At the recent Free Suicide Management Course, I talked to a colleague who told me about patients who regularly come to his county clinic and say words to the effect, “If you don’t give me X medication, I’m going to kill myself.” This doctor clearly felt these types of statements are manipulative and designed to extract from the doctor a prescription for a medication with high abuse potential.
When I was a resident and covered a VA emergency room on call, we residents (and attendings) would call this behavior “extortion of care.” One of our attendings would give us advice on how best to handle such situations in the emergency room when confronting a patient who on a frequent repetitive basis claimed suicide or some other form of severe mental illness in order to get admitted.
So, I wanted to share three thoughts with you on how to handle such challenging clinical situations. I’ll start with the broadest suggestion and move to the most specific one.
First, if you face a situation in which you have strong reason to believe that in your clinic you have a sizable number of patients who present “threatening” suicide if not given what they want, then engage the other clinicians (and perhaps administrators) in the system in which you work – be it a community or county mental health center, a university clinic, or a group practice. Mutually discuss “best practices” when confronting such situations. It’s hard to face such a situation alone. And it’s especially hard if you end up the only one resisting such pressure from patients, be it for admission or for a prescription. And if you work as a sole practitioner, you should at least think through an approach to such situations ahead of time. My next two thoughts might be a starting point for you.
Second, (here I’ll sound like a broken record) ensure that every patient starting treatment with you knows and understands the “rules of the clinic.” Not only should these “rules” address issues such as missed appointments, payment, calling in of prescriptions, and other so-called “house-keeping topics,” but also additional clinical issues. For example, your treatment contract can include the message that you do not dispense medications with high abuse potential without conducting a search on that patient’s prescriptions on your state’s Prescription Drug Monitoring Program (PDMP) database. All states other than one have a PDMP database, although who has access to it differs by state.
Another item that may be in your treatment contract – or conveyed orally – is that “lost” prescriptions or dispensed medications, will not lead you to write another prescription. One colleague who has a large ADHD practice and writes many prescriptions for psychostimulants tells his patients that they only get one “get out of jail free” prescription for lost or stolen prescriptions or meds.
Third, when facing a patient already in treatment with whom you did not have a prior discussion setting out the rules, and who now threatens suicide if not given a certain medication, always consider what is that person’s best interest. Is it in any person’s best interest to receive an abusable medication for an unclear indication? Probably not. For example, if a patient tells me, “I’m going to kill myself if I don’t get my Ativan,” then my providing them with a prescription for Ativan will not really address their issue, whether it’s suicide risk or addiction. So, I probably will say ‘No.” Then it gets down to what do I need to know to help this person? What really is the nature of their problem? What is the solution to their real problem the way I understand it?
I’d love to hear from you the nature of these types of problems you face and how you handle them. I’d be happy to include it in this eNewsletter, with your name or anonymously. Up to you.
Until next time,
“Be patient toward all that is unresolved in your heart. Try to love the questions themselves. Do not now seek the answers, which cannot be given because you would not be able to live them. And the point is to live everything. Live the question now. Perhaps you will then gradually without noticing it, live along some distant day into the answers.”
– Rainer Maria Rilke