Ambien Case Study

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This is a 57-year-old female with 8/01/06 date of injury, due to a slip and fall.

Diagnosis: chronic pain syndrome primary OA-L ankle and foot, MDD, Single Episode and Generalized Anxiety disorder.

12/08/15 progress note by Mehtani documented that the claimant had been seeing Dr. Desai for a period of time. She has been on a complex medication regimen. The provider is trying to cut down the use of Klonopin and Ambien. The patient was told this was her last prescription. In the meantime, he will try her on Vistaril 25 mg 2-3 times a day for anxiety and panic attacks #90 and trazodone 50 mg at bedtime #30. She will stay on Geodon 80 mg at bedtime #30 and Lexapro 20 mg a day #30. The patient will be seen once a month for medication and psychotherapy.
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Additionally, pain specialists rarely, if ever, recommend Ambien for long-term use. While improved sleep was noted in this patient, chronic use of Ambien noted since 2011 has far exceeded the guideline recommendations. Moreover, Ambien can be addictive; it may impair function and memory more than opioid pain reliever; and it may increase pain and depression over the long-term. The provider indicated in the 12/08/15 progress note that he is trying to cut down the use of Klonopin and Ambien and the patient was told that this was her last prescription. The provider also mentioned in a phone conversation on 12/16/15 that zolpidem needed to be weaned and discontinued. Medical necessity of Ambien has not been substantiated. Recommend …show more content…
However, the effectiveness of hydroxyzine as an antianxiety agent for long term use, that is more than 4 months, has not been assessed by systematic clinical studies. Vistaril is medically necessary as the provider started this medication to wean the patient off from benzodiazepine, which has been accomplished. For further requests, documentation of functional improvement and weaning must be discussed as this medication is not recommended for long-term use. Recommend

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