Doctor Being Weird About Prescription, How To Discuss?
March 4, 2015 11:05 AM   Subscribe

I take alprazolam to help fall asleep, 2 right before bed. This was prescribed by my sleep specialist doctor (more on that inside). My doctor is now acting strangely over it and changed my dose on refill without telling me. I'm not sure how to talk to him over this, without the risk of being seen as a drug seeker.

Normally I'd just call and ask what the hell, doc? But I know there is a potential to be seen as a drug seeker/addict/what have you with this and certain other medications. And if it is, it might end up a black mark on my file, making any medical treatment more complicated in the future. I've read far too many horror stories of exactly that happening to people. So I'm not sure how to proceed.

The backstory.

The alprazolam was initially prescribed by another doctor for anxiety. I only occasionally needed it - we're talking 60 pills needed to be filled every 6 months to a year. But I also have insomnia. Like weapons grade insomnia. Went to see a sleep doctor, have the sleep study, the whole shebang. No sleep apnea. After sleep hygiene, relaxation and a few other things, we resorted to different medications. Most didn't work or made me too groggy in the morning.

Eventually, seeing my prescription for alprazolam, he asked me if it made me sleepy. It does. He said I could take the alprazolam before bed. And he said I could take up to two. And I did, and it worked! So I take two every night, along with a few other things (melatonin, magnesium, cyclobenziprine). And it works well. This started fall 2013, I think. When I saw him in the spring (2014), I asked him to take over the prescription when I saw him because it didn't make sense to have my gp prescribing something I was using for sleep.

Fast forward to a week ago. I called to get the prescription refilled a little early because I'm traveling. It was only 5 days early (I was trying to time it before my flight. His office called and left a message for me that they needed to speak to me about my prescription. I saw the doctor in December as more of a check up, we talked about how I was using it (the same as how I was using it in the spring), so I found that really weird.

I called back, and the nurse asked if I was still taking it for anxiety. "Occasionally" I said. But when I do, I don't take it at night - or if I take one for anxiety, I only take one at night. The nurse asked that if I'm going to take it for anxiety, I see a therapist and have them prescribe it. No problem, I have a therapist, I'm sure I could talk to him about it. Then a light bulb went off in my head. "Oh. I'm filling it early because I'm traveling, is that what you're concerned about?" She seemed satisfied by that answer and that was that.

Or so I thought. Now, a week later, I notice that I have far fewer pills in the bottle than I normally do. I look at the bottle and it's a prescription for 30; and it says to take 1 at night for sleep. I have always been upfront about how much I've been taking, I even told the nurse I was taking two at night. I told the doctor at the last visit, and at the previous visit. I told the nurse on the phone that was the case.

I honestly don't care if the doctor wants me to take a lower dose; but what I'm both concerned about and pissed is that this wasn't communicated to me. I've even been concerned about taking it myself and brought it up at my December appointment. I had read that alprazolam changes your sleep architecture for the worse. (Doc said it's not a problem). I'm upset because it's a medication with withdrawal side effects, and of those being exactly the thing we're trying to treat (insomnia). It has a long list of problems with withdrawal; so I feel that if he wanted to lower the dose, we should have come up with a plan on how to do that safely.

But as I said at the very beginning, because of the addictive nature and bad reputation, I'm actually concerned about having this conversation with my doctor (or more likely, his nurse). I doubt the smaller dose was an accident, considering the recent conversation. And this doctor books up 6 weeks in advance, so it's really unlikely I'd be able to even get in to see him before my prescription expires. I'm really not sure what to do here. I don't know if the doctor and his nurse just literally didn't hear me when I said I was taking two at night. I repeated it over two visits and more recently with the nurse.

I'm flustered too, because I feel like I'm finally mostly sleeping like I should be. But my concern remains; if I approach them over this, I'll be seen as a drug seeker and fuck my medical record for now until kingdom comes. Something seems to have them spooked. And because I didn't read the bottle until a week in, I now don't even have enough to make it to the refill date taking one a night - presuming that I try to follow the instructions and deal with the withdrawal effects. How do I approach this? Insight and advice needed.
posted by LANA! to Health & Fitness (20 answers total) 1 user marked this as a favorite
I'd start by telling your doctor that you're glad he thinks a lower dose will work for you and that you want to be on the lowest possible dose that'll get you to sleep... and then 'What the hell, doc' him about the lack of communication. If they offer to up your dose, maybe say no and say you'll try the low dose for a while and revisit later.
posted by Huck500 at 11:19 AM on March 4, 2015

It sounds to me that the doctor is only willing to prescribe it to you for sleep, which would be the 30 pills (1Xday for sleep at bedtime) and if you want anything further than that, you'll have to go to a psychiatrist, as your sleep doctor isn't comfortable with prescribing it for both uses.
posted by xingcat at 11:33 AM on March 4, 2015 [6 favorites]

You're making a lot of assumptions about what could have been a simple misunderstanding or error. Reach out to the office ASAP and explain that you would like to stay at your previous dosage level. Maybe they'll be able to rectify, or maybe you will need to transfer it back to the psychiatrist.
posted by ThePinkSuperhero at 11:34 AM on March 4, 2015 [17 favorites]

One thing that I would do in between if you can is what the nurse recommended, which is this: ...if I'm going to take it for anxiety, I see a therapist and have them prescribe it. A psychiatrist might be better than a therapist since they typically use those of medications and would be familiar with both on-label (anxiety) and off-label (insomnia) use.

At least make an appointment for as soon as possible. Then when you contact the sleep specialist, remind them that you previously took it 2 doses/night, are traveling, and you have an appointment with a psychiatrist per the recommendation of the nurse to manage it in the future.

Yet another alternative since this was via your PCP in the past is to request that they take over your prescription. I don't know what would be easier in terms of time.

I wouldn't look at this necessarily as them viewing you as using the drug for abuse purposes, but rather that the physician might want to comply with on-label vs off-label use. I have known pharmacists who also refuse to administer meds off label and/or insist that a patient see a specialist. The sleep specialist was useful in finding a solution to insomnia, which is phenomenally difficult to treat; now the best step might be to find someone very familiar with the medication. Good luck.
posted by Wolfster at 11:35 AM on March 4, 2015

I had a doctor suddenly start acting weird and suspicious about prescriptions a few years ago. About a year later I stumbled across notices on my state's Secretary of State web site indicating that just before he'd started acting weird, he had been fined by the state's medical board and actually had his license suspended for a month for inadequate record-keeping.

So in that case it wasn't me, it was him.

(I don't think he was doing anything wrong as far as patient care; I got the impression he'd just gotten sloppy about billing or tracking his controlled substance prescriptions or something like that. His medical notes were exclusively on paper at the time but he's since transitioned to a computer system for everything and I get nice orderly printed patient notes when I check out, as opposed to just getting the yellow copy of a handwritten receipt for my copay after an office manager squints at an Excel spreadsheet for a few minutes.)
posted by Sockpuppet Liberation Front at 11:38 AM on March 4, 2015

Your post just says "1 tablet" and "2 tablets" without mentioning the strength of the tablets. Alprazolam comes in different strengths. Start by checking to be sure that the tablets in the new prescription aren't twice as strong as the tablets in the old prescription.

Frankly, I don't see any "spooking" of your doctor in this story. You seem to be impugning the professionalism of your doctor. Maybe just a misunderstanding, maybe they just decided to reduce the quantity for better followup.

Doctor-patient relationship should be one of trust and understanding. Speak to your doctor(s) and reach an understanding, don't just guess at what you think is going on.
posted by JimN2TAW at 11:39 AM on March 4, 2015 [1 favorite]

Is it possible that your doctor prescribed you 30 pills that are 2x the strength, rather than 60 pills of 1x the strength? It is cheaper for insurance to pay for the bigger-dose pills so almost all of my meds come that way now.
posted by joan_holloway at 11:44 AM on March 4, 2015

First call the pharmacy and ask them to pull the prescription to make sure it wasn't a mistake on their end, because it's different from what you usually get. Then call the doc and ask why your prescription was changed. There's nothing wrong with that or odd about it. If you proceed with a neutral tone it should be fine.
posted by bleep at 11:45 AM on March 4, 2015 [2 favorites]

Is it possible they filled a smaller number because it's about to expire? When I need to call for totally uncontrolled substances in a situation like this, they usually give me a shorter term prescription to tide me over until an appointment where the full prescription is written.
posted by pixiecrinkle at 12:14 PM on March 4, 2015

The smaller dose is probably just because it's a refill. The take 1 could be because it's a different dosage or just because it's an error. See your gp as soon as you can and just emphasise that the medication and dosage work really well for you and you'd like to continue.

There was probably just a bit of confusion with the nurse doing the refill because it's usually prescribed for anxiety.
posted by betsybetsy at 12:47 PM on March 4, 2015

Best answer: I don't think you have to be so concerned about being seen as drug-seeking. A sudden reduction in your prescription with no discussion is definitely something to talk to the doc about. I'd just call and tell the truth - you just realized that your prescription has been halved, and you don't know why. You are concerned because you had been taking them as previously - two a night, so now you will run out before your next refill and are worried about possible withdrawal symptoms. Then ask why your dose was lowered, is this a mistake? If not, why was it not discussed with you first? This is all perfectly reasonable. Then I'd say that two a night has been working for you, and either ask to stay at that, or of they seem to want to lower your dose, ask for a plan to taper down. I don't think there is a lot of risk here for you to be labeled as drug-seeking. It's not like you're asking for a massive dose increase or something, just what you've been taking for some time, and better comminication.
posted by catatethebird at 1:47 PM on March 4, 2015 [3 favorites]

Best answer: Nthing the notion that the first thing you should do is find out the per-pill dosage of your old Rx and your new Rx. This might all be over nothing if you used to take 2 x 1mg and your new Rx is for 1 x 2mg.

But if the actual dosage has changed without any discussion, you need to inquire with the doctor about that.

I'm not a doctor but I confess I'm a bit surprised to hear that you're taking a benzo long-term for sleep. *shrug* but it sounds like you went through the entire drill of testing other meds to find one that works for you.
posted by doctor tough love at 2:04 PM on March 4, 2015

my doctor recently sent the wrong strength pill for one medication and 1/2 the dose on another medication. i called the doctor, pointed out their error and they fixed it. so far it seems like you're assuming the doctor did this purposefully - approach him like it's a mistake on their end and see if it gets rectified.
posted by nadawi at 4:56 PM on March 4, 2015

My doctor's office gave me a really weird number of pills recently when I called for a refill (like five instead of thirty, I think, something like that) and when I called, being scrupulously careful to not sound like a drug-seeker, they were just "oops, our bad, must have been the new person."

So before you make it a big deal in your head, call or make an appointment and just talk clearly and carefully about what is going on and how to get you the best treatment for your situation. There are a lot of links in the communication chain between your call for a refill and the pharmacy handing over the pills, and at any step things can be changed. It is a huge pain and worse when it is something like Aprazolam that requires extra paperwork.
posted by Dip Flash at 6:57 PM on March 4, 2015

Has your cyclobenzaprine dosage changed? That is pretty powerful stuff and would likely impact how much you can take of the alprazolam.

I agree with the person above who finds it surprising that these are being used long term for sleep but IANYMD.

Open communication is important with your doc so , yes, just ask how come it is 30 vs 60 and see what s/he says. It could be a state law change or any number of things.
posted by NikitaNikita at 9:35 PM on March 4, 2015

I had a pharmacy give me the wrong number of pills just last month. I could even see the prescription on my health care providers website listed as 90 pills with one refill, so I know that's what my doctor intended, and yet for some reason the pharmacy gave me 30 with one refill. Errors like this definitely happen. Be sure to keep the bottle with the number of pills and refills printed on it in case the error was on the pharmacy's end. Then you can show the bottle to your doctor as proof of how many you actually received.
posted by insoluble uncertainty at 12:16 PM on March 5, 2015

I had a pharmacy give me the wrong number of pills just last month. I could even see the prescription on my health care providers website listed as 90 pills with one refill, so I know that's what my doctor intended, and yet for some reason the pharmacy gave me 30 with one refill.

I just had this happen, and it turned out that it wasn't an error so much as it was the insurance company imposing its own standard of care. They would only pay for 30, so never mind what the doctor prescribed, I was getting 30.
posted by Dip Flash at 6:50 PM on March 5, 2015

Response by poster: Thanks for all the feedback. Follow up for anyone that might run into a similar problem. (I hope not!) I checked the dose because I hadn't before, and it was the same. I then called the doctor's office and spoke with the nurse. I more or less used catatethebird's answer as my script; because it really was the most straight forward (and took the emotional language I was using in my head out.) At first the nurse was rather confrontational; she insisted I was using it wrong, that I was only supposed to be taking it for anxiety, that the doctor only took over the prescription as a courtesy and that I had to have my PCP take back the script, refer me to a psychologist (not a psychiatrist) and have that person help me taper.

I told her that if I wasn't supposed to be taking it that way, that's fine, but then I really misunderstood his instructions and I could use some help figuring the next steps out, and tha they at some level had a responsibility because his office has been filling my prescription incorrectly for the past year and two office visits no one caught that. I stressed that it would be really weird for me to both ask Dr. Sleep to take over an anxiety prescription, something I rarely if ever needed anymore, and that it would be equally inappropriate to pass it back to another doctor; especially as I believe I was following his instructions.

I got the sense she was going over the notes as we talked because her demeanor changed mid-sentence and she started reconfirming my (failed) history of trying different drugs. Once she got to that, she made a non-specific apology and said she'd talk to the doctor and get back to me. When she got back to me, yup, it was all better, they would keep filling my prescription at the previous dose.

Thank you all for giving me the language and the courage to get this straightened out. I don't do well with confrontation; and this fell squarely into that category.
posted by LANA! at 10:42 PM on March 5, 2015 [6 favorites]

Best answer: Just for future reference:

and that I had to have my PCP take back the script, refer me to a psychologist (not a psychiatrist) and have that person help me taper.

Only two states in the US (New Mexico and Louisiana) allows psychologists to prescribe or manage medications, though other states have considered and so far rejected it. If you don't live in one those two states, the nurse is likely confused (or she may have trained in one of those two states).
posted by jaguar at 6:59 AM on March 6, 2015

Response by poster: Yes, I meant to expand on that. It was around the time I asked if she wanted me to see a psychologist or if the doctor meant a psychiatrist that I think she started looking closer at the records. She isn't new, but also isn't the nurse I normally interact with. I wasn't confrontational about it, and it was around that time she started pausing while I assume reading the notes (a lot of "okays" and repeating parts of past visits).
posted by LANA! at 5:38 PM on March 7, 2015

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