When Inheriting a Patient Panel Means Inheriting Unsafe Prescribing
🚨 Part 1 of 4: The Xanax Trap
In primary care Facebook groups, a painful question keeps popping up, often from NPs who are new to their workplaces: "I just took over a panel and realized the previous doctor was prescribing chronic, long-term Xanax and complex psychiatric cocktails. I don't feel safe continuing this. How do I proceed without causing chaos or losing my job?"
If this is your reality, I want you to know two things immediately: You are not alone, and you are doing the right thing by stopping.
You didn't become a provider to function as a refill machine. You became one to provide safe, evidence-based care. The dilemma you face is a high-stakes clash between patient expectations and safe practice.
My Story: Standing on the Solid Ground of Safe Practice
Early in my career, I inherited the panel of a retired physician who, bless his heart, had not updated his prescribing habits in two decades. The result was a panel of patients on chronic opioids for non-cancer pain and long-term benzodiazepines for anxiety, prescribing that was now well outside the standard of care.
I quickly realized I had a choice: continue an unsafe practice out of fear, or stand my ground and face the music. I chose the latter, but it was an ordeal.
I faced angry patients who accused me of abandonment. I faced frustrated colleagues who thought I should "just go with the flow." My own medical director, who had implicitly endorsed the previous doctor's habits, was initially resistant.
The Two Non-Negotiable Moves I Made:
Refill & Refer: I gave a single, short-term refill and immediately referred the patient to a specialist (like pain management or psychiatry) to either manage a taper or continue the complex regimen. My license and training did not permit me to manage those complex conditions.
Redirect to Leadership: For the most clinically inappropriate cases, I transferred the care directly to my medical director. If they implicitly allowed the practice before, they could own the liability now. They were not happy with this, but it was their mess to clean up.
It was a battle, but here's the ultimate truth I learned: Prescribing is a privilege that can be revoked, and malpractice attorneys salivate at high-risk cases. I was affirming the patient's safety (and protecting my license) by sticking to my scope of practice and the standard of care.
Here’s What to Do If You’re in This Situation:
1. Protect Your License First: Set Clear Standards
You are not obligated to continue unsafe or non-evidence-based prescribing patterns. Continuing unsafe care is not quality care. It is 100% appropriate and necessary to set clear boundaries and standards.
Your Practice, Your Rules: It's professional to state clearly, "My practice follows current clinical guidelines for benzodiazepine use. For safety, I do not continue long-term Xanax unless we have a taper plan and appropriate behavioral health support."
Safety Over Satisfaction: You are not punishing the patient; you are practicing safe medicine. You are the one who is ultimately responsible for what you prescribe.
2. Start with a Chart Audit and Risk Assessment
You cannot fix all problems at once. Before their first visit, prioritize who needs the most urgent intervention by quickly reviewing the charts:
• The High-Risk Checklist:
• Length of time on benzodiazepines, opioids, stimulants, and/or hypnotics and dose/frequency.
• Any history of substance use, falls, overdose, or ED visits.
• Co-prescribing of other sedating medications (opioids, Gabapentin, Trazodone).
• Prior involvement of psychiatry or failed taper attempts.
This stratification helps you focus on the patients who need an immediate and firm boundary versus those who can transition more slowly.
3. Re-Establish Expectations (Don't Judge)
The first visit is critical. Your goal is to establish yourself as an ally, not an adversary.
Acknowledge and Validate: Tell patients you understand they have been managed this way for a long time.
Frame it as Safety: Stress that sudden discontinuation is dangerous and that your job is to follow evidence-based guidelines and keep them safe.
Collaborate on a Plan: You will work with them to create a safe taper or transition plan. Patients are far less reactive when they feel heard and not judged.
4. The Path Forward: Taper, Refer, and Document
This is the hardest part. You must be clear, kind, and consistent.
Taper Slowly: For chronic benzodiazepine, opioid, stimulant, or hypnotic users, gradual tapers (5-10% every 2–4 weeks) reduce panic, withdrawal, and mistrust. Stress flexibility, not a hard end date.
Redirect Complex Care: For patients on multiple agents, frame the redirection to psychiatry as a team-based approach: "I want to bring in a specialist so you’re getting the safest and most appropriate care for a complex regimen".
Document Everything: Document the patient's reaction, your clear taper plan, and that you offered behavioral health referrals, even if they refused. Boundaries are a clinical intervention; document them.
💡 Ready to Master Your Workflow and Reduce Your Risk?
If navigating high-risk panels, dealing with upset patients, and feeling unsupported by leadership has you overwhelmed, the issue is not your clinical skill; it's your need to have a defined workflow and professional boundaries.
Chart Smart Mastery provides the tactical blueprint you need to manage risk and protect your time:
Module 8: Inbox & Administrative Tasks: Learn strategies for delegating or deferring non-urgent patient messages and complex paperwork, so you can focus on high-risk clinical tasks.
Module 9: Charting for Quality & Compliance: Master medical-legal documentation by learning exactly what to document when patients refuse a taper, exhibit disruptive behavior, or threaten to leave. This module is your defense.
Your longevity in primary care depends on your ability to set and enforce professional boundaries.
👉 Free Trial of Chart Smart Mastery
Read This Whole Series:
Part 2: When Safe Practice Makes You The “Difficult” Provider
Part 3: Unsafe Prescribing is a System Problem, Not Just a Provider Problem
Part 4: How to Leave a Toxic Practice (or Survive It) with Your Professional Identity Intact
The Refill Request Message Master Kit is a targeted resource for primary care providers designed to streamline medication management. It provides pre-written, customizable templates and a comprehensive workflow guide to efficiently respond to, approve, or reject refill requests. Quickly communicate critical decisions, ensure patient safety with re-evaluation protocols, and reduce the time spent managing this high-volume, administrative task to reclaim your evenings and weekends.
