of narcotic pain medication over time and/or the medicines themselves can make pain worse with time by changing a person’s brain chemistry — and only about 1 out of every 3 patients who take narcotic pain medications actually gets relief of their pain. For most people, narcotic pain medication may decrease pain by about half or less.
As such, when we prescribe narcotics or opioids for pain, we create a gradual taper over several months to get our patients to zero narcotics/opioids. Sometimes this taper is longer; sometimes it’s shorter — it just depends.
We are happy to refer patients to pain management specialists during their transition away from narcotics/opioids and help them connect with other non-opioid/non-narcotic forms of pain management like antidepressants, selected analgesics, anticonvulsants, topical pain remedies, injections (not all of which are available at KCDPC), referral to specialists, PT or OT, massage/acupuncture, exercise therapy, and/or cognitive behavioral therapy.
Alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), temazepam (Restoril), triazolam (Halcion), and other medications ending in – zepam or -zolam belong to a group of medicines called benzodiazepines (sometimes referred to as “benzos” for short). These medicines act on GABAA receptors in the brain that are in charge of slowing down the nervous system; the same receptors are affected by alcohol, barbiturates, muscle relaxers, and other medicines with sedating effects.
People get used to the effects of benzodiazepines over time, requiring higher and higher doses of the medication to achieve previous results. This is caused by changes in brain chemistry that actually change GABA receptors to decrease the brain’s natural ability to calm down and slow down. Paradoxically — similar to opioids — using benzodiazepines in the long run actually can cause more anxiety or insomnia.
Moreover, benzodiazepines can cause problems with addiction and abuse, progressively changing the way the brain functions with regard to the “reward” (dopamine) system. With prolonged use or high dosing, benzodiazepines can cause lethal overdoses (especially a concern when combined with other medications and/or alcohol) and withdrawal can, similarly, be life threatening with seizures or psychosis as part of withdrawal.
As such, when we prescribe benzodiazepines, we create a gradual taper over several months to get our patients to zero. Sometimes this taper is longer; sometimes it’s shorter — it just depends.
We are happy to refer patients to behavioral health specialists during their transition away from benzodiazepines and/or help them connect with other forms of anxiety or insomnia management like antidepressants, referral to specialists, massage/acupuncture, exercise therapy, and/or cognitive behavioral therapy.
Medicines like dextroamphetamine-amphetamine salts, dextroamphetamine, and amphetamine sulfate (Adderall); lisdexamfetamine (Vyvanse) and methylphenidate (Ritalin, Methylin, Concerta, Focalin, etc.) are used to treat diagnoses like ADD, ADHD, hypersomnolence, shift work, among others, and fall into the category of “stimulants.” Similar to cocaine and methamphetamine, stimulants flood the brain with dopamine, norepinephrine, and serotonin.
As such, these medicines can cause problems with addiction and abuse; one study noted up to ⅓ of college-age individuals reported nonprescribed stimulant use in the year before the study.
As such, we only prescribe stimulants to patients who have had a thorough, evidence-based workup by a psychiatrist or other behavioral health professional. We must have this workup on hand and will prescribe up to 4 months of stimulants until our patient is able to establish with a psychiatrist. We do not prescribe stimulants longer than 4 months.
In the meantime, we are happy to refer patients to other behavioral health specialists to help them connect with tools for attention management like books, online resources, and cognitive behavioral therapy.
WEIGHT LOSS AIDS
Weight loss is more than prescribing a medicine; the bedrock of weight loss is progressive changes in eating, physical activity, cultivating healthy behaviors, and specific attention to mental health, if applicable. Moreover, not every therapy works for every person in weight loss, and sometimes we don’t recommend weight loss at all! We firmly believe that medicines for weight loss are not to be used alone and are generally reserved for those with certain characteristics.
As such, those interested in medication for weight loss will be invited to participate in our 90-day program for behavioral change as a precursor. We will not prescribe weight loss medications until successful completion of the program.
Medicines like eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien) — along with benzodiazepines (see above) — are often prescribed for insomnia and act on selective GABA receptors as inhibitors of brain activity. These medicines, however, are not the first thing that a clinician should recommend for someone with insomnia. The first-line (i.e. best) treatment for insomnia is actually cognitive behavioral therapy (CBT) and healthy sleep habits. These interventions have much stronger evidence that they help people in the long term than these medicines.
As such, we only prescribe the above sleep aids for up to 21 days. This should give patients enough time to establish a CBT relationship and ease into healthy sleep habits.
We refer patients to behavioral health specialists during their transition away from these sleep aids and/or help them connect with other forms of anxiety or insomnia management like antidepressants, other non-addictive sleep medicines, massage/acupuncture, exercise therapy, among others.