Two months ago, you saw Rupesh Shetty, a 34-year-old nurse, to whom you prescribed fluoxetine to 20 mg daily and buspirone 5 mg po BID for anxiety. Today, Rupesh Shetty, his mom, and his life partner, Duncan, present for a follow up visit. You note that his chart indicates that his PCP prescribed him Xanax (alprazolam) 1 mg, three times a day as needed for anxiety.
Rupesh Follow Up Visit Transcript
Rupesh: This is my mom, Suma. She insisted on coming today. You know Indian Mums. She’s worried and wants to be sure I’m getting the best care, so I said sure, whatever, come along.
Suma: I am very worried about my Rup. He hasn’t been looking good.
Rupesh: I’ve tried to tell her that I’m doing ok as long as I take my medication, and I have been. Except, I haven’t been able to come in to work for the past three days because I ran out of my Xanax and I cannot even think about going to work without it. Tell them, Duncan, what it’s like.
Duncan: Yesterday, Rupesh couldn’t get through the day, so um, yeah, he took some of my mom’s Xanax yesterday—.
Suma: Did Rupesh tell you about his history of alcohol addiction? He’s been an alcoholic since he was in his early 20s. And did he tell you his dad also had problems with addiction? That’s not an addictive drug, is it?
Duncan: Addiction? Are you worried about addiction to this drug? Should we be worried? Rupesh are you addicted?
Duncan [agitated]: Did you know Rupesh is sometimes taking up to seven pills a day? At least that I know of. Is that overusing or addiction?
Rupesh almost starts crying: But, but, I can’t function without Xanax. Duncan, you know how hard nursing has been ever since I started 12-hour shifts. I love my job, but I just want to feel normal. And the Xanax makes me feel that way. Please…Xanax—it’s almost like a miracle drug and makes me so much more comfortable in uncomfortable situations, like at work and when dealing with people who can be very stressful. Without it my anxiety returns, like ten times worse. I used to feel euphoric and the pills relax my body. My doctor said the Xanax decreases abnormal brain activity, and has a calming effect on the body. Lately, yeah, I’ve taken probably more than seven pills a day. And I know it can sometimes cause mood changes, irritability, stomach problems and the worst part is when I take too much and become drowsy. I can never predict how Xanax will affect me but usually it just helps me function better.
Suma: Roop, that sounds terrible! I think you are addicted. Oh my goodness, what’s going to happen to your job? He’s a nurse!
After an extensive assessment of Rupesh, you conclude that he needs to be admitted inpatient because of his dependence on benzodiazepines. Rupesh is unwilling to go inpatient and asks you to just prescribe something to help him get off the alprazolam.
Explain to Rupesh, Duncan, and Suma the following:
- Why is it so important for Rupesh to go inpatient? What are the risks of detoxing off Xanax on his own?
- How does alprazolam work? What makes the medication so addictive?
- How do you answer Suma when she asks why anybody would prescribed alprazolam for Rupesh?
- Are there any special considerations for Rupesh because he is a registered nurse?
- What are the rules and regulations in your state of practice (Oklahoma) for impaired nurses?
- What resources are in your community for addiction? Are there any resources specifically for benzodiazepines?
