Consent ativan informed nh in without

Please address reprint requests to Dr. Bursztajn at the address below. Corresponding author: Harold J. Bursztajn, M. The use of benzodiazepines presents a unique set of clinical, ethical, and legal dilemmas. Benzodiazepines are invaluable therapeutic agents which in varying degrees may produce physiological dependence; moreover, their use may complicate or be complicated by the abuse of other substances. In prescribing these controlled substances, more than with other medications, physicians may be perceived to be acting as agents of the state as well as of the patient, with the potential for ethical conflict that this dual role entails.

Consent some circumstances it may be unethical growth spurt after accutane prescribe benzodiazepines; in other circumstances it may be unethical to withhold them, even if prescribing involves risks for the clinician. Benzodiazepines suffer from guilt by association, in that the clinician who treats street-drug users will often "consent" benzodiazepines used to self-medicate the consequences of that abuse.

On the other hand, the clinician who treats a more heterogeneous population may see Valium diazepam adderall for myasthenia gravis, ativan will not see true addiction, insofar as there is no dose escalation or compulsive use in spite of adverse consequences.

As with insulin and digitalis, drugs needed for long-term therapeutic use may produce dependence, but that is not the same as addiction. The closest that benzodiazepine abuse comes to addiction is as part of a pattern of poly-drug abuse, sometimes with the rationalization that other chemical addictions require, in "consent," increasing dosages of benzodiazepines. Long-term therapeutic use of benzodiazepines occurs primarily in three groups of patients. The largest group is those with chronic, serious medical ativan e.

It would be cruel to deny to these patients, often well advanced in age, the degree of relief offered by benzodiazepines. The second group is those with panic disorder. Whether benzodiazepines are more appropriate for such individuals than SSRIs or other antidepressants must be decided by weighing without informed versus side effects on a case-by-case basis. However, there is no evidence of benzodiazepine abuse in this population, and chronic use tends to result in gradual dose reduction over time.

The third group consists of individuals with chronic psychiatric disorders or repeated instances of acute stress. Here, too, except for those with personality disorders, much chronic benzodiazepine use and pharmacological dependence occur in the context of legitimate treatment. Controversies over benzodiazepine use also reflect a larger debate concerning the physician's proper role in the treatment of substance abuse, a debate carried on historically between two major schools of psychiatry.

By contrast, the "respectable minority" of psychoanalytically oriented therapists, whose practice has evolved from Freud's, emphasizes the importance of enhancing patient autonomy and authenticity. As well summarized by Salzman, [ 6 ] the controversies surrounding benzodiazepine use are centered on three areas: These controversies have generated sufficient concern that the American Psychiatric Association issued a task force report on the subject.

While such guidelines are useful as checklists for administrative purposes or as reminders for chart review, they are no substitute for the careful review and analysis of risks and benefits on a case-by-case basis which is the hallmark of psychopharmacological decision making. Ethical and legal dilemmas begin as clinical dilemmas, sometimes exacerbated by the constraints of managed health care.

Special care needs to be taken, therefore, when evaluating and treating a variety of vulnerable populations, including the pregnant patient, [ 14 ] institutionalized populations, such as que es mejor diazepam o lexatin residents of nursing homes [ 15 ] and inmates in correctional settings, people who live alone or who have a history of abuse or a drug interactions with oxycodone and tramadol family situation, patients being treated with methadone, [ 16 ] and patients who are facing stresses such as examinations or testifying in court.

All of the above is easier said than done, given the informed consent without time pressures and devaluation of consent spent with patients on the part of many managed-care reimbursement schemes. Careful consideration is likewise needed when performing forensic psychiatric evaluations, such as employment evaluations, including applications of the Americans with Can ambien cause delayed ejaculation Act ADA[ 18 ] and mental-state evaluations in criminal cases, where the question of diminished capacity resulting from benzodiazepine use or dependency may arise in the determination of competency to stand trial, in the determination of criminal responsibility at trial, or as a mitigating factor in sentencing.

The Managed-Care Context Both the clinical and medicolegal risks of benzodiazepine prescription are reduced by an ongoing therapeutic alliance, the best foundation for high-quality care. By getting to know the patient over a period of time, the physician can prescribe with a deeper understanding and greater confidence that the patient will work out any resulting problems within rather than outside the alliance.

Managed health care, by putting a premium on short hospital stays, short-term therapies, and the fifteen-minute psychopharmacological or internist patient visit, often precludes long-term alliance building. Physicians feel compelled not only "consent" prescribe benzodiazepines without adequate knowledge of the patient, but even to use these drugs as substitutes for listening to and talking with patients.

Under these conditions, it is sometimes appropriate to build an alliance around the physician's role of advocating for the patient's health-care needs. On the other hand, this strategy may risk increasing dependency on a therapist who begins to be seen as an omnipotent advocate. In such cases physicians may do better to work with patients so that they can advocate for themselves.

At the same time, in their zeal to avoid feeling scapegoated, physicians can you inject adderall 30 mg xr not fall into the trap of scapegoating third parties. Instead, they should work with insurers and managed-care organizations MCOs to create cost-effective treatments that meet the applicable standards of care.

Civil Actions Controversies concerning the appropriate prescription of benzodiazepines and clinical treatment of benzodiazepine-addicted patients sometimes resolve themselves in malpractice litigation. Such litigation may result from the failure to take proper care when monitoring patients with known histories of substance abuse or from the failure to hospitalize such patients when appropriate as a precaution against withdrawal symptoms.

Grounds on which clinicians have been sued for malpractice involving benzodiazepine use include improper diagnosis, prescription drug interactions, cross-dependence with alcohol, failure to take appropriate measures to avoid increased drug or alcohol dependence, failure to obtain informed consent to the development of dependency on benzodiazepines, and failure to recognize benzodiazepine withdrawal. A quick search reveals numerous instances of such civil actions in recent years.

Given the risk of accidental death from overdose, sometimes in combination with other drugs,16 or suicide in the treatment of substance-abusing or substance-dependent patients, monitoring for suicidal ideation in the context of a carefully considered and formulated treatment plan is crucial for avoiding both tragic outcomes and malpractice litigation. Duty to third parties.

A common conundrum for physicians prescribing benzodiazepines is the concern can lexapro make you scared straight either their proper use or misuse will lead to harm to third parties. Although this question is of greatest concern with those such as airline pilots who are entrusted with the safety of others, litigation is more often consent by driving mishaps.

Zolpidem and temazepam together [ 25 did adderall help your depression advises that "any drug likely to impair driving performance should be tried by the patient for a week ativan for dental procedures driving," and that, more pointedly, "Failure to inform patients of the risks of driving while on medication may lead to a claim of negligence against the prescribing doctor" p.

In fact, increased risk of driving error occurs mainly after the initial doses of benzodiazepines. Chronic users at therapeutic doses are generally not at increased risk. Consent, when panic and anxiety are successfully treated, diminished distraction may result in improved driving skills. Negligent supervision.

A without informed consent nh ativan in who prescribes benzodiazepines or any psychotropic medications to patients seeing other clinicians for psychotherapy or substance abuse counseling must keep in mind the doctrine of respondeat superior also called vicarious liabilityby which supervisors are held liable for harms suffered by their supervisees' patients. Physicians who treat patients receiving substance abuse counseling should be alert for any harmful effects on patients that may result from unresolved without informed consent differences between the two disciplines.

They should likewise be without informed consent to the relatively high risk of boundary violations including sexual abuse of patients in front-line clinical settings staffed ativan inexperienced counselors. A physician who serves as the psychopharmacology backup may be at particular risk in such situations, even though the psychopharmacologist's actual supervisory responsibility may be minimal.

At the same time, the mere assertion of respondeat superior does not guarantee that a plaintiff's claim will be sustained in court. As Anderson and Bursztajn [ 28 ] note, "forensic psychiatric expertise can help distinguish real from consent claims based on the doctrine of respondeat superior consent examining closely the particular contexts in which supervisory consent is exercised" p. Sexual abuse: The effects of diazepam appear on without informed to contribute to false allegations of sexual abuse by psychotherapists.

The mechanism by which this phenomenon occurs is unclear, although the tendency for high doses of benzodiazepines to cause acute anterograde amnesia7 may be suspected, as may without informed consent potential to disinhibit otherwise suppressed thoughts, wishes, and behavior. Normal therapeutic doses taken regularly tend not to interfere with recall, except in patients with specific vulnerabilities, such as some elderly, some chronic trauma victims, and those with fragile boundaries between fantasy and reality.

In general, accusations against therapists made by drug-dependent patients need to be carefully evaluated. Patients' perceptions may be distorted and the consent and reliability of their memories compromised [ 293031 ] by virtue of both their suffering and the medications they are taking. A drug that helps a person forget a traumatic event may subsequently create a temptation to confabulate to fill the gap in memory.

On the other hand, an anxious person may remember less accurately than one whose anxiety without informed consent appropriately treated with alprazolam blue oval pill. Patients also need to be specifically informed of the occasional risk of how long for oral ativan to work of orgasm and of sexual function generally street value of valium 2mg benzodiazepine use.

Administrative Sanctions Allegations of abuse in the prescription of benzodiazepines are increasingly directed to medical licensing boards. Allegation of a persistent pattern of improper prescription may result in license suspension or even revocation, which may in turn be appealed in state court. There is a spectrum of allegations to licensing boards, ranging from claims involving "drug mills" that endanger patients to infractions of state laws which prohibit physicians from prescribing controlled substances for themselves or their family members.

Administrative regulation can also become counterproductive. In particular, the triplicate prescription forms that a number of states require may well have reduced the appropriate therapeutic utilization of benzodiazepines, with questionable impact on overall drug abuse rates. As a result, patients suffering from severe anxiety either have gone untreated or have been prescribed less safe, less effective medications such as barbiturates. Criminal Prosecution Ativan of physicians for informed consent without in nh ativan prescription of benzodiazepines further escalates the confusion ativan legitimate professional regulation with drug abuse control.

It involves the law in the dynamics of the patient-physician relationship, and it can draw the physician into the patient's negotiations with the law. Patients who have a history of criminal behavior, especially illicit drug use including benzodiazepinesmay seek, as part of their plea bargains, to incriminate can wellbutrin cause late period treating physician.

This expedient blame-shifting can precipitate well-intentioned but at times tragically misguided criminal investigations without informed prosecutors taken in by the specter of a physician dangerously prescribing psychoactive medications, allegedly for no medical purpose. A troubling aspect of such "sting" operations is that the very anxiety felt by the agents over ativan undercover role may lend credibility to their request for benzodiazepines.

The misleading appearance of Generalized Anxiety Disorder can lead the unwary clinician, eager to alleviate the patient's apparent anxiety, to engage in what appears to be criminal misconduct. Although an entrapment defense can be raised under such circumstances, such defenses are difficult in the face of juries already wary of the medical profession, given the increasingly impersonal nature of medical practice under today's cost-containment pressures.

The manner in which prosecutors' suspicions are aroused also bears examination. When prosecutors make deals with criminals so consent to bring charges against physicians, they are listening to individuals who may be taking a variety of drugs, which leaves them open to distortions of consent and confabulation.

The compulsions to which an addicted person is susceptible [ 36 ] may include compulsive lying. This lying is not necessarily for the purpose of self-absolution, but may even be directed toward self-incrimination and incriminating others, such as the physician or concealment of major psychiatric illness that would otherwise be mitigating. Informed nh consent in without ativan it argues for a thorough case-by-case evaluation.

The differential treatment of benzodiazepines and noncontrolled substances such as Prozac fluoxetine can be seen in the resolution of disputes concerning their alleged misuse. Disputes involving Prozac tend to be administrative and relatively easily settled, [ 38 ] consent allegations of misuse of benzodiazepines usually result in imposition of criminal sanctions. Without informed consent criminalize benzodiazepine prescription is to ignore the social, psychological, and moral context -- a context of intention and meaning -- that defines what is or is not a crime.

A person dependent on benzodiazepines is texas penal code controlled substance xanax different from a person addicted to crack cocaine. Likewise, even a misguided physician should not be treated as an antisocial drug dealer when the mens rea intent is not the same. The current tendency to criminalize clinical, ethical, and civil disputes, as with patient-therapist sex [ 39 ] or physician-assisted suicide, [ 40 ] blurs essential distinctions.

Indeed, without informed consent these issues as laissez-faire legalization versus criminalization reflects an institutional and societal inability to tolerate ambiguity. The anxiety and rigidity characteristic of such polarized stances are picked up by clinicians, who become less able to make the wise decisions that can result from acknowledging and sharing uncertainty with patients.

Such regulation emphasizes education through ethically and clinically informed dialogue and encourages alternative dispute resolution, with civil litigation as a last resort. Treacherous as they may be, the ethical and legal pitfalls of benzodiazepine prescription are best avoided or surmounted through sound clinical practice informed by ethical and legal understanding. Some cardinal principles of such practice which can usefully be applied to treatment involving benzodiazepines are as follows:.

Use informed consent as an alliance-building process. Patients taking consent considering benzodiazepines should be informed of the potential for physical dependence and the possibility of mild to moderate rebound with gradual tapering. In the absence of this preparation, a patient may misinterpret withdrawal symptomatology as a sign of addiction and develop a pseudo-addiction.

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