Benzos

[JordanP]

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I'm a new pharmacist...have worked 2 weeks now...and one thing that ive seen more than once is people getting more than one benzo at the same time month after month.

The profile looks like this...Lorazepam, Alprazolam, Temazepam....from the same doctor. Other pharmacists at my store are verifying it.

Should I be concerned? By pharmacy school standards this is unacceptable?

What should I do? I'm already freaking out because I verified one like this....hoping nothing will happen. I counseled the patient..she said her doctor has her on them for different reasons..she has epilepsy...but i didnt call and verify with the doc...

Any thoughts? Do you see this in practice? 😱

 

[spacecowgirl]

I see you are in FL...are you having the same issues down there as with opiates?

 

[charfdorn]

I'm a new pharmacist...have worked 2 weeks now...and one thing that ive seen more than once is people getting more than one benzo at the same time month after month.

The profile looks like this...Lorazepam, Alprazolam, Temazepam....from the same doctor. Other pharmacists at my store are verifying it.

Should I be concerned? By pharmacy school standards this is unacceptable?

What should I do? I'm already freaking out because I verified one like this....hoping nothing will happen. I counseled the patient..she said her doctor has her on them for different reasons..she has epilepsy...but i didnt call and verify with the doc...

Any thoughts? Do you see this in practice? 😱

Yeah, one for sleep, one for anxiety, one for diabetic neuropathy... I think physicians throw benzos at the patient until they're so relaxed they can't complain.

 

[Tenor CS]

Welcome to retail Pharmacy in South Florida.

I'm a tech in the Orlando area, (but I used to live in Miami) and a good portion of our scripts are for benzos. There are 2-3 docs that give out xanax like tic-tacs. He routinely writes for xanax 2mg 1t po tid. It's not fun to double-count 90 xanax all day.

The "pain clinics" often write for a combination of xanax/soma/oxycontin, but we have a TON of people with scripts from legit doctors on a combination of xanax/vicodin that gets refilled every month.

Our "fast movers" section is almost entirely painkillers and benzos.

 

[spacecowgirl]

I can maybe see one short acting and one long acting together, but that's about it. 3 different benzos? No way. I would call and document on that.

ETA: does FL have a PMP?

 

[ronkoshy]

...

 

[J ROD]

How about the habit forming concerns of long-term, scheduled use?

Personally, I try to keep them to PRN use and at the homes I service. From what I remember there is nobody on 3 benzos scheduled.

I would call on that.....

 

[Farcus]

LoL i don't think the doctor know wtf he's doing 3 benzos? ehhh lol that'll just permanently knock the patient out of any clue of wtf is going on so they don't real feel anything.

 

[oh no dont stop]

To go along with this topic, caregivers here write constantly for ARBs on top of ACEs....After about the 100th time I've seen it, I stopped worrying about it. I would never see this in my previous area of the country

 

[Ackj]

To go along with this topic, caregivers here write constantly for ARBs on top of ACEs....After about the 100th time I've seen it, I stopped worrying about it. I would never see this in my previous area of the country

We have 1-2 docs that do this. First time I saw it, i was like 😕 especially when I saw that it was that way for the past year.


About the benzos... probably not the best practice, but I guess if they're using one for different indications, it's somewhat legitimate. Probably should be consolidated, but if doc insists, what can you do?

 

[Praziquantel86]

To go along with this topic, caregivers here write constantly for ARBs on top of ACEs....After about the 100th time I've seen it, I stopped worrying about it. I would never see this in my previous area of the country

That's a different issue. For a while the going theory was that they would additive renal- and cardioprotective effects in diabetic/heart failure patients. One study supported this (with slightly higher rates of adverse events), but most of the others since then have found nothing other than more AEs. It is still (somewhat) up in the air though.

Multiple benzos are still a straight up therapeutic duplication. As others have said, the combination of a long-acting and short-acting product may be reasonable (think fentanyl patches plus Percocet for breakthrough pain), but anything more than that is overkill - either the physician has no idea what he's trying to do or something more "insidious" is going on.

 

[Pharmavixen]

To go along with this topic, caregivers here write constantly for ARBs on top of ACEs....After about the 100th time I've seen it, I stopped worrying about it. I would never see this in my previous area of the country

If patients were actually compliant with their meds, this could be a problem. It's really only indicated for pts with CKD & proteinuria. In others, there's the risk of elevated K+, hypotension & increasing serum creatinine without really any benefits.

Are you certain the caregivers know they are giving both of these at once? The drs I work with are great guys, but they aren't as diligent about reading the patients' charts as they could be.

 

[Pharmavixen]

How about the habit forming concerns of long-term, scheduled use?

The addictive potential of benzos is underestimated by many physicians. I can't count the number of times I've had drs tell me that clonazepam isn't addictive - an astonishing statement to those of us who work in addiction medicine.

Multiple benzos on a LT basis isn't evidence-based.

 

[VA Hopeful Dr]

The addictive potential of benzos is underestimated by many physicians. I can't count the number of times I've had drs tell me that clonazepam isn't addictive - an astonishing statement to those of us who work in addiction medicine.

Multiple benzos on a LT basis isn't evidence-based.

True, but most of us have seen enough patients with just awful agoraphobia that, once on xanax and often klonopin, are able to live reasonably normal lives. Often this does require long-term use. Its the art aspect of medicine.

That said, I've never gotten angry at a pharmacist who calls me to make sure that I actually meant to write for something like that. I like having you folks to keep an eye on my therapy plans to make sure everything is going OK.

 

[J ROD]

True, but most of us have seen enough patients with just awful agoraphobia that, once on xanax and often klonopin, are able to live reasonably normal lives. Often this does require long-term use. Its the art aspect of medicine.

That said, I've never gotten angry at a pharmacist who calls me to make sure that I actually meant to write for something like that. I like having you folks to keep an eye on my therapy plans to make sure everything is going OK.

Exactly....you treat the patient. 👍

 

[Pharmavixen]

True, but most of us have seen enough patients with just awful agoraphobia that, once on xanax and often klonopin, are able to live reasonably normal lives. Often this does require long-term use. Its the art aspect of medicine.

That said, I've never gotten angry at a pharmacist who calls me to make sure that I actually meant to write for something like that. I like having you folks to keep an eye on my therapy plans to make sure everything is going OK.

Fair enough - drs like you aren't the problem. But the use of LT benzos seems to massively exceed the incidence of anxiety disorders.

Have you tried starting the panic disorder pts on a combination of an SSRI or venlafaxine + the benzo, then slowly tapering the benzo? Anxiety disorders run in my family - the big complaint I hear about ongoing benzo tx is the cognitive impairment.

 

[type b pharmD]

Fair enough - drs like you aren't the problem. But the use of LT benzos seems to massively exceed the incidence of anxiety disorders.

Have you tried starting the panic disorder pts on a combination of an SSRI or venlafaxine + the benzo, then slowly tapering the benzo? Anxiety disorders run in my family - the big complaint I hear about ongoing benzo tx is the cognitive impairment.

does it? i thought these days like 30% of the population had an anxiety disorder 😱

 

[All4MyDaughter]

does it? i thought these days like 30% of the population had an anxiety disorder 😱

This site: http://www.nimh.nih.gov/health/publ...ntal-disorders-in-america/index.shtml#Anxiety says it's about 18%. But not every patient with an anxiety disorder needs medication (of any type) and certainly not every patient who requires medication needs to be on a BZD. They are not considered first line treatment for the long term management of anxiety disorders.

 

[type b pharmD]

This site: http://www.nimh.nih.gov/health/publ...ntal-disorders-in-america/index.shtml#Anxiety says it's about 18%. But not every patient with an anxiety disorder needs medication (of any type) and certainly not every patient who requires medication needs to be on a BZD. They are not considered first line treatment for the long term management of anxiety disorders.

agreed.

 

[Pharmavixen]

But not every patient with an anxiety disorder needs medication (of any type) and certainly not every patient who requires medication needs to be on a BZD. They are not considered first line treatment for the long term management of anxiety disorders.

Agreed - drug of choice for LT tx is an SSRI or venlafaxine. And of non-drug strategies, there's CBT. But where I live, the wait lists for CBT are long...

In my experience, people with anxiety disorders who also like to use their brains prefer not to take LT benzos, instead keeping them in reserve for especially triggering situations. Like flying, maybe.