PH5.

5 Demonstrate an understanding of the caution in prescribing drugs likely to produce

dependence and recommend the line of management.

CASE SCENARIO

A 50-year-old woman presents for evaluation for anxiety and sleep problems. She has a long history of
periodic anxiety attacks. She has been prescribed alprazolam for 30 days for anxiety and sleep problems.
She describes episodes of shaking and dyspnea with anxiety lasting for about an hour several times per
day for which she would take alprazolam. For the past days she had crying spells, decreased appetite, and
weight loss. She has gradually been increasing the amount of alprazolam. She admits to taking more
alprazolam than prescribed. She wants to stop alprazolam because it has been causing memory problems
(blackouts) and her physicians have expressed concern about her overuse. However, she feels she needs it
and wants something to help her anxiety symptoms and her insomnia. She denies abusing illicit drugs or
alcohol. She denies suicidal ideation. She is widowed and lives alone, and she has poor coping skills and
limited social support.

Case Scenario Narrative:

Patient: Good morning Doctor

Doctor: Good morning,

Patient: I’m really tensed about my health condition, I’m not getting proper sleep without tablets

Doctor: Relax please what tablet you are taking, explain your problem

Patient: I was prescribed Tab.Alprazolam 0.5 mg for 30 days initially, I was comfortable, and my
symptoms got relieved. Then my physician advised me to taper the dose.

Doctor: Good, as these drugs cause dependence it has to be tapered and to be stopped.

Patient: I also discussed with my relatives and friends, I frequently increase my doses by own without
advise, help me out. At present my major concern is lack of sleep.

Doctor: Don’t worry your problem can be addressed.

There are certain groups of drugs which help in inducing sleep without producing dependence; the drugs
to be taken under proper advice, doses should not be altered. I also suggest you few investigations and
Psychological counseling.

Patient: Thanks Doctor, I will follow your advice. Will these drugs cause any side effects?
Doctor: All drugs cause side effects, so that only I advise you to go for counseling, life style
modifications, and proper diet.
You should understand for lack of sleep drugs are not prescribed as first line, life style
modifications, counseling, yoga and other exercises are advised. As you are already on drugs I’m
prescribing low dose safer drugs with low possibility of developing dependence, I will prescribe Tab.
Zolpidem 5mg to be taken at night time which also helps to relieve your anxiety.

Patient: Ok doctor can you explain me, how the drugs does not produce dependence.

Doctor: In comparison to Alprazolam, Zolpidem produces fewer withdrawal symptoms and therefore
does not produce too much of dependence. Also it has advantages of causing minimal residual day time
sedation, no or little rebound insomnia on discontinuation. However it has few side effects like headache
and dizziness.

We will consider your concomitant medications and comorbidities. Lifestyle modifications and sleep
hygiene needs to be followed and drugs need to be taken at the right time in the prescribed dose. Drugs
should not be withdrawn/ stopped without tapering the dose.

Drugs to be taken only for the prescribed days and the dose or duration should not be escalated without
proper advice. Regular visits to be made.

Patient: Thanks Doctor I will follow your advice and come for regular follow up.

Doctor: Good, have a good day.

Doctor: So before you can leave did you understand completely about the medications and can you repeat
all that I told you about the medications. (The doctor confirms the patient has understood all aspects and
suggests corrections if needed)

And thanked the patient