Holy trinity-would you put your name on this?

[pharmchica15]

Not a pharmacist, but I’ve been a tech for the past five years while completing my undergrad, and I’m starting med school this July.

While home for the summer, I was filling at my local (chain) store. At work today, I received a script for Vicodin 10. After looking at their recent fills, I noticed they were also getting morphine IR 30, klonopin 0.5, and soma 350 for the past several months. I pointed it out to my pic, and she said to just continue to fill as is.

Forces notes stated that pt had narcan, but I feel like that’s kind of like a bandaid for a bullet wound.

My home store/pic was always more conservative (no otc needles, dispensed very few buprenorphine containing products etc) and we refused our fair share of control scripts. In this case, I’m not sure if I’m just not used to seeing as many “concerning” combinations, or if it actually is an absurd combination.

Thoughts? TIA

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[pencilandpen]

off topic, but good for you for not going to pharmacy school lol. although is medicine getting more and more saturated too ?

 

[right500]

I have worked in hospice and know some "troubling" combinations are just what the patient needs. If they are from multiple prescribers that worries me more than all from a single provider (particularly if a pain specialist). If the system has a hard stop: note naloxone (unless specifically nasal spray, a pet peeve of mine) co-prescribing and patient (and even better caregiver/family/friend) counseled on use and that a single prescriber is overseeing each. It's all about documenting and checking for trends. Morphine IR 30mg q2h isn't for opioid-naive patients complaining of hangnail pain but fine in actively-dying cancer patients with years of therapeutic opioid use.

Hopefully the backlash to both opioids and benzo doesn't sink combos completely. Short-acting opioids and benzos with 24-hour max doses are completely appropriate together in many cases. I would be worried about COPDers, patients with repeated pnas, and vent weaners. Make sure patients with sub-clinical dementia/delirium have a support network to make sure they don't accidentally overdose but pharmacists can't do anything about that.

 

[Sine Cura]

In my area holy trinities are not just outside of standard of care, they are simply not being prescribed anymore, even by pain management. You can thank in part the opioid backlash. Only quack FPs and pill mills write for holy trinities anymore. Even Xanax 2 mg has now become taboo

 

[zelman]

What they’re on now is less important than what they were on before. I will fill a trinity combo for a patient who has failed other non-opioid pain therapies and at least two other muscle relaxants. I will not fill them as an initial therapy (regardless of how long they have been taking it already). Some lazy MDs will just write for opiate/bzd/soma because it makes patients feel better. I don’t doubt the effectiveness of the therapy. It’s simply very addictive and dangerous. We could just as easily start all pain patients on heroin and get similar results (“easily” being used somewhat tongue-in-cheek here).

 

[SoylentGreen]

I wouldn't fill it. If they die from a trinity you dispensed, where does that leave you?

 

[CetiAlphaFive]

Not a pharmacist, but I’ve been a tech for the past five years while completing my undergrad, and I’m starting med school this July.

While home for the summer, I was filling at my local (chain) store. At work today, I received a script for Vicodin 10. After looking at their recent fills, I noticed they were also getting morphine IR 30, klonopin 0.5, and soma 350 for the past several months. I pointed it out to my pic, and she said to just continue to fill as is.

Forces notes stated that pt had narcan, but I feel like that’s kind of like a bandaid for a bullet wound.

My home store/pic was always more conservative (no otc needles, dispensed very few buprenorphine containing products etc) and we refused our fair share of control scripts. In this case, I’m not sure if I’m just not used to seeing as many “concerning” combinations, or if it actually is an absurd combination.

Thoughts? TIA

Nope. There is never a legitimate reason to fill an opioid + benzo + Soma.
Never, outside of hospice and *maybe* onco heading towards hospice.

The pharmacists telling you that it's ok because a Fam Med MD is "monitoring" need to do CE.

Soma metabolizes to mepobramate, which activates the gate that causes respiratory depression, unlike benzos which simply modify the gate.

Soma seems fine if you don't really know anything about med chem or its metabolism.

It's also banned in Europe

 

[right500]

I was answering from the POV of hospice (both inpatient and at-home) and I agree Soma shouldn't be used but I pick my fights carefully. The Fam Med MD is irrelevant for the hospice meds unless they happen to work on the non-hospice side of the house. The single prescriber I had in mind in my comment was the hospice director or pain specialist consultant but an oncologist is a possibility. My concern is that the patient's outside oncologist had them on one or two of the meds and then the hospice director unknowingly completes the trinity. Inpatient monitoring is a whole different beast from "following" the patient in the community.

Basically, we are in agreement: the holy trinity is a recipe for apnea.

 

[projektreverb]

Personally, I wouldn’t fill it. No reason you should be legitimately getting this. unless you’re hospice or an onc patient that’s a goner.

 

[Dred Pirate]

My home store/pic was always more conservative (no otc needles, dispensed very few buprenorphine containing products etc) and we refused our fair share of control scripts. In this case, I’m not sure if I’m just not used to seeing as many “concerning” combinations, or if it actually is an absurd combination.

what the hell is wrong with OTC needles?

 

[CetiAlphaFive]

I pick my fights carefully. .

This is interesting. Why?

 

[CetiAlphaFive]

Also, filling it because the patient has been on it is like a drunk driver saying "I do this every weekend and I've never died yet!"

 

[zelman]

what the hell is wrong with OTC needles?

They might use them to inject heroin without getting HIV or Hepatitis. Then how will they learn?

 

[pharmchica15]

what the hell is wrong with OTC needles?

I worked at a store that was on a Big 10 campus (>30,000 undergrads), but it was an urban area so we got plenty of people who walked to our store. We were also located near a large bus station that had lots of layovers frequently. We used to sell otc needles, but the used needles would be found in the store/on shelves or the surrounding sidewalks near the store. It became a safety issue for not only FS employees but all patients/customers.

 

[pharmchica15]

And more info on pt/thread, pt was in mid 30s, and appeared to be on the same combo for the last year or so. So not to say that it can’t happen, but I think it’s unlikely that he has terminal cancer or is in need of hospice.

What would you do if you started working at store and realized the old pharmacists were dispensing? Would you flat out refuse the “long term” therapy or call to verify with doc before filling (or I guess not call and still dispense ). And I’m viewing this as it’s your new assigned store and you aren’t just floating.

Thanks everyone for your opinions! I realize that only working for one pic I really only get to learn their opinions and not to understand the whole picture. While I absolutely loved working for them, I agree that we probably could have been slightly more relaxed.

 

[zelman]

And more info on pt/thread, pt was in mid 30s, and appeared to be on the same combo for the last year or so. So not to say that it can’t happen, but I think it’s unlikely that he has terminal cancer or is in need of hospice.

What would you do if you started working at store and realized the old pharmacists were dispensing? Would you flat out refuse the “long term” therapy or call to verify with doc before filling (or I guess not call and still dispense ). And I’m viewing this as it’s your new assigned store and you aren’t just floating.

Thanks everyone for your opinions! I realize that only working for one pic I really only get to learn their opinions and not to understand the whole picture. While I absolutely loved working for them, I agree that we probably could have been slightly more relaxed.

I’ve been in this situation. I do not dispense without talking to the doc and getting them to agree to try a different muscle relaxant for the next fill (or verifying that they have tried them all...which is never the case). I don’t really care which BZD or opiate they use, but choosing Soma is so reckless and stupid in just about every case. I’d say 80% of patients are able to stop or change the Soma and the other 20% find a new pharmacy.

 

[CetiAlphaFive]

I’ve been in this situation. I do not dispense without talking to the doc and getting them to agree to try a different muscle relaxant for the next fill (or verifying that they have tried them all...which is never the case). I don’t really care which BZD or opiate they use, but choosing Soma is so reckless and stupid in just about every case. I’d say 80% of patients are able to stop or change the Soma and the other 20% find a new pharmacy.

Awesome post

 

[Dred Pirate]

I worked at a store that was on a Big 10 campus (>30,000 undergrads), but it was an urban area so we got plenty of people who walked to our store. We were also located near a large bus station that had lots of layovers frequently. We used to sell otc needles, but the used needles would be found in the store/on shelves or the surrounding sidewalks near the store. It became a safety issue for not only FS employees but all patients/customers.

Minnesota?

 

[Dred Pirate]

They might use them to inject heroin without getting HIV or Hepatitis. Then how will they learn?

exactly - this type of mentality just pisses me off.

I used to feel this way a bit, I had a guy who would always come through my drive thru (I worked night shift) with a jeep with skulls on the handle, all tatted up, with a mohawk - I knew he was an addict - buying 10 needles at a time. Then he came in, discharged from the local hospital with an insulin rx - I felt like a complete judgemental a-hole

 

[zelman]

exactly - this type of mentality just pisses me off.

I used to feel this way a bit, I had a guy who would always come through my drive thru (I worked night shift) with a jeep with skulls on the handle, all tatted up, with a mohawk - I knew he was an addict - buying 10 needles at a time. Then he came in, discharged from the local hospital with an insulin rx - I felt like a complete judgemental a-hole

Doesn’t even matter if they’re shooting up. If you denied them syringes and then a year later have to start filling their Harvoni Rx on Medicaid do you feel great about your taxes going to pay for your share of the $84,000 treatment? A few years after that fails do you feel double great about every Cellcept Rx they get and have dreams about how much their liver transplant cost taxpayers?

I’ve said it a million times: until someone finds an addict who says “I didn’t shoot up because I only had access to a used needle,” giving people clean syringes is in everyone’s best interest.

 

[SoylentGreen]

And more info on pt/thread, pt was in mid 30s, and appeared to be on the same combo for the last year or so. So not to say that it can’t happen, but I think it’s unlikely that he has terminal cancer or is in need of hospice.

What would you do if you started working at store and realized the old pharmacists were dispensing? Would you flat out refuse the “long term” therapy or call to verify with doc before filling (or I guess not call and still dispense ). And I’m viewing this as it’s your new assigned store and you aren’t just floating.

Thanks everyone for your opinions! I realize that only working for one pic I really only get to learn their opinions and not to understand the whole picture. While I absolutely loved working for them, I agree that we probably could have been slightly more relaxed.

I've been the old pharmacist in this scenario and the new pharmacists wouldn't fill it. They would give it to me or tell the pt to wait if I wasn't there. I did some research and decided they were right.

 

[APN-59 rph]

Narcs are cutting back a lot around here...The poultice wallopers are scared..and should be....The problem is..how do you back some old timer off when they have been using it for years..long term hospital ?

 

[CetiAlphaFive]

Narcs are cutting back a lot around here...The poultice wallopers are scared..and should be....The problem is..how do you back some old timer off when they have been using it for years..long term hospital ?

 

[beautifulrobot]

I worked at a store that was on a Big 10 campus (>30,000 undergrads), but it was an urban area so we got plenty of people who walked to our store. We were also located near a large bus station that had lots of layovers frequently. We used to sell otc needles, but the used needles would be found in the store/on shelves or the surrounding sidewalks near the store. It became a safety issue for not only FS employees but all patients/customers.

How many public sharps containers did the store have in the restrooms or in easily accessible areas around the store?

 

[owlegrad]

How many public sharps containers did the store have in the restrooms or in easily accessible areas around the store?

Not to mention the needles could just as easily been used for insulin rather than heroin.

 

[lgrw16]

what the hell is wrong with OTC needles?

I will never say no to/judge someone purchasing OTC needles. Even if they’re using them for illicit drugs, I’d rather them have a clean 35¢ needle instead of reusing or sharing. With the opioid epidemic, it’s not worth endangering the rest of the community – even those not using – with bloodborne pathogens.