Case Study: Ms. T
Alprazolam Refill Request
Ms. T, a 42-year-old woman, presents to the ED requesting a refill on her alprazolam.
She reports feeling shaky and anxious; her PCP refused to refill it, and she has been out of it for a day.
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Alprazolam Refill Request
Case Study: Ms. T
Past medical history:
- Generalized anxiety disorder (GAD)
- GERD
- Hypertension
- "Social" consumption of alcohol
- No history of illicit drug use
Social history:
- Alprazolam 1 mg four times/day
- Pantoprazole 40 mg daily
- Amlodipine 5 mg daily
Current medications:
- Pulse 110 beats/min, blood pressure 140/85 mm Hg
- Slightly tremulous, irritable
Physical exam:
Review her medical history below.
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Alprazolam Refill Request
Case Study: Ms. T
Electronic health records:
- Remote history of wrist fracture after combining BZD with wine.
- Diazepam allergy listed, described as "withdrawal symptoms".
- Multiple recent ED visits (12 in the past month) seeking alprazolam refills, noting "drug seeking" and aggressive behavior
ED notes:
- Multiple short prescriptions for alprazolam from 9 different providers in the past 2 months.
PDMP database:
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Alprazolam Refill Request
Case Study: Ms. T
Discussion with Primary Care Provider (PCP)
- Patient was given notice of practice dismissal 2 months ago.
- Has been on alprazolam for at least 16 years, prescribed for GAD.
- SSRIs/other therapies for GAD were offered but declined.
- BZD taper was recommended multiple times - declined by patient.
- History of early refill requests for lost/stolen medication.
- Saw multiple other physicians when PCP declined to prescribe further.
- History of aggressive behavior when interacting with staff.
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Alprazolam Refill Request
Case Study: Ms. T
Take a moment to reflect.
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Alprazolam Refill Request
Case Study: Ms. T
Ms. T meets the DSM-5 criteria for a benzodiazepine use disorder (BZD-UD).
Reiterate your concerns regarding risks of BZD-UD and continued BZD use, that BZD withdrawal can be a medical emergency, and abrupt discontinuation is unsafe.
Considerations
- Inpatient/medically-managed settings can be appropriate for acute BZD withdrawal. Discharge the patient home with a 3-day lorazepam prescription and close follow-up.
- Refer to addiction care, psychiatry, and/or peer support.
- Carefully document the care plan.
It is also unsafe to continue the prior regimen and refill alprazolam. Discuss boundaries and options for care plan.
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BZD Ms. T's Case
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Transcript
Case Study: Ms. T
Alprazolam Refill Request
Ms. T, a 42-year-old woman, presents to the ED requesting a refill on her alprazolam. She reports feeling shaky and anxious; her PCP refused to refill it, and she has been out of it for a day.
Continue
Alprazolam Refill Request
Case Study: Ms. T
Past medical history:
Social history:
Current medications:
Physical exam:
Review her medical history below.
Continue
Alprazolam Refill Request
Case Study: Ms. T
Electronic health records:
ED notes:
PDMP database:
Continue
Alprazolam Refill Request
Case Study: Ms. T
Discussion with Primary Care Provider (PCP)
Continue
Alprazolam Refill Request
Case Study: Ms. T
Take a moment to reflect.
Continue
Alprazolam Refill Request
Case Study: Ms. T
Ms. T meets the DSM-5 criteria for a benzodiazepine use disorder (BZD-UD).
Reiterate your concerns regarding risks of BZD-UD and continued BZD use, that BZD withdrawal can be a medical emergency, and abrupt discontinuation is unsafe.
Considerations
It is also unsafe to continue the prior regimen and refill alprazolam. Discuss boundaries and options for care plan.
Restart