Pharmacist in need of advice

[techniques]

A patient comes in with prescriptions for hydromorphone, alprazolam, carisoprodol (I also saw gabapentin on her profile) all from the same prescriber from a reputable pain management clinic. I told her I would not fill her scripts until I talked to her doctor/physician's assistant, which isn't possible since I'm staffed overnight.
I normally refuse all holy trinity scripts, but this is the first time I've see that combo prescribed from that clinic (we fill a ton of their other scripts and they do have a good reputation). After consulting the day staff, it turns out that that combo has been prescribed for other patients that use our pharmacy (different opioid/benzo but always with carisoprodol).
Is there any legitimate reason to be on that pain management regime? I'm thinking about calling them at some point during the day rather than dumping it off to the morning pharmacists. Any information would be much appreciated!

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[Timeoutofmind]

Could be weaning down the patient off that stuff inherited from a different provider

Often more to the story

Should just talk to the office directly

 

[drusso]

Is there any legitimate reason to be on that pain management regime?

I'm thinking about calling them at some point during the day rather than dumping it off to the morning pharmacists. Any information would be much appreciated!

No. Rarely a benzo and opioid (maybe for spasticity and other pain condition), but never Soma in the mix.

 

[hyperalgesia]

A patient comes in with prescriptions for hydromorphone, alprazolam, carisoprodol (I also saw gabapentin on her profile) all from the same prescriber from a reputable pain management clinic. I told her I would not fill her scripts until I talked to her doctor/physician's assistant, which isn't possible since I'm staffed overnight.
I normally refuse all holy trinity scripts, but this is the first time I've see that combo prescribed from that clinic (we fill a ton of their other scripts and they do have a good reputation). After consulting the day staff, it turns out that that combo has been prescribed for other patients that use our pharmacy (different opioid/benzo but always with carisoprodol).
Is there any legitimate reason to be on that pain management regime? I'm thinking about calling them at some point during the day rather than dumping it off to the morning pharmacists. Any information would be much appreciated!

When you think a cocktail is unsafe, I think you should refuse to fill until you confirm with the doc. And I would consider not carrying Soma altogether.

 

[techniques]

Could be weaning down the patient off that stuff inherited from a different provider

Often more to the story

Should just talk to the office directly

Same drugs/dose/frequency for years. It's been filled previously after documenting a diagnosis code for the narc because it was a month's supply but no documentation regarding the combo.

 

[techniques]

When you think a cocktail is unsafe, I think you should refuse to fill until you confirm with the doc. And I would consider not carrying Soma altogether.

I have no control over our inventory (I work retail). I would never fill any one of those scripts if I saw that the patient was on that combo (usually prescribed from different doctors). I've only ever seen that combo prescribed from the same physician once before and I'm pretty sure he's running a pill mill and does not specialize in pain management.

I was just curious from a pain management perspective if there was any legitimate reason to be on those meds, especially if another muscle relaxant hasn't been tried in the past. These scripts are coming from a reputable pain management clinic that we have a good relationship with the clinic and I don't want to start beef by telling them that I need more than a diagnosis code to dispense that combo.

 

[SeniorWrangler]

Carisoprodol can cause a nasty withdrawal syndrome if you stop it suddenly. Likewise alprazolam.
I certainly do not think it's a good idea to stay on all three of these medications at the same time, but I also think it might be reasonable to prescribe all three if you are tapering the patient off the opioids at the time. Context is everything.

 

[jsaul]

I have not prescribed soma since I was a resident over 15 years ago.

 

[techniques]

Carisoprodol can cause a nasty withdrawal syndrome if you stop it suddenly. Likewise alprazolam.
I certainly do not think it's a good idea to stay on all three of these medications at the same time, but I also think it might be reasonable to prescribe all three if you are tapering the patient off the opioids at the time. Context is everything.

Yes, I did take the benzo withdrawal into account and when I told the patient that the combo was dangerous she told me she just needed the narc filled (at 12:01 AM, the earliest available fill date of course).

I'm being extra cautious because my preceptor on rotations last year was being sued for malpractice (along with the prescribing physician) because a patient overdosed perc/xanax/soma.

Thank you all for your responses!

 

[hyperalgesia]

Yes, I did take the benzo withdrawal into account and when I told the patient that the combo was dangerous she told me she just needed the narc filled (at 12:01 AM, the earliest available fill date of course).

I'm being extra cautious because my preceptor on rotations last year was being sued for malpractice (along with the prescribing physician) because a patient overdosed perc/xanax/soma.

Thank you all for your responses!

Out of curiosity, do you guys have a consent for pts to sign, indicating they understand the risks? I haven't really seen this from pharmacy but it seems like it would go a long way with regard to malpractice risk.

 

[techniques]

Out of curiosity, do you guys have a consent for pts to sign, indicating they understand the risks? I haven't really seen this from pharmacy but it seems like it would go a long way with regard to malpractice risk.

Nothing other than consent to

Out of curiosity, do you guys have a consent for pts to sign, indicating they understand the risks? I haven't really seen this from pharmacy but it seems like it would go a long way with regard to malpractice risk.

They can either consent to or decline counseling at the register and I can manually document what was communicated, if they wanted to step over to the consultation window. But I don’t know how much weight that would have if someone were to OD on the holy trinity combo. In my limited experience, 100% of patients will decline to be counseled.

 

[101N]

Just out of curiosity, can/do you coprescribe naloxone?

 

[lobelsteve]

A patient comes in with prescriptions for hydromorphone, alprazolam, carisoprodol (I also saw gabapentin on her profile) all from the same prescriber from a reputable pain management clinic. I told her I would not fill her scripts until I talked to her doctor/physician's assistant, which isn't possible since I'm staffed overnight.
I normally refuse all holy trinity scripts, but this is the first time I've see that combo prescribed from that clinic (we fill a ton of their other scripts and they do have a good reputation). After consulting the day staff, it turns out that that combo has been prescribed for other patients that use our pharmacy (different opioid/benzo but always with carisoprodol).
Is there any legitimate reason to be on that pain management regime? I'm thinking about calling them at some point during the day rather than dumping it off to the morning pharmacists. Any information would be much appreciated!

Define reputable. Because that combo defines pills for shots.

 

[pmrmd]

What Steve said. I don't think a reputable pain clinic prescribes dilaudid, xanax, and soma together. To answer your question directly, there is no legitimate reason I can think of to be on that regimen.

 

[cowboydoc]

If you call with concern about that combo before despensing, the response will define whether they are "reputable." A "please fill, we are weaning from an inappropriate regimen..." vs. "STFU, how dare you question me" will tell you everything you need know. If the latter, they may divert patients from you, but you'd be better off.

 

[Doctodd]

If the pt has cancer and is end of life, anything goes

 

[Tapspatellas]

Only reason to rx soma is to wean off someone else’s mistake.

 

[oreosandsake]

I received a referral from an oncologist for a patient with stage 3-4 CA
fentanyl 75mcg/hr, percocet 10s, lorazepam, clonazepam, alprazolam

had the staff call the patient and explain to him I would not take over the prescriptions but he was welcome to come see me if he needed to. checked the PDMP and the same pain doc was Rx all of these for at least the past 12 months.

not sure how others would have handled this. if it's palliative, then let a palliative doc handle it...

he told my staff that he's been on benzos for over 30 years. btw, former heroin addict, alcoholic

 

[244913]

I received a referral from an oncologist for a patient with stage 3-4 CA
fentanyl 75mcg/hr, percocet 10s, lorazepam, clonazepam, alprazolam

had the staff call the patient and explain to him I would not take over the prescriptions but he was welcome to come see me if he needed to. checked the PDMP and the same pain doc was Rx all of these for at least the past 12 months.

not sure how others would have handled this. if it's palliative, then let a palliative doc handle it...

he told my staff that he's been on benzos for over 30 years. btw, former heroine addict, alcoholic

Tough situation. That's a very dangerous combination. Probably would send to pallative. They will do a better job then that pain doc, and at least if something bad happens it will be under their auspices

I know we tend to take our feet off the brakes for patients dying of cancer, but has anyone thought about this guy's quality of life? How good can it be in a high dose opioid fog and a primordial soup of benzos.

This is the one- and only one- population that makes me enthusiastic about IT therapy

Even tapering/rotating might improve the little time this guy has left

- ex 61N

 

[techniques]

"Reputable" in the sense that have offices across three states and make patients sign contracts before they write prescriptions and are denied if they break the stipulations of the contracts. Not so reputable I guesAlso a note about PMP. I've been telling the ER doctors to use both the middle name and the first name and their listed first name on a driver's license on a search. Hyphenated last names with both the hyphen, a space, or as one word. For some reason, it doesn't catch everything.

I filled a percocet script one night and took over for someone that called out sick at another store. My tech enter her script and checked her out the night before but I remembered the name only spelled differently on her drivers license (she's used a passport that night). Called the doctor and he had me rip up the script.

Anyway, thank you all so much for the insight, will not be filling Soma/opioid combo anymore unless they are being weaned off.

 

[oreosandsake]

"Reputable" in the sense that have offices across three states and make patients sign contracts before they write prescriptions and are denied if they break the stipulations of the contracts. Not so reputable I guesAlso a note about PMP. I've been telling the ER doctors to use both the middle name and the first name and their listed first name on a driver's license on a search. Hyphenated last names with both the hyphen, a space, or as one word. For some reason, it doesn't catch everything.

I filled a percocet script one night and took over for someone that called out sick at another store. My tech enter her script and checked her out the night before but I remembered the name only spelled differently on her drivers license (she's used a passport that night). Called the doctor and he had me rip up the script.

Anyway, thank you all so much for the insight, will not be filling Soma/opioid combo anymore unless they are being weaned off.

we're all in this together. it helps when everyone is on the same page. I always point to "big brother" and say that these recommendations are coming down from the holy hilltops...

so they dont come back to my office with weapons

 

[Kathy21078]

You have no clue at all about 24/7 pain.

 

[Blitz2006]

I received a referral from an oncologist for a patient with stage 3-4 CA
fentanyl 75mcg/hr, percocet 10s, lorazepam, clonazepam, alprazolam

had the staff call the patient and explain to him I would not take over the prescriptions but he was welcome to come see me if he needed to. checked the PDMP and the same pain doc was Rx all of these for at least the past 12 months.

not sure how others would have handled this. if it's palliative, then let a palliative doc handle it...

he told my staff that he's been on benzos for over 30 years. btw, former heroin addict, alcoholic

3 benzos?

Xanax just causes rebound anxiety. Klonopin covers you for q12h....so no need for ativan.

Just because a patient is "palliative" doesn't mean we should forget about good medical practice.

Benzo + Opioid is fine for a palliative care patient. But >1 benzo...?

 

[oreosandsake]

3 benzos?

Xanax just causes rebound anxiety. Klonopin covers you for q12h....so no need for ativan.

Just because a patient is "palliative" doesn't mean we should forget about good medical practice.

Benzo + Opioid is fine for a palliative care patient. But >1 benzo...?

I think the stage 4 CA is incidental and now a "reasonable" indication for having all the meds

former heroin and alcohol abuser

alcohol and benzos have similar effects on the brain

 

[Ducttape]

You have no clue at all about 24/7 pain.

We hear this ALL the time.

Which is why from here on out, we declare that no male can ever be a gynecologist or obstetrician, no female can ever be a urologist, and only diabetics can become endocrinologists.

Not including the fact that you can’t be a real oncologist until you get cancer....

(We may not have enough cardiologists or neurologists to go around...)