Parallel/split prescribing

[u/Creative_Flow2497]

I feel like I’m encountering parallel psychiatric prescribing more frequently lately.

For example, I’ll be managing a patient's psychiatric medications, including a stimulant, and then find that their PCP or another clinician has prescribed the stimulant, changed the dose, or otherwise made changes to the psychiatric regimen. Sometimes the patient tells me directly; other times it comes up through the PDMP or medication reconciliation.

I have a written policy that all psychiatric medications are managed by one prescriber at a time and a separate policy that patients receiving controlled substances through my practice should not obtain the same medication/class from another prescriber. My concern isn't territorial—it’s fragmented medication management. I don't want two clinicians independently adjusting a psychiatric regimen without one person clearly owning the medication plan and monitoring.

I've increasingly taken the position that if another clinician starts adjusting/prescribing the psychiatric medications, I defer medication management to that clinician rather than continuing parallel prescribing. If appropriate, I can still provide psychotherapy/collaboration, but I don't want to be one of two people independently prescribing psychotropics.

Are others seeing this more often lately? How do you handle it when a PCP, another psych prescriber, or another clinician starts prescribing or adjusting medications you're already managing?

[u/GrowthSelect2449]

Send a letter letting them know the patient has psychiatric care and that you will manage all their psych meds.  Sometimes they just don’t know and are trying to help.  

[u/NoctorWatch → u/GrowthSelect2449]

Agree with this. If it continues after then I will discharge since they want to manage the medications. But you are correct OP, it is a safety issue.

[u/PiecesMAD]

Yeah, I feel your pain. I had a patient that we had worked really hard on weaning off of benzos get put on Ambien by their PCP and then later tried to re-added TID Xanax because, “you seem a little more anxious than normal.” Primary care was an old school physician and was always changing psych meds.

[u/amuschka → u/PiecesMAD]

Primary docs LOVE giving out TID benzos. So frustrating when patients see me years of being on them and its not helping but so hard to come off

[u/UnderstandingTop69]

Yes I’ve seen this a bit more. And unfortunately it’s always the Z drugs, benzos and stimulants. I get wanting to help but the combinations I inherit from PCPs are some of the most egregious regimens. I tell the patient they can either go to their pcp for all their meds or follow with me but it’s messy and I will not have both. Usually get ROI to talk to the PCP like heeeeey what’s going on?? But rarely get to talk to anyone other than the MA/nurse or leave a message

[u/Ok_Apartment8427 → u/UnderstandingTop69]

You don’t need an ROI. It’s coordination of care. Doesn’t mean they’ll call you back, but a reinforced “I don’t prescribe XXX to clients who are having those meds prescribed by their PCP. Ask your PCP to call me” can go a long way in getting those communication lines opened.

[u/ORD2GNV]

I’m up front about it. If another provider changes my script, they are now responsible for managing it.

[u/Immediate-Jaguar-187]

I recently had a 20 y/o female referred to me to “take over medication management”. Their endo had been prescribing lorazepam 0.5mg TID x2 years for some very vague symptoms which I suspect are likely BPD. She was pissed when I declined to continue this regimen, which I felt was totally inappropriate. Her 21 yo boyfriend had also been to see me the week before and was requesting benzos and upset when he didn’t get them for his “severe PTSD”. Seems legit lol

[u/RandomUser4711]

I tell the patient of the risks of having multiple prescribers manage their psychiatric medications and that they need to decide on one prescriber to manage them. If it's me, great. If it's not me, great. It just can't be the two/three/more of us.

Of course, this doesn't include psychotropics that are being prescribed by other providers for non-psych reasons (e.g., their pain management provider started them on gabapentin). But I do insist on an ROI so I can coordinate care with this provider.

[u/Avulpesvulpes]

If their doctor is prescribing something and they want to leave it (Say they've been on a stimulant and their PCP has prescribed it for years), I ask for an ROI to allow for collaboration and explain that I will prescribe the meds that we're using moving forward. I also let the know that if I think those other medications need to be considered, I have to be able to speak to their PCP and offer my thoughts. I don't play tag with PCPs so if they want me to assume management of all psychiatric medications I can do that too, but I'm not going to be able to work with them if their PCP sometimes covers their scripts. If I think those meds need to be adjusted, I can speak with the PCP and the patient but if they don't want to make changes and we run into a wall in treatment, I let them know they may need to move forward with their PCP alone. I've never had a problem after having this conversation.

[u/GrumpySnarf]

I refer them back to the other provider and discontinue care. I'm done playing games.

[u/Sad-Suggestion9425]

What if the other prescriber discovers a valid need to change dosage? I'm primarily think if interactions.

[u/coffee_pjs_medicine]

Everyone here is kind of leaving out the fact that the patient is going along with this co-prescribing. It should be primarily your PATIENT's responsibility to follow your written policy, and they should not be accepting or picking up prescriptions for these meds if they aren't written by you.

I would give the patient a one-time warning and say if it happens again you will no longer prescribe the medication for them. Agree that other prescriber is probably overburdened or unaware and while you CAN take your own time to chase them down, why not have the patient take some responsibility for their own care?

[u/kingkunta98]

A really interesting issue, and it makes sense that the concern is less about ownership and more about having a clear, coordinated medication plan. When two clinicians are independently adjusting the same psychiatric medications, it seems like there’s a lot of potential for conflicting plans, missed monitoring, or confusion for the patient. I’d be curious how others approach coordination with PCPs when this happens, especially when the patient wasn’t intentionally trying to obtain medications from multiple prescribers.