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By Leesa Scott-Morrow, Ph.D., J.D., LP

At this point, we all have four kinds of patients: Those whose are coping without much trouble, those whose coping mechanisms for COVID-19 anxiety are near failing, those whose coping mechanisms for COVID-19 anxiety have failed, and those who are utterly clueless. For persons in the first group, there is no reason to worry, and you likely know who these people are. For those in the second group, whose coping mechanisms are stretched, but still keeping them functional with residual patchy capacity for pleasurable distraction, you may be able to comfort them simply by telling them what your clinic is doing to ensure safe treatment. You all are probably already prepared to inform your patients of these measures, and you may be doing this routinely. That’s good. Continue doing that but be sure to give your patients the opportunity to ask questions about what you’ve told them. Answer their questions clearly, in some detail. Don’t joke around or try to make light of things. We are well beyond that. If your patient makes light of things, that gives you some license to respond in kind. But this is serious stuff, and it calls for a serious approach.

For those patients in the third group, whose coping mechanisms have failed, who cannot be comforted, it is appropriate to consider benzodiazepine. Perhaps you have used benzodiazepine, but not likely routinely.  It’s cliched to say that we are in a new normal, but we are, and that calls for some change in your routines such that you might use benzodiazepine more liberally.

If you choose to prescribe a benzodiazepine, there are things you need to keep in mind and discuss with your patient. You need to ask about drugs the patient is taking on a regular basis and be attentive to possible synergies or contraindications. Be aware, if the patient has an undisclosed problem with alcohol, serious trouble can ensue due to the synergy between alcohol and benzodiazepine. If the patient has an alcohol problem, but refrains from drinking on the day of treatment, their response to the benzodiazepine will be attenuated due to alcohol withdrawal. Xanax (alprazolam) is a short acting benzodiazepine that peaks in one to two hours with anxiolytic efficacy for three to five hours. Ativan (lorazepam) is somewhat longer acting; it peaks in approximately two hours, with anxiolysis lasting six to eight hours. Neither drug is safe to use in early pregnancy. Please keep in mind that your patient may need a driver if you choose to use a longer acting benzodiazepine. It would be wise to use a consent form that specifically addresses these issues.  The patient should sign the consent form to cover your malpractice exposure. Be aware that the benzodiazepines are problematic for many people in terms of addiction. Xanax is a drug that some people will go to great lengths to get hold of. Make sure you set limits around the use of these drugs. Tell your patient that you will only prescribe enough to get through the procedure, and only once.

So, here are the takeaways. If you are talking with a potential patient and they seem inconsolably fearful, understand that you will not likely be able to talk them down. In these cases, a sedating medication may be indicated. If you are willing to prescribe benzodiazepine, choose something fairly quick acting, and instruct the patient when to take it so that it peaks at an appropriate time. Understand that acute pain will make effective analgesia and sedation harder to achieve, but you already knew that. If you prescribe a benzodiazepine, you must be prepared to address the alcohol issue before you issue a prescription. Ask every patient for whom you are considering benzodiazepine how much they drink and how often. If red flags go up, listen to that still small voice telling you not to go there.  Your informed consent form should include a series of “I understand” statements. For example, “I understand that combining this medication with alcohol is dangerous; thus, I agree not to use alcohol within twelve hours of the procedure.” Include a statement along the lines of, “I understand that this medication will be prescribed one time, for this procedure only.” For your female patients, include a statement along the lines of, “There is no risk that I am pregnant.” Your informed consent needs to protect you, and in my opinion, addressing these issues is non-negotiable in that regard.

For the clueless group, be aware, these people remain clueless as a way of coping. Denial is a primitive coping mechanism, as we say in psychology. When people cope with denial, they are unteachable, and unreachable. That’s what makes denial a primitive coping mechanism: it shuts off higher order cognition. Denial prevents people from taking in information, no matter how cogently or convincingly it is delivered. Given that COVID-19 is transmitted by asymptomatic individuals, these people can be dangerous. They are resistant to wearing masks, and/or social distancing, as a part of their denial. It is entirely appropriate to ask your patients if they are typically wearing a mask or socializing in groups. Again, this calls out for a questionnaire that becomes a part of their record. Ask them when they last socialized within a group, even a small group of family members. Ask if the individuals there wore masks. Follow up any concerning answers with a little talk about your concerns. Actually, this conversation probably needs to happen with all your patients.  Your folks who are still coping, but fearful, will be comforted by the fact that you ask your patients these things.

I am certain you all are wondering what you might do if you find reason to worry about the risky behavior of a patient. You may feel that you cannot ethically deny them care. If you are seriously concerned about the risk the patient presents, and you can get them by a few days with antibiotic while you wait for viral molecular test results to come back, you might consider doing that. Of course, as you know, the antigen tests have very high error rates; they are quick, but they are imprecise. I am sure you all have given these issues considerable thought at this point, so I will leave you to consider whether it makes sense to offer benzodiazepine to your patients. If you go that direction, get your consent form ready first. Do not skip this step. Prepare your front desk to discuss the relevant issues to whatever level of specificity you desire; they will likely have to answer questions they are not accustomed to answering. Good luck. These are definitely trying times that justify approaching things in a way that may not have made sense a year ago.

Dr. Scott-Morrow recently held a position with Health Partners Interventional Pain Management in the Department of Neurosciences before beginning a private forensic practice, where she now devotes her professional time. Dr. Scott-Morrow regularly speaks on a national level regarding the management of medically complex patients who have significant psychological overlay.