Plan B - Overdosing?

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parabolic

parabolic

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A patient's profile shows that she has picked up Plan B ten times since late August (about once every four days). Each time is without a prescription.

The pharmacist flagged her profile for counseling the next time she tries to pick some up, but my question is --assuming she isn't giving it away to friends or hoarding it for future use-- what is happening to the patient's body? I don't think Plan B was ever meant to be used as a daily contraceptive, so what detrimental effects (if any) will it have for the patient? We were busy today, so I didn't want to pester our pharmacist with my curiosity.

Thanks.
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Welcome to America! If it's legal, someone will abuse it. That's why it's behind the counter. Honestly, I don't think it's the pharmacist's business, unless they solicit them for counseling.
 
I respectfully disagree; if a patient is repeatedly using Plan B the most appropriate thing to do is to talk to the patient and see what is going on. They are most likely due for a referral for a more reliable form of contraception at that point.
 
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it's expensive too! 45 bucks at my pharmacy. If they used it 10 times per month, thats 450+ dollars a month for birth control.
 
bananaface said:
I respectfully disagree; if a patient is repeatedly using Plan B the most appropriate thing to do is to talk to the patient and see what is going on. They are most likely due for a referral for a more reliable form of contraception at that point.
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Would you ask someone who keeps buying Claritin-D why they need the pseudophed instead of just buying something with phenylephrine? What about Tylenol PM? You know that they have a problem with sleep, but should you talk to them about it?

What if the customer doesn't want to see a gynecologist in order to get a BC prescription? It's an uncomfortable experience for some people. Personally, I don't like hormone therapies, because of their side effects. Therefore, I refuse to get that type of prescription filled.

When you're dealing with the public, there are some boundaries that just shouldn't be crossed.
 
While I agree that there's certainly the potential to discuss the pros and cons of Plan B being available without a prescription (and please discuss away!), does that mean that regular use of Plan B is not negatively impacting the patient? It seems like massive doses of hormones every few days cannot be a good idea. That was my original question.
 
parabolic said:
While I agree that there's certainly the potential to discuss the pros and cons of Plan B being available without a prescription (and please discuss away!), does that mean that regular use of Plan B is not negatively impacting the patient? It seems like massive doses of hormones every few days cannot be a good idea. That was my original question.
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Each Plan B tablet has 0.75mg of Levonorgestrel. I think they come in a pack of two, but please correct me if that's wrong!

Essentially, one tablet is not a "massive" dose when compared to the daily dose of 0.15mg in Tri-Levlen. Maybe they have a tablet splitter? If a single Plan B tablet is spread over 5 days, meaning that they don't take more than one-fifth of the tablet per day in a 5 day period, the amounts of the drug would be the same as if they had taken the contraceptive daily.
Hopefully they aren't taking both of the pills! If they are taking it as the package directs, that would be a "massive" dose if taken as often as it was being bought.

The patient could experience any of the side effects associated with Plan B.
If it were me, I'd be worried about the costumer experiencing blood clots and/or contracting STDs. If the costumer tried to buy cigarettes with Plan B, I would tell them, "cigarettes will increase your chance of having a blood clot while taking this medication"- but that would be all.

If they are acting within the law, I don't think they should be confronted about their purchasing habits.

This is where I got my information about the drug strengths:
http://www.go2planb.com/PDF/PlanBPI.pdf
http://www.wdxcyber.com/ncontr13.htm
 
PharmDstudent said:
Hopefully they aren't taking both of the pills! If they are taking it as the package directs, that would be a "massive" dose if taken as often as it was being bought.
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You would not confront the patient based on your assumption that they are not taking the medication as directed? Doesn't that seem like you're hoping that the patient is non-compliant with their medication? You're not supposed to make any assumptions in pharmacy- especially that they aren't taking their medication as directed. I think that IF you are going to make any assumptions in this case it is that the patient is taking the medication as directed by the package insert (which says to take the two pills 12 hours apart from each other)- in which case there could be a potential for overdose if they are doing it every 4 days.
 
VCU2011 said:
You would not confront the patient based on your assumption that they are not taking the medication as directed? Doesn't that seem like you're hoping that the patient is non-compliant with their medication?
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I said, "hopefully they aren't taking both of the pills". Wishing something to be a certain way is different from assuming it is that way.

VCU2011 said:
You're not supposed to make any assumptions in pharmacy- especially that they aren't taking their medication as directed. I think that IF you are going to make any assumptions in this case it is that the patient is taking the medication as directed by the package insert (which says to take the two pills 12 hours apart from each other)- in which case there could be a potential for overdose if they are doing it every 4 days.
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Don't forget that this medication is OTC! The customer is only directed by what the package says and not by a physician, therefore you have no way of knowing if they are taking it as they are suppose to- unless you confront the customer about it.

88my0l5s.jpg


When confronted, she could always lie to the pharmacist, which she probably will, unless she's purchasing it for some altruistic reason. Maybe she's passing it out at a shelter or something, who knows?

We know nothing about the situation other than that she is buying it approximately every four days, which is legal.
 
PharmDstudent said:
Would you ask someone who keeps buying Claritin-D why they need the pseudophed instead of just buying something with phenylephrine? What about Tylenol PM? You know that they have a problem with sleep, but should you talk to them about it?

What if the customer doesn't want to see a gynecologist in order to get a BC prescription? It's an uncomfortable experience for some people. Personally, I don't like hormone therapies, because of their side effects. Therefore, I refuse to get that type of prescription filled.

When you're dealing with the public, there are some boundaries that just shouldn't be crossed.
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I disagree with you. In pharmacy school we are taught to look for these kinds of overuse of medication. It would require simply speaking with the patient and seeing what's going on. For instance OTC sleep aids should not be used more than 2 weeks (as per the package). If someone is using an OTC med wrong (which MANY MANY people do without realizing it) then someone should talk with them. They might not even realize it, furthermore many people think since it's OTC then it's safe which is not the truth. There are also other things they can try like good sleep hygiene which the general public probably isn't aware of. It's our responsibility to be observant and our duty is to keep our patients safe.
 
PharmDstudent said:
Would you ask someone who keeps buying Claritin-D why they need the pseudophed instead of just buying something with phenylephrine? What about Tylenol PM? You know that they have a problem with sleep, but should you talk to them about it?

What if the customer doesn't want to see a gynecologist in order to get a BC prescription? It's an uncomfortable experience for some people. Personally, I don't like hormone therapies, because of their side effects. Therefore, I refuse to get that type of prescription filled.

When you're dealing with the public, there are some boundaries that just shouldn't be crossed...

Each Plan B tablet has 0.75mg of Levonorgestrel. I think they come in a pack of two, but please correct me if that's wrong!

Essentially, one tablet is not a "massive" dose when compared to the daily dose of 0.15mg in Tri-Levlen. Maybe they have a tablet splitter? If a single Plan B tablet is spread over 5 days, meaning that they don't take more than one-fifth of the tablet per day in a 5 day period, the amounts of the drug would be the same as if they had taken the contraceptive daily.
Hopefully they aren't taking both of the pills! If they are taking it as the package directs, that would be a "massive" dose if taken as often as it was being bought.

The patient could experience any of the side effects associated with Plan B.
If it were me, I'd be worried about the costumer experiencing blood clots and/or contracting STDs. If the costumer tried to buy cigarettes with Plan B, I would tell them, "cigarettes will increase your chance of having a blood clot while taking this medication"- but that would be all.

If they are acting within the law, I don't think they should be confronted about their purchasing habits.
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Pharmacists most certainly can question any patient. It's a part of our job to ensure safety.

Banana is 100% correct in her post. You seemed to assume that oral contraceptives is the only type of birth control there is...patients can also be counseled on proper use of condoms.

As far as your examples, again the correct answer is yes. If you honestly feel that they are going thru Claritan like its going out of style, you have a right to ask whats up. If someone is buying a ton of benedryl/tylenol PM for sleep, the pharmacist has the right to step in, and they should. It's so weird that you take the total hands off approach but yet you will say something about cigerettes. (and an insignificant one at that since thats not an immediate issue)

and for the record, no one has ever died taking Plan B, regardless if you took two or 200.
 
PharmDstudent said:
If they are acting within the law, I don't think they should be confronted about their purchasing habits.
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This statement exemplifies an ambivalence to the patient. Horrible attitude to have.

It's legal for me to buy 3 packs of Gravol every day from you, so therefore you should just smile as I see you day after day?

The idea behind being a Health Professional is taking a proactive stance in helping people with their health. Did you miss this day in P1?
 
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Requiem said:
This statement exemplifies an ambivalence to the patient. Horrible attitude to have.

It's legal for me to buy 3 packs of Gravol every day from you, so therefore you should just smile as I see you day after day?

The idea behind being a Health Professional is taking a proactive stance in helping people with their health. Did you miss this day in P1?
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I guess we should make every female take a pregnancy test before ringing up their alcohol. Maybe we shouldn't sell large bottles of acetaminophen, because of the potential for suicide by ingesting the entire contents of the bottle. How about the diphenhydromine liquid? Let's regulate that too, because it can be used to sedate unruly children.
🙄
The list could go on and on... Let's just pull all of the OTC products of the shelf and force people to get prescriptions for everything.

Pharmacists are not the OTC police. If the customers/patients have questions, we should be there for them. Otherwise, it's none of our business.

The only reason why I would comment about the cigarettes is because that risk is not on the Plan B package.
 
PharmDstudent said:
I guess we should make every female take a pregnancy test before ringing up their alcohol. Maybe we shouldn't sell large bottles of acetaminophen, because of the potential for suicide by ingesting the entire contents of the bottle. How about the diphenhydromine liquid? Let's regulate that too, because it can be used to sedate unruly children.
🙄
The list could go on and on... Let's just pull all of the OTC products of the shelf and force people to get prescriptions for everything.

Pharmacists are not the OTC police. If the customers/patients have questions, we should be there for them. Otherwise, it's none of our business.
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You're making straw man arguments by throwing out the "ask people buying alcohol if they're pregnant" comments.

It's very unfortunate you associate asking people about their medication habits with the police; when in fact it's your job as a pharmacist. It doesn't matter if its OTC. I didn't once say "Don't sell" or "regulate diphenhydramine". You know, maybe that person coming in for a pile of tylenol thinks that tylenol is the best thing to take for a hangover. Since he doesn't go up to you and ask, it's therefore not important why he is using the tylenol.

You have to differentiate getting into people's personal lives and acting as an educated person who has something to offer them in terms of information. Taking a back-seat approach to practice in general offers little benefit to patients.
 
PharmDstudent said:
I guess we should make every female take a pregnancy test before ringing up their alcohol. Maybe we shouldn't sell large bottles of acetaminophen, because of the potential for suicide by ingesting the entire contents of the bottle. How about the diphenhydromine liquid? Let's regulate that too, because it can be used to sedate unruly children.
🙄
The list could go on and on... Let's just pull all of the OTC products of the shelf and force people to get prescriptions for everything.

Pharmacists are not the OTC police. If the customers/patients have questions, we should be there for them. Otherwise, it's none of our business.

The only reason why I would comment about the cigarettes is because that risk is not on the Plan B package.
Click to expand...

whoa buddy, which phamacy school do you go to. In reality, phamacists ARE OTC police. If someone was to come in and get 100 boxes of 10 tablets each of sudafed, you bet you better call the cops on them. Its like cigarettes. If you suspect someone is selling to minors, you better tell them that its illegal or you are liable yourself.

Your arguement reminds me of the case where a pharmacist got sued because he dispensed medication to an alcoholic, causing death.
 
parabolic said:
-- what is happening to the patient's body? I don't think Plan B was ever meant to be used as a daily contraceptive, so what detrimental effects (if any) will it have for the patient? Thanks.
Click to expand...

Addressing the OP's original question I found some relevant info under Contraindications/Warnings in MicroMedex:

Precautions:
-not recommended for routine use as a contraceptive (oral)


Using Plan B routinely as a contraceptive is obviously not how it should be used, therefore the pharmacist should breech the subject. It should be done in a non-judgmental way that protects the privacy and dignity of the patient.

Someone said that taking 200 doses won't kill you, but I seriously doubt that that info is anything more than hot air. What a preposterous statement, can you back that up? It sounds like you're just assuming you can't overdose on it, but don't forget that even too much water can kill you. Don't make claims about not being able to overdose on a drug unless you have some data to support it.

As for Pharmacists being the OTC police, don't forget that liability is present whenever someone (ie. Pharmacist) financially benefits from the sale of any OTC drug. Check the end of chapter 4 of The Handbook of Nonprescription Drugs for a summary of liability issues, some of which directly pertain to OTC drugs.
 
As for the original topic, I think that the pharmacist on duty at the next pickup should definitely have a 1 on 1 with the woman. Not in an accusatory fashion, but maybe she doesn't know what her other options are. Maybe she doesn't have insurance and you can recommend a planned parenthood. Maybe she doesn't know that Plan B is not like regular birth control pills. Maybe she is a nurse at a doctor's office or something and keeps it on hand. If you don't ask, HOW WILL YOU KNOW?

Long term use of high doses (higher than regular OCs) should increase the risk for blood clots (since even regular OCs have this risk). I am assuming the risk is greater with long and frequent use. The data may or may not be there (I am lazy to do a search) and if it is not, it's because Plan B is intended to be a once in a while type thing, not a daily or twice weekly form of contraceptive.

As for the future hands-off, don't hold me liable, keep out of the customer's business pharmacist, If you are planning to work retail, it is your job to take care of patients. Often patients have no idea about the dangers of OTC products and it is up to us to be alert and offer friendly advise/suggestions. If I see someone pick up sudafed, you better bet I just do a quick "hey, you wouldn't happen to have high BP, would you?" or if they are buying the 1000 ct Advil, I might ask them what and how often they are using it and just slip in, "I just wanted to let you know to be cautious with these as they can be harmful to your stomach and kidneys when you use high doses or for a long time." Or maybe they are treating something with the wrong OTC or they have progressed to the point they need physician intervention. All these reasons are part of why retail pharmacists get paid 100K. We take care of people everyday, it is our job.
 
PharmDstudent said:
Would you ask someone who keeps buying Claritin-D why they need the pseudophed instead of just buying something with phenylephrine? What about Tylenol PM? You know that they have a problem with sleep, but should you talk to them about it?

What if the customer doesn't want to see a gynecologist in order to get a BC prescription? It's an uncomfortable experience for some people. Personally, I don't like hormone therapies, because of their side effects. Therefore, I refuse to get that type of prescription filled.

When you're dealing with the public, there are some boundaries that just shouldn't be crossed.
Click to expand...


Im sorry, but are 100% WRONG. you as a pharmacist are the last line of defense for the pt for any product they buy, even OTC. Thats what we are there for. and yes, i have talked to people about their OTC therapy such as claritin-d. Just because it is OTC doesn;t mean you shouldn't talk to the pt. And your tylenol PM example is a good example of your inexperience. Any little information you can extract from the pt will help you in recommending what the pt should do. If the pt refuses to speak with you well then ok. I had a man come in wanting to buy tylenol PM for his wife b/c she was having trouble sleeping at night. After asking him a few questions as check out turns out his wife was a pt at my pharmacy and was in extreme pain which was causing her not to sleep at night. After talking to him a little bit, i found out his wife wasn't taking her medicine correctly. I advised him how his wife should be taking the drugs and he glady put the tylenol PM back. So you see, you as a pharmacist have a duty to help any way possible. As far as boundries, i dont know what you mean there. there is nothing wrong with speaking to a pt about plan-b or other OTC.
 
I think everyone is worried about the customer harming herself. That is understandable. I don't want to see people hurt either, especially women and children. However, the reality is that people will do what they please. There is a point in time when we all neglect warnings and cautions, resist the advice of those who are more experienced than ourselves, harm our bodies directly or indirectly, etc. If the customer wants to buy 50 packages of Plan B, so be it. You can refuse to sell them to her, but that doesn't mean she can't get it somewhere else.

What if she takes the emergency contraceptive every four days? Then what? You tell her that it's bad for her and that she should see her health professional. Fine. But, have you really solved anything by informing her if she chooses to buy it again? No. Instead, perhaps you've satisfied yourself, because you know she's been informed.
 
PharmDstudent said:
I think everyone is worried about the customer harming herself. That is understandable. I don't want to see people hurt either, especially women and children. However, the reality is that people will do what they please. There is a point in time when we all neglect warnings and cautions, resist the advice of those who are more experienced than ourselves, harm our bodies directly or indirectly, etc. If the customer wants to buy 50 packages of Plan B, so be it. You can refuse to sell them to her, but that doesn't mean she can't get it somewhere else.

What if she takes the emergency contraceptive every four days? Then what? You tell her that it's bad for her and that she should see her health professional. Fine. But, have you really solved anything by informing her if she chooses to buy it again? No. Instead, perhaps you've satisfied yourself, because you know she's been informed.
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No, im concerned about your statement that its not a pharmacists business whats shes using it for or for that matter any OTC item. It is my business when i see a pt buying a product they may be overusing or i know they are taking medication that should not be used with OTC. That is a large part of our job. Just a suggestion and i dont want to be jugdmental because i dont know you, but you really need to think differently if your on your way to become a pharmacist. i must say that i have made differences in peoples lives by just walking over and just start talking to them w/o them asking.you have to pretend that the public doesn't know anything about what they are buying. anyway, goodluck.
 
Doctor M said:
No, im concerned about your statement that its not a pharmacists business whats shes using it for or for that matter any OTC item. It is my business when i see a pt buying a product they may be overusing or i know they are taking medication that should not be used with OTC. That is a large part of our job. Just a suggestion and i dont want to be jugdmental because i dont know you, but you really need to think differently if your on your way to become a pharmacist. i must say that i have made differences in peoples lives by just walking over and just start talking to them w/o them asking.you have to pretend that the public doesn't know anything about what they are buying. anyway, goodluck.
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I hope I never go to your pharmacy!
 
PharmDstudent said:
I hope I never go to your pharmacy!
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And i hope no one i care about goes to yours! You can't just take the attitude that people will do whatever they want so you're not going to give out advice.
 
Has anyone ever heard of consent? Unsolicited advice is wrong!
 
I have made my peace with this thread. I will no longer post here.
 
PharmDstudent said:
I hope I never go to your pharmacy!
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I take your statement very lightly and understand that you have not experienced much yet in the retail setting as a pharmacist. For me, it has nothing to do with the "liabilty" or that i have "warned" the pt and it is of "my back". anyway, i have many patients return to me for advice after consulting with them even when they never asked for it. Again, i dont intrude in their privacy, but i do state it in a way so as not to sound intrusive. Good luck on your journey to becoming a pharmacist😉
 
Doctor M said:
I take your statement very lightly and understand that you have not experienced much yet in the retail setting as a pharmacist. For me, it has nothing to do with the "liabilty" or that i have "warned" the pt and it is of "my back". anyway, i have many patients return to me for advice after consulting with them even when they never asked for it. Again, i dont intrude in their privacy, but i do state it in a way so as not to sound intrusive. Good luck on your journey to becoming a pharmacist😉
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damn Dr. M...you just blew your chance for some nookie with pharmdstudent!

It was starting to look like you were THIS close to getting some...I hope you have something else to look forward to after your 15 hours day! :laugh:
 
Caverject said:
damn Dr. M...you just blew your chance for some nookie with pharmdstudent!

It was starting to look like you were THIS close to getting some...I hope you have something else to look forward to after your 15 hours day! :laugh:
Click to expand...

15 hours? not a chance. And for your info, i lit my cigarette a few hours ago...😉
 
JerryPharmD said:
Question: What is the cost of each Plan B for this particular patient?
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This is a completely different issue, but for the particular patient in question, the cost is $0 (it is covered by state aid). The cost of Plan B without insurance at my pharmacy is $41.99 per box.
 
parabolic said:
This is a completely different issue, but for the particular patient in question, the cost is $0 (it is covered by state aid). The cost of Plan B without insurance at my pharmacy is $41.99 per box.
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Ohhh...the plot thickens. My first reaction was to say I don't want my tax money to go to that, but then I thought about it. :idea: I'll let you all come to your own conclusions.

Out of curiosity, if this patient were to take regular birth control pills would the state pay for it? This could be a possible loop-hole in the system.
 
fenixtnlfan said:
Ohhh...the plot thickens. My first reaction was to say I don't want my tax money to go to that, but then I thought about it. :idea: I'll let you all come to your own conclusions.

Out of curiosity, if this patient were to take regular birth control pills would the state pay for it? This could be a possible loop-hole in the system.
Click to expand...

state programs do pay for birth control. mostly generics
 
parabolic said:
This is a completely different issue, but for the particular patient in question, the cost is $0 (it is covered by state aid). The cost of Plan B without insurance at my pharmacy is $41.99 per box.
Click to expand...

Based on this, my guess is that she is distributing it among her friends/associates. I do not imagine that someone would want to take the emergency contraceptive 10 times, based upon the possible nausea and abdominal pain that go along with it.

Another issue is the doctor that writes for a Plan B with 12/PRN refills (which I imagine is necessary for her insurance to cover it). Just another great day in America🙄
 
JerryPharmD said:
Another issue is the doctor that writes for a Plan B with 12/PRN refills (which I imagine is necessary for her insurance to cover it). Just another great day in America🙄
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So what? Research indicates its better to keep plan B at home before it happens than trying to go find it after the fact.
 
Caverject said:
So what? Research indicates its better to keep plan B at home before it happens than trying to go find it after the fact.
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👍 Better to have it than not at all. Look at it this way - it gives you many,many opportunities for counseling.

Plan B doesn't protect against stds. You can talk about HPV, stds, more reliable & predictable forms of contraception and she is giving you a reason to do so!
 
Caverject said:
So what? Research indicates its better to keep plan B at home before it happens than trying to go find it after the fact.
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exactly. I hear classmates discuss (very disrespectfully) patients who have a Rx for Plan B on file, and particularly with refills.

I was in the Gardasil trial. When PlanB first came out as a Rx my nurse practitioner at the study asked me if I wanted a rx for it. I appreciated her offer and she told me she was doing them for patients with 3 refills just in case. But she was also one of those fantastic practitioners whose "emergency" number on her business card was her actual home number.

In all reality the whole Plan B stigma thing is basically people trying to regulate when people can have sex. Of course regular birth control would be better (she's obviously not afraid of hormonal intervention) from the consistency standpoint but we don't know her story.

Things like this are why I'm getting in with Planned Parenthood. I'm young enough that almost anyone will talk to me about such things and preventative women's health is a big issue for me.

When we did OCPs in Therapeutics the prof mentioned a program in Washington state where Pharmacists can prescribe OCPs for up to 2 years for patients? I'm not sure of the entire context, has anyone else heard this? She said a big point was for girls who take it for acne, so they don't need a pelvic exam, but I also think most GPs are more than willing to write for it for acne.
 
njac said:
exactly. I hear classmates discuss (very disrespectfully) patients who have a Rx for Plan B on file, and particularly with refills.

I was in the Gardasil trial. When PlanB first came out as a Rx my nurse practitioner at the study asked me if I wanted a rx for it. I appreciated her offer and she told me she was doing them for patients with 3 refills just in case. But she was also one of those fantastic practitioners whose "emergency" number on her business card was her actual home number.

In all reality the whole Plan B stigma thing is basically people trying to regulate when people can have sex. Of course regular birth control would be better (she's obviously not afraid of hormonal intervention) from the consistency standpoint but we don't know her story.

Things like this are why I'm getting in with Planned Parenthood. I'm young enough that almost anyone will talk to me about such things and preventative women's health is a big issue for me.

When we did OCPs in Therapeutics the prof mentioned a program in Washington state where Pharmacists can prescribe OCPs for up to 2 years for patients? I'm not sure of the entire context, has anyone else heard this? She said a big point was for girls who take it for acne, so they don't need a pelvic exam, but I also think most GPs are more than willing to write for it for acne.
Click to expand...


Are you serious?
 
My issue with Plan B with refills is that Plan B is designed for emergency use. If you are having that many "emergencies" that often then you are very irresponsible. I have no problem with people having sex whenever they feel like it but there is responsibility involved. Using plan B alot demonstrates lack of responsibility. If you're gonna be getting it alot, then get some real protection. I'd much rather take 99% effective with other methods versus ~85% with Plan B. Condoms only slip and break so often but drunken 1 night stands after the bar happen every weekend
 
npage148 said:
My issue with Plan B with refills is that Plan B is designed for emergency use. If you are having that many "emergencies" that often then you are very irresponsible. Using plan B alot demonstrates lack of responsibility. If you're gonna be getting it alot, then get some real protection.
Click to expand...

wow...I think you have a lot more issues than just Plan B. It's nice to know that you are an unassuming soon to be health care provider.
 
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