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opioid dispensing

Discussion in 'Pharmacy' started by sosoo, Sep 10, 2017.

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  1. sosoo

    sosoo 7+ Year Member

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    please follow Express Script's lead to reduce opioid abuse and reduce poisoning your community and hospital ER. it is already at epidemic level! the physician provides the gun (scripts). the pharmacist provides the bullet (opioids). and the patients pull the trigger. understand that analogy and save your community. stop the recklessness in dispensing opioids!

    Express Scripts to limit opioids; doctors concerned
     
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  3. Unchained

    Unchained 5+ Year Member

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    I'm entirely with you on this. Most of the pharmacists I know still practice like it's 2005. Pharmacists are more worried about getting a complaint from an oxyzombie that they were rude and getting in trouble. The AMA always opposes any restriction on opioid prescribing no matter how small. I have to begrudgingly give CVS credit for their opioid controls. However they only did this after being fined 10's of Millions.
     
  4. Sine Cura

    Sine Cura 10 seconds or less 7+ Year Member

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    Express Scripts already imposes a 7 day supply maximum without PA and max 2 fills in 30 days (implemented July 1, 2017) for any short-acting opioid agonist regardless of previous paid claims for opioids with DS > 7, at least for managed Medicaid and Covered California (Obamacare in CA) plans (well, these are the only plans that I see that use ESI as the PBM).
     
    catalyzt likes this.
  5. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    Yes, let's make it harder for legitimate pain patients to get their medications, because of the few abusing it. The problem is, the abusers know how to game the system, they are always willing to pay cash, they are willing to self-harm to get pain meds from the ER, and they don't care if they break laws. On the other hand, legitimate pain patients, will not break laws, do not understand the system, have a hard time paying multiple co-pays since they aren't illegally selling half the drugs they get, and are the ones who suffer when more restrictions are made. There is a legitimate medical reason why the AMA imposes opoid limitations (let's face it, they could make more money by requiring the patient to make an appt every week with them to get their 7 day supply.) I agree with you, there is an drug epidemic in our country, the number of deaths from it is horrific--but most of those deaths are from heroin and other drugs which are already illegal. There aren't easy answers, but making things harder for legitimate pain patients is going to do nothing to help stop the drug epidemic.
     
  6. npage148

    npage148 Senior Member 10+ Year Member

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    Report after report come out confirming opiates poor efficacy on non-ca chronic pain, doctors inability to prescribe prudently and the probability of dependency after initial Opiate exposure. In my opinion we are not doing enough to handcuff patients, prescribers and dispensers.

    We can go down the road and say they help alleviate the pain of a difficult life and freely dispense while dealing with the social consequences or we can actually do things that are effective for chronic pain and limit their excessive use in acute pain.
     
    Carboxide and lord999 like this.
  7. sosoo

    sosoo 7+ Year Member

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    thats an incorrect assumption. epidemic is not endemic. its not a few.... flooding the ER with opioid overdose is not a few. a "librarian" in Philly administering naloxone on a daily basis is not "for the few abusing it."
     
  8. CetiAlphaFive

    CetiAlphaFive

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    This thread is as stupid as saying taking guns off the streets will solve violence in America.

    Chinese factories are pumping out fentanyl analogs at alarming rates, and I'd wager that the majority of counterfeit oxys on the street are now fentanyl.

    Furthermore, the sheer number of pharmacies getting burglarized and the vast quantities of CIIs stolen during these break ins is staggering.

    These guys are the reason librarians are giving people naloxone:

    Stop Houston Gangs - Report Gang Crime Tips & Violence - Texas Gangs

    Welcome to Texas.
     
    Last edited: Sep 11, 2017
    catalyzt and BidingMyTime like this.
  9. sosoo

    sosoo 7+ Year Member

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    as usual, this isn't about me. i put a link to express scripts, the largest pbm in the business. an industry leader. i don't see how u can say this is "coming from sosoo." when ppl are full of bias, they are blind...... // when people like Prince comes to Walgreens to get Fentanyl and died from overdose, what will u say to their family? you're sorry for killing him, and he's just a few bad apples? or are u gonna say, oh u thought he needed it because u thought he had cancer? any other excuses you're gonna give when they die from overdose?
     
    Last edited: Sep 11, 2017
  10. Dred Pirate

    Dred Pirate 2+ Year Member

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    There has to be a middle ground on this - you can't just take away oxy, but you also can't give it out like candy. Whatever happened to using your professional judgement? Most of us are capable of this - although from reading these boards (and the EM boards) I feel maybe enough of us aren't (or are afraid of the repercussions)
     
    BidingMyTime and lord999 like this.
  11. lord999

    lord999 Moderator Emeritus 10+ Year Member

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    Well, and they should be annoyed that district management routinely overrides even legitimate concerns, so "fill baby, fill" is a reasonable response to practice! This sounds horrible, but if you do ever get to really know your patient population and the prescribers, you know who your trouble patients are. I certainly did, and raised the appropriate objections for the paperwork's sake (including making written complaints to the Board of Medicine with supporting prescriptions), but who am I to stop someone committing legal gap suicide as there is no authority to stop them?

    I can say from repeated experience as one of those 2005 generation pharmacists that the AZ Board of Medicine/Osteopathic Examiners (separate Boards) are extremely lenient and won't take action unless it basically gets to the Arizona Republic (and even then, they just fire the current Board Executive Director and keep on covering their colleagues, I'd personally recommend problem physicians and osteopaths to get their license there as the likelihood of discipline is remote even for open screw-ups). Short of the prescriber himself or herself being openly taking the merchandise, they only act when a civil judgment is rendered against the practitioner. And patients who I had filled for got crossed off my list after a year or two. From my own mental lists of people I had openly suspected to be addicts at my old pharmacy, none of them that I filled for lived more than seven years, and most didn't make it two years. That's not even considering the one-time pharmacy shoppers who got a post-ER/post urgent care hit at the 24 hour pharmacy who are too incidental to remember. (And yes, if you do work in a pharmacy long enough and give remotely a damn about the people, you do actually learn your regulars, good and bad.)

    There's patients you can actually help, and those that you can "help." Opioid addicts are in the latter category unless you're part of an institution with coordination control over the prescribing and dispensing practices like VA. And even in places like mine, how would you know? There's little of an evidence basis for non-narcotic pain relief algorithm outside the "consensus panels" (remember the "5th vital sign" campaign). These practices swing as a pendulum between a permissive era (00 and the 70s) and hardcore control eras (80s, now). I'm now jaded as the trends keep going on a cyclical pattern. When enough of them die off like the 70s, then we'll go back to a more permissive era. This issue is not new and is not solvable given our lack of political will.

    So, if you wonder if I were in a position to know that a patient was basically dosing themselves to death with their drugs, what would I do? I'd go through the process but know that in the end, no one cares about that patient enough to stop the problem. If you are willing to, then great, but you can't afford to do that with everyone, so it's basically a personal decision on how much you care, professionalism does not have an answer to this.
     
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  12. Lnsean

    Lnsean 7+ Year Member

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    there are legitimate uses for these drugs so I don't advocate cutting off supply or blanket refusal. I've worked with a few rphs at WAGS that would refuse a 5 day supply of percocet 5 because the patient is new or has no history of pain meds. Turns out...they had a procedure done and went to all the Rite-Aids and CVS's in the area that told them it was out of stock. Pretty ridiculous to me how unprofessional some of you guys are in your practice (directed mainly to the people that are lying to their patients). I know i'm not the only pharmacy in the area that carries generic perc 5s.
     
  13. txpharmguy

    txpharmguy 7+ Year Member

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    Had an issue this weekend. Lady was prescribed Norco several days earlier (small Qty like 30 or something). Got an rx for Percocet (20 tabs) and Express Scripts wouldn't override (same doctor). Help desk said they can only get one short acting opiate every 7 days.
     
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  14. CetiAlphaFive

    CetiAlphaFive

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    You mentioned hospice patients.

    Why do you seem to think it's OK for hospice patients to overdose?

    Do you think their families will be ok on losing a few precious weeks or months?
    Do you think the board will say, "eh, they were gonna die anyway"?

    As with everything from you, this thread is a knee jerk guessing game, devoid of critical thinking and robust logic.

    Shifting gears:

    Let's say a patient comes in with an opioid Rx, diazepam tablets, and soma.

    You, the almighty arbiter of opioid control, refuse all three, no questions asked.

    Patient, with extensive history of seizures, has a grand male later and dies because their spouse opens the diazepam bottle to get a tablet to shove up the patient's butt and it's empty.

    You then get sued, and the spouse makes a complaint with the board.

    You have no documentation except deleted Rxs in the system.
    What do you think happens to you?
     
    Last edited: Sep 11, 2017
  15. Carboxide

    Carboxide 7+ Year Member

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    Nothing happens to you. You have the right to refuse to fill for any reason. The patient could have taken it somewhere else and chose not to.



    The state of Ohio just put in some new opioid Rx laws - max 30 morphine equivalents a day x 7 days for acute pain (which is like 4 percocet 5s), you can only go over this if you document a specific reason in the chart (and only MDs can do this, NP/PA are restricted to the limit no matter what). See more here:

    http://www.pharmacy.ohio.gov/Docume...ts on Prescription Opioids for Acute Pain.pdf

    (For those who didn't read the article - there are disease-state specific exceptions.)
     
    catalyzt likes this.
  16. lord999

    lord999 Moderator Emeritus 10+ Year Member

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    Not wanting to make an ad hominem attack (and it isn't), but Ohio is the same Board that let a pharmacist go to prison for involuntary manslaughter for a honest mistake, so I wouldn't necessarily take their Board word on it unless it is codified as a regulation (what you linked to is not law as it's not part of the statutory change). But I do agree with you, nothing if you refuse except for district management complaints. No one's going to know, and even if they do (see Joseph v. CRW), there is no requirement to take business as that is a practice right of ours as individuals (one of the very few).

    I don't suggest you decline for illegal reasons (you can't decline to fill because they are Asian, for example), but "I don't trust you and these are controls" is a legitimate one and has been defensible in the past especially without prior patient history. Also, the patient does not have documentation that they even tried it with you (as counsel will advise you), so having a memory problem is what you're going to do on the stand ("I can't recall..."), and even if they do, unless you're a critical access pharmacy (which no chain is), there is no compulsive argument to do anything for controls. If necessary, patient goes to hospital for a critical fill.

    If society wants to fix this, they have to take the decision making out of everyone's hands like Ohio apparently did in regulation. That causes suffering because of undertreatment, but that's the problem. Any judgment call, you have to implicitly accept that all possibilities can happen at all possible times.
     
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  17. CetiAlphaFive

    CetiAlphaFive

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    That is false in Texas.
    You must have a valid reason to refuse to fill a prescription.

    And, as we all know, if it's not documented, it didn't happen.
     
    catalyzt, RxVampire and BidingMyTime like this.
  18. sosoo

    sosoo 7+ Year Member

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    hospice patients has terminal illness. fatality is inevitable. the drugs will relieve their pain n suffering.. ppl like Prince are alive and well. fatality from drug overdose is not inevitable. u have to weigh the risks vs benefits. increasing the risk of death by overriding multiple DUR red flags for a person who doesn't have terminal illness is unethical in many ways.
     
  19. sosoo

    sosoo 7+ Year Member

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    this is a valid point to make. the concern is opioid abuse and overdose and deaths. the concern currently is not with benzos and muscle relaxant combo.. u can deny the opioid. only.
     
  20. Carboxide

    Carboxide 7+ Year Member

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    It actually is a new regulation. That was just the best link I found. It's brand new.
     
  21. Charcoales

    Charcoales 5+ Year Member

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    If they're not getting it early, it's from the same MD/clinic, they're not getting anything from other doctors, and the pdmp checks out... why send them away?
     
  22. CetiAlphaFive

    CetiAlphaFive

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    Fatality is inevitable for all of us.

    Why is a dangerous and potentially fatal dose ethical for a terminally ill patient?
    A lot of people come off hospice or stay on it much longer than expected.

    I think you're experiencing cognitive dissonance.
    Do they give hospice patients higher doses because it's OK for them to die, or are the doses higher because the pain level is higher?
     
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  23. doublehh03

    doublehh03 Senior Member 10+ Year Member

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    It's pretty sad. I know of a couple of pharmacies in my district that won't take in any new control scripts and would turn everyone away. I mean, it's not that hard to identify red flags and determine whether a particular script is legitimate or not. The bad ones, don't fill. The unsure ones, call the doctors and then make a decision. The good ones, fill.
     
  24. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    SOSOO, why did you like this guys post? Do you think it's cool that this lady has uncontrolled pain for several days based on an arbitrary insurance recommendation? Perhaps she could pay cash, but not everyone will be able to afford that, and they will have to suffer. It is beyond sadistic to think it's good to see sick people suffering in pain. I liked the comment because it is evidence of the hardship that these ill-thought out limits cause, but obviously that is not the reason you liked the comment.

    Actually, their IS concern with people taking these multiple classes of abusable drugs. THIS is actually a sign that the person is potentially abusing drugs, NOT the taking of a LA and a SA narcotic as you seem to think. Are you in your first year of pharmacy school? If so, then I hate to be too hard on you, most pharmacists will develop empathy and real world knowledge after a year or two. You will most likely look back on these threads in 10 years and laugh at your naivete.
     
  25. txpharmguy

    txpharmguy 7+ Year Member

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    We did fax MD to get prior authorization, but being a weekend and immediate need for medication, that wasn't practical
     
  26. sosoo

    sosoo 7+ Year Member

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    whenever i comment or post how they should decline the holy trinity combo or other more deadly combo, the ppl on this forum come out making excuses why they are legit and should not refuse sales. i'm glad express scripts are now taking the lead so i dont have to waste time arguing with these reckless individuals. // btw, i never said LA and SA opioids are potential abuse. im saying Fentanyl plus oxy combo is "deadly." the terms deadly and abuse are different. my concern is fatality and hospitalizations.
     
  27. Sine Cura

    Sine Cura 10 seconds or less 7+ Year Member

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    Real-world experience and empathy tend to be negatively correlated.

    We all know the short-acting opioid is always replenished every month, in full, like clockwork along with the long-acting. Unless they fail a drug screen. Then the compassionate mid-level will schedule more frequent visits to the pain clinic. $$$$$$$$$$$$$$$$$$$$$$
     
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  28. Dr Wario

    Dr Wario Hey you! Want to try this pill? 5+ Year Member

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    Why is it that all of the research on chronic opiate use is ignored? Time and time again, it is shown that chronic opiate use for non-cancer pain has very poor efficacy and massively high morbidity/mortality. For those of you who always fall back on the argument of "why do you want to see these people in pain, don't you care?" have really fallen into the trap of kicking the can down the road.

    If you were a parent and your child was addicted to cocaine and one day came to you to ask you for money to buy more because he/she does not have a job/is a loser, would you give them the money? Ok most people would say no to this, but how about the child that is just lazy, comes to you begging for money because they "need" a car to get to work, would you give it to them? Pain management is exactly the same thing, if there is a massive bump in the road (surgery, broken bone etc) give what is needed to get over that hump, but you don't keep feeding the problem a person's entire life until you have created an empty shell of a human being.
     
  29. lord999

    lord999 Moderator Emeritus 10+ Year Member

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    I'm not saying this because you're wrong, you're right. But you have to pick and choose your fights if you are going to remain in practice. As a prescriber, what are you going to do with a patient that you have your 15 minute CPT ratio that you have to clear? Sure, treat them with the standard factory algorithm, then ship the uncontrolled off to "pain specialists" who some of them blithely ignore the research for all the wrong reasons and all the right reasons together.

    The situation you define as a parent is one where there is a relationship beyond the transactional one between pharmacist and patient/customer. So, yes, you're supposed to intervene, not just because you're a pharmacist, but as a responsible parent, you have certain responsibilities. But which ones cause you to act in your child's case, your responsibility to the profession or patient, or your responsibility as a parent, or as a human being? All three can apply, so it's probably going to be heartless not to intervene.

    But, there's limits. For every felon in prison, they did have a mother and a father, and not all of those felons came from broken homes. Some of them came from people like you and me, and it's not always irresponsible parenting that causes it as well. You raise your children with the hope that they turn out to be respectable citizens, but implicit in the freedom of adulthood is a choice to go down the wrong roads. Yes, we do have the responsibility of doing what we can even to the point of self-harm, but there's such a situation as not salvageable.

    This pharmacy dean had a problem with this choice:
    Dad unfit for trial on charges of aiding fugitive killer son – Twin Cities

    Anoka County / Mother of fugitive will avoid jail – Twin Cities

    Doesn't matter how good you are, and it doesn't matter how bad your child is, there are conflicting expectations on what is the responsible conduct in these situations. In Larry and Dee Weaver's case, what does career success mean if your children don't become useful? What use are you to the people you care about if you sink all of your time in people who couldn't care less about you or anyone as that's what addiction is really about. Better than sex, and better than life, how are you really going to argue with that in the end? And while some are treatable, it should not be at the expense of your own well-being. You owe too many people that deserve your care more to overpriortize these patients.

    But patients? Sure, there is a responsibility to do the right thing for each patient. However, that does conflict with your greater responsibilities to make sure that your co-workers aren't stressed out due to you (think of the pharmacists who take forever to verify causing the rest of the staff to have to run around to make up for the slowpoke) and your responsibilities to your own sanity and relationships with people that are not transactional in nature, so you really have realistic limitations on what you can do for a patient clearly screwed by the system or by themselves.

    While trying to care, it's that choosing of if and when to intervene for actual effectiveness and results that separates new practitioners and midcareer. I am not a junior social worker, there are risks and benefits that you have to consider and the ability to have perspective on the ones that you want to fulfill gives the focus to do the best good. It's those who try to be all things to all people who tend to end up falling apart as the little things catch up with them.
     
    catalyzt likes this.
  30. quickpic007

    quickpic007

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    Does the texas board reprimand a lot on that statute/rule??

    I hear texas reprimands a ton on the mandatory consult, expired license etc... A real moneymaker !
     
  31. Abby Atwood

    Abby Atwood

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    Do you have safety data to point to for that particular opioid combination? I'm not trying to call you out if you've got nothing, but I am interested if there's something to it.
     
  32. sosoo

    sosoo 7+ Year Member

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    wow. a pharmacist actually asks me something like that. another reason i blame pharmacists for the opioid epidemic. such recklessness.
     
  33. Abby Atwood

    Abby Atwood

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    Can I take it that you don't have any specific data on oxycodone and fentanyl patches resulting in worse outcomes than an oxycodone ER + IR combination?* I sort of had a feeling that you were basing that statement on your gut vs a journal article. :)

    Addendum;
    *I should clarify that this is just an example. I'm interested in any data you have on worse outcomes on fentanyl patches vs other long acting opioids. I have found limited short term data showing similar outcomes, but nothing more.

    I'm not sure your background or expertise, but I'm always open to learn something.
     
    Last edited: Sep 12, 2017
  34. CetiAlphaFive

    CetiAlphaFive

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    Care to answer my previous question about hospice patients that you so conveniently ignored?
     
  35. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 7+ Year Member

    You have a good attitude but keep in mind this is the same guy who thinks that you need to be on death's door to deserve pain relief. I wouldn't put too much stock in what he says.

    I do think it's probably worth keeping in mind that you should never give fentanyl to opiate naive people. That is a major safety concern that I ran across frequently in retail. I used to have a great chart that showed how many morphine equivalents were required for what dose and how long the patient needed to have been on it.
     
  36. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    Your wishing something was true, doesn't make it true.
     
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  37. ChalupaBatman86

    ChalupaBatman86 2+ Year Member

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    I like the Larry Kudlow reference.


    Sent from my iPhone using SDN mobile
     
  38. txpharmguy

    txpharmguy 7+ Year Member

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    Another issue today: one for Norco for moderate pain and tramdol (I had to misspell since drug name is banned from SDN) for mild pain. Only when went through insurance, other rejected with plan limits exceeded. We filled the Norco. Docs are gonna get tired of this real quick
     
    BidingMyTime likes this.
  39. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    Why is tramadl banned on sdn
     
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  40. Charcoales

    Charcoales 5+ Year Member

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    Wut why would fentanyl (long acting patch, 72 hr duration) + a short acting med for breakthrough like oxy ir be a weird combo???
     
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  41. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    ???? Maybe cause it looks like how it would be filled in the fake pharmacy scam e-mails?
     
  42. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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  43. sosoo

    sosoo 7+ Year Member

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    i never heard of the word "weird" when describing opioids. fentanyl (10x stronger than oxy). when ppl "abuse" it, they use both together, at the same time. and that is a deadly combo. with oxy at a high dose, four times daily. fatality is just waiting to happen. / please do not ever think that they are using them responsibly. long acting, short acting? what the crap do they care? thats why theres increasing deaths and hospitalizations. the concern has always been around the opioid "abuse." not the "weirdness" of it.
     
    Last edited: Sep 14, 2017
  44. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 7+ Year Member

    I actually wasn't aware that word was banned on sdn and I'll look into it. I pretty much guarantee we were getting spam so we added it to the filter to prevent the spam.
     
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  45. PharmD500

    PharmD500 SDN Gold Donor Gold Donor

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    Lol. I just tried it and SDN said it was banned.
     
  46. Abby Atwood

    Abby Atwood

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    You need to look at the fentanyl dose. Fentanyl is much stronger than oxycodone, but the doses used are much smaller.

    You also should take a look at the oxycodone dose that is being used. Four times daily is a frequency not a dose, so it may or may not result in a high dose of oxycodone. I have seen some patients with low tolerance to opioids treated with 1/2 Percocet 5mg tablet four times daily as needed (not in combination with fentanyl obviously). Even though it's being taken up to four times daily, that's not a very high dose.
     
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  47. CetiAlphaFive

    CetiAlphaFive

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    What is the mortality rate?
    What's the mechanism of action for this supposedly fatal combination?
    What's the dose limit for the two combined?

    Do you have any papers to post regarding these two meds?
     
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  48. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 7+ Year Member

    So if fentanyl is 10x stronger than oxy, does that mean a 25mcg patch is equivalent to a 0.25 mg dose of oxycodone? I don't have my morphine equivalents chart in front of me but that doesn't seem right.

    Also does any educated person care about how potent it is? In the end isn't it the dose we care about not the potency?
     
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  49. zelman

    zelman 7+ Year Member

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    Duragesic patches' strength is in mcg/hr, so the 25mcg patch for 3 days would be 18 mg of oxycodone if the potency is 10 times greater. Which it isn't.
     
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  50. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    Once again Sosooooooo shows they are a 1st year pharmacy student with ALOT to learn.
     
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  51. sosoo

    sosoo 7+ Year Member

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    please read the express scripts article, and watch some tv news.
     

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