Opiods/Benzodiazepines Combination

[drakegrad2011]

We have been getting a lot of new patients trying fill the Norco/Xanax Combination. If the patient is not also getting a maintenance anxiety medication such as an SSRI, the pharmacists I work with and I will typically require documentation on failed treatment therapies and rationale for being on the combination. Most of the time we receive nothing more from the prescriber stating that "the patient has been on the Benzodiazepines forever and they can't tolerate anything else." Most of the time these patients take the prescriptions back to the their regular pharmacy, but it got me thinking what would happen if we refused to fill the combination and the patient would withdrawal from the BZD? Is the pharmacy liable for that? Just curious to hear your alls thoughts on this.

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[ldiot]

You aren't liable if they go into withdrawal lol.

 

[JustFillIt]

If you work in a busy retail pharmacy you will see that this combination is very common. Not something that I get involved with.

However, if a muscle relaxer is added to that combo I get a bit testy.

 

[Modest_anteater]

We have been getting a lot of new patients trying fill the Norco/Xanax Combination. If the patient is not also getting a maintenance anxiety medication such as an SSRI, the pharmacists I work with and I will typically require documentation on failed treatment therapies and rationale for being on the combination. Most of the time we receive nothing more from the prescriber stating that "the patient has been on the Benzodiazepines forever and they can't tolerate anything else." Most of the time these patients take the prescriptions back to the their regular pharmacy, but it got me thinking what would happen if we refused to fill the combination and the patient would withdrawal from the BZD? Is the pharmacy liable for that? Just curious to hear your alls thoughts on this.

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[zelman]

We have been getting a lot of new patients trying fill the Norco/Xanax Combination. If the patient is not also getting a maintenance anxiety medication such as an SSRI, the pharmacists I work with and I will typically require documentation on failed treatment therapies and rationale for being on the combination. Most of the time we receive nothing more from the prescriber stating that "the patient has been on the Benzodiazepines forever and they can't tolerate anything else." Most of the time these patients take the prescriptions back to the their regular pharmacy, but it got me thinking what would happen if we refused to fill the combination and the patient would withdrawal from the BZD? Is the pharmacy liable for that? Just curious to hear your alls thoughts on this.

SSRIs don’t treat all anxiety disorders. They treat generalized anxiety, not panic attacks. You should be asking for an indication first and foremost. An SSRI won’t help if they’re taking BZDs for epilepsy.

 

[Sine Cura]

Where's the responsibility of these ****ty prescribers? Xanax 2 this, Xanax 1 #120 that. Start multiple benzos and see what sticks or, why not, keep them on multiples forever.

 

[hye345]

It’s best dealt on a case by case basis. In a perfect world, this combo wouldn’t be used as often, but it is; just like combining simvastatin with amlodipine, or gemfibrozil. If you want to call on every single instance of this combo, you will be tied up on the phone forever. For me, the ones I try to call on/possibly refuse are triple or larger combinations (opioid/soma/benzo/tramadol/ambien), or if it’s a new rx for short-term use, on top of other regular ones: a common example is cough syrups w/codeine if patient is already on some combo of opioid/benzo/ambien. You gotta pick your battles.

 

[VA Hopeful Dr]

SSRIs don’t treat all anxiety disorders. They treat generalized anxiety, not panic attacks. You should be asking for an indication first and foremost. An SSRI won’t help if they’re taking BZDs for epilepsy.

False.

 

[sakigt]

We get people in the ER all the time from withdrawls. You can send them there.

 

[VictorOfHungerGames]

Oh the holy trinity lol

 

[JustFillIt]

False.

Look out guys we got Dr. Hairsplitter in the house.

 

[VA77]

Don't worry. When they get to the nursing home they will take away all these combos and let them suffer.

 

[CetiAlphaFive]

We have been getting a lot of new patients trying fill the Norco/Xanax Combination. If the patient is not also getting a maintenance anxiety medication such as an SSRI, the pharmacists I work with and I will typically require documentation on failed treatment therapies and rationale for being on the combination. Most of the time we receive nothing more from the prescriber stating that "the patient has been on the Benzodiazepines forever and they can't tolerate anything else." Most of the time these patients take the prescriptions back to the their regular pharmacy, but it got me thinking what would happen if we refused to fill the combination and the patient would withdrawal from the BZD? Is the pharmacy liable for that? Just curious to hear your alls thoughts on this.

No. You are not liable at all

 

[VA Hopeful Dr]

Look out guys we got Dr. Hairsplitter in the house.

?

 

[CetiAlphaFive]

?

Tbh there's probably a gap in my knowledge too.

I didn't realize SSRIs were able to treat panic attacks

 

[VA Hopeful Dr]

Tbh there's probably a gap in my knowledge too.

I didn't realize SSRIs were able to treat panic attacks

Evidence-based pharmacotherapy of panic disorder: an update

 

[Thoughtfulsinner]

Tbh there's probably a gap in my knowledge too.

I didn't realize SSRIs were able to treat panic attacks

Well, not acutely. Onset of effect is slow.

 

[CetiAlphaFive]

Evidence-based pharmacotherapy of panic disorder: an update

Ah, I think they (and I) were thinking of treating an attack as it happens, not the underlying disorder

 

[VA Hopeful Dr]

Ah, I think they (and I) were thinking of treating an attack as it happens, not the underlying disorder

Yeah not so much that as prevent them from happening in the first place

 

[JustFillIt]

Yeah not so much that as prevent them from happening in the first place

Good - well thanks for putting us on the right track.

 

[Laradd]

I would always ask for the reason they are on these medications. I sure wouldnt want to take benzos away from someone who is using them for epilepsy.

 

[CetiAlphaFive]

I would always ask for the reason they are on these medications. I sure wouldnt want to take benzos away from someone who is using them for epilepsy.

 

[eeyore spice]

Hey, if you don't like dispensing benzos, move to NY, where they're schedule 2 and prescribers seem to think they're more dangerous than clozapine.

And no one anywhere seems to understand that if a patient's been on an opioid and a benzo before and been fine, prescribing them the same drugs again will not suddenly kill them.

 

[CetiAlphaFive]

Hey, if you don't like dispensing benzos, move to NY, where they're schedule 2 and prescribers seem to think they're more dangerous than clozapine. And no one anywhere seems to understand that if a patient's been on an opioid and a benzo before and been fine, prescribing them the same drugs again will not suddenly kill them.

Can you elaborate on this post?

Do you believe that the thousands upon thousands of deaths involving Opioids + BZDs are all first time users?

 

[drakegrad2011]

Yeah, obviously if a patient is on one for seizures that is a different story. The majority we see, both meds are from there PCP and they don’t have the patient on an maintenance med not are willing to put them on one. Heck, I’d say even if the opioid is from pain management and the bzd is from a psychiatrist that looks a lot more legit as well.

 

[Thoughtfulsinner]

Can you elaborate on this post?

Do you believe that the thousands upon thousands of deaths involving Opioids + BZDs are all first time users?

Why would you be concerned unless there is a dosage change or evidence of abuse?

Do you think the patient is at risk if they have been on the same opioid/benzo combination/dosage for a year?

 

[CetiAlphaFive]

Why would you be concerned unless there is a dosage change or evidence of abuse?Do you think the patient is at risk if they have been on the same opioid/benzo combination/dosage for a year?

Are you under the impression that the majority of patients take opioids and bzd exactly as prescribed?

 

[Thoughtfulsinner]

Are you under the impression that the majority of patients take opioids and bzd exactly as prescribed?

Not a pharmacist's problem as long as you aren't filling them early.

You also moved the goalposts and didn't answer the hypothetical question.

 

[zelman]

Not a pharmacist's problem as long as you aren't filling them early.

You also moved the goalposts and didn't answer the hypothetical question.

“Not the pharmacist’s problem”? Is that the official DEA and civil liability stance? Or just your vocal-rectal proclaimation?

 

[Thoughtfulsinner]

“Not the pharmacist’s problem”? Is that the official DEA and civil liability stance? Or just your vocal-rectal proclaimation?

If you fill 20 Norco 10's for a patient and they decide to take the whole bottle and die, I assume you believe that's on the pharmacist for not confirming with the patient about his intentions?

 

[WorthlessOxygen]

Hey, if you don't like dispensing benzos, move to NY, where they're schedule 2 and prescribers seem to think they're more dangerous than clozapine.

Prescribers apparently have very different attitudes in my area of NY

 

[owlegrad]

Can you elaborate on this post?

Do you believe that the thousands upon thousands of deaths involving Opioids + BZDs are all first time users?

Aren't you aware that all interactions and side effects are seen immediately and that if it has been filled before that there is no danger in filling it again? "Time to adverse event" and monitoring over time are apparently useless concepts since you only have to survive the first dose to determine the amount of danger.

 

[zelman]

If you fill 20 Norco 10's for a patient and they decide to take the whole bottle and die, I assume you believe that's on the pharmacist for not confirming with the patient about his intentions?

You're Suing Me for What?

 

[CetiAlphaFive]

Not a pharmacist's problem as long as you aren't filling them early.
You also moved the goalposts and didn't answer the hypothetical question.

I didn't answer it because the answer should be readily apparent to anyone with a brain and an actual Pharm.D

Yes. They are still at risk.

 

[Thoughtfulsinner]

I didn't answer it because the answer should be readily apparent to anyone with a brain and an actual Pharm.D

Yes. They are still at risk.

Ding ding ding!

There is no telling what and when something will happen to a patient. You can document and counsel all you want, but this along with making sure these medications are not being filled early are the extent of what a pharmacist is able to do.

Which is why I decided to grab an MD.

 

[CetiAlphaFive]

Ding ding ding!

There is no telling what and when something will happen to a patient. You can document and counsel all you want, but this along with making sure these medications are not being filled early are the extent of what a pharmacist is able to do.

Which is why I decided to grab an MD.

Congrats on the extra semester of drug action

 

[Thoughtfulsinner]

Congrats on the extra semester of drug action

 

[hye345]

I didn't answer it because the answer should be readily apparent to anyone with a brain and an actual Pharm.D

Yes. They are still at risk.

It’s a question of degrees though. Yes, they can take them incorrectly and the family can sue you, just like they could if you dispense Benadryl for allergies while the patient is on Klonopin, You tell the patient not to take both at the same time, & not drive, yet he does anyway, falls asleep at the wheel, and gets in a car crash. Theoretically they can sue you, or anyone for that matter. But can they actually win? Doubtful, especially If the pharmacist has shown a consistent record of counseling on other similar situations.

 

[MARX22]

Hey, if you don't like dispensing benzos, move to NY, where they're schedule 2 and prescribers seem to think they're more dangerous than clozapine.

And no one anywhere seems to understand that if a patient's been on an opioid and a benzo before and been fine, prescribing them the same drugs again will not suddenly kill them.

Lol we get a lot of benzo and opioid combos in NY too. It’s treated as a CII in terms of not having any refills, but it’s still a CIV

 

[JustFillIt]

I love a good necro-post..

I get to look back and see how much of a dick I was.. Maybe my wife is right…

 

[allantois]

Tale as old as time..

 

[GrandTheftAutumn]

Love seeing the pretty faces of the axed members.
Wonder if the anteater guy is still living in his minivan.