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Discussion in 'Pharmacy' started by Deja, Sep 6, 2017.
you guys ever heard of adding zolpidem pen to lunesta daily?
"Zolpidem pen" = zolpidem prn?
But no, I have not personally seen the simultaneous use of both, at least via prescription. What dose of each?
I have seen it, pt and prescriber claimed they have two different insomnia types and don't take them together... I said ok fine, I will fill 30 tabs of each for a 60 days supply since u don't take them together... pt said no and took it somewhere else lol
I think it's a new special Appleby's.
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...Two different insomnia types? WTF does that mean?
Dumb dumb dumb. Good call on your solution, I like that.
Overall, it seems like an inappropriate duplication of therapy, and is not something that is supported by ASSM clinical guidelines or any other guidelines I am aware of. But since refractory insomnia can literally drive people mad, I've seen lots of last ditch efforts, like prescribing a z-drug + a benzo. I don't recall ever signing off on dual z-drug therapy specifically, but it's not that much different from combining a z-drug with a benzo, and I definitely have seen that (granted, it's a bit more excusable, since benzos have other indications besides insomnia, but still). It's a tough call, and I don't think it's wrong to refuse to fill both, and I would definitely want to have a conversation with the provider (and document it) if I was considering filling both.
I can't imagine any pharmaceutical advantage to prescribing both. If the prescriber means by "different insomnia types" that the person both can't fall asleep and also can't stay asleep, there are better ways of dealing with that then giving zolpidem and lunesta. I can't believe any insurance would pay for both of those either. Then again, if someone wants to abuse drugs, they probably aren't looking at mixing zolpidem and Lunesta as their first choice either, so maybe Giga is right, and it's just a "nothing else has worked, so we'll try this" approach from the doctor. I still frown on it, more of the same often doesn't work, and just gives increased side effects.
A better way would be to figure out if there is something else causing the insomnia, like pain, anxiety, urinary frequency, etc. and deal with that.
What kind of conversation do you expect to have other than "I write, you fill"
at cvs, you're required to fill them both. including zolpidem and xanax/klonopin. even Fentanyl and oxycodone together. while it is duplication therapy, your cvs supervisor will get on your tail for not filling them.... aside from cvs, if u work for any other company then u can use professional judgment.
if that is true - you need to grow a backbone and say no - or find a new employer
Well sometimes that stuff makes sense...clonazepam is often scheduled and takes longer to kick in so low-dose xanax prn wouldn't be insane. Fent patch + oxy for breakthrough is totally normal. Two z-drugs? Not normal. I mean honestly if one isn't working, don't just throw more of the same at it - hit a different MOA at least.
There are legitimate reasons to fill those. I don't know if you are even serious.
there are legit reasons definitely. one of which is the increasing death rate and hospitalization from Fentanyl. why else would they try to limit C2 distribution from warehouse and went as far as calling it an opioid crisis? an epidemic? people on the news are saying the opioid crisis are destroying their communities! and guess what who better to destroy communities than these pharmacists and you?
That's likely what I would have done. Pull out a piece of paper and calculate that days supply. Then PDMP the hell out of it and write on the script the last two fill dates listed on the PDMP report. Don't like it? Go somewhere else.
I filled alprazolam and zolpidem for someone the other day. I didn't like it, but she had been getting it for months now at the pharmacy I took over, so it put me in an awkward position. Called prescriber and verified dose for both, documented, counseled and away she went. Will definitely push harder to change therapy for new scripts i get like that in the future. The pharmacist who was here before me literally filled everything it seems. Lots of people on inappropriate combinations of pain and psych meds and sketchy people who should have been turned away.....very frustrating. End rant lol.
Just like everything else, Americans always want a quick "fix" for health concerns and doctors are "terrible" or "good" based on how fast they can alleviate symptoms, not how well they cure. The root issue of the abuse epidemic in this country is not a drug problem, but really a cultural problem. I see an interesting process of natural selection happening in the prescriber community of where those that try to do things the right (but slow) way of correcting the actual underlying disease state are failing and those that understand the public wants to just feel better right now and have no concern for the future, are thriving. The DEA keeps wanting point the blame at "bad" doctors for pushing all of these drugs on people, but isn't the real problem that we are not holding patients accountable for their own actions? It is time to stop treating the public like mindless monkeys and start realizing that they fully have the capacity to make their own decisions and to hold them responsible for the results of those choices.
I personally am overweight, it would be easy for me to blame food manufactures for marketing unhealthy products, it would be easy to blame genetics or even stress from my job. The truth is, however, that my weight is 100% the result of the decisions I have made and 100% my responsibility to fix or to live with the consequences. The only real way to tackle the drug problem in this country is to fight the real source of the problem, the patients who decide to take the drugs.
Oh and back on topic, taking Ambien and Lunesta together is stupid (as is taking either one alone in most cases). Get the damn tv out of your bedroom, do some exercise once in awhile, and you probably won't have trouble sleeping.
You limit if the scripts are not for legitimate reasons. The crisis is b/c of that. Ambien and lunesta together don't make any sense. A long acting (Fentanyl) and a short acting (oxy) pain medication used together to control pain do make sense. You want to get documentation on what kind of pain and how the patient has been titrated up to that specific combination, sure. But that's not a surprising combination.
Usually the problem is people who can't fall asleep, not people who can't stay asleep.
Increasing the dose or adding a second hypnotic will do nothing to make people fall asleep faster.
They'll only stay asleep longer.
This is a huge distinction that most MDs who want to argue with me (she needs 30mg Ambien!!!) Never even think about.
Adding on a benzo is better if they don't care about getting dementia.
I'm honestly starting to wonder if sosoo is just a tech masquerading as an RPh for fun
I hope you are right, but I am pretty sure she isn't -
fall asleep longer - like forever unfortunately
I've noticed they have an axe to grind with pain meds.
Not sure why
it's not a surprising combo. it's just killing and more people. that's all. and i'm seeing pharmacists around this district dispensing recklessly. how many people must die before you disregard the surprising factor and just look at the number of deaths and hospitalizations?
I've seen a combo with the following:
3mg Lunesta + 5mg zolpidem
Walgreens' software (IC+) doesn't have very good ways to leave notes like other chains. I called the Doc and he said the patient needs it because of his weight. Seemed like a valid enough reason to me. He had been on the combo for over 6 months.
Did you not tell the MD the logP of Ambien and Lunesta don't support that bologna reason?
Are you not a drug expert?
Did you think it's ethical for insurance companies to force docs to put their patients on benzos before trying Suvorexant/Balsomra? I was shocked to see it in rheum clinic. The doctor ran into that issue repeatedly. In Florida, the psych I worked with was under strict orders not to write any new scripts for benzos (granted he was at a public, pay what you're able sort of clinic).
Patient weighed at least 300 pounds.
Walgreens' software (IC+) doesn't have very good ways to leave notes like other chains. I called the Doc and he said the patient needs it because of his weight. Seemed like a valid enough reason to me. He had been on the combo for over 6 months.[/QUOTE]
If the patient is obese/morbidly obese, there is likely underlying apnea. Then that gets tricky; i.e.., central sleep apnea, risk of respiratory depression. Some studies show using ambien improves adherence to a sleep routine.
As someone that pays insurance premium, it's ethics and necessary. Prescribers will make up the most bogus reasons to justify their poor prescribing habits and someone needs to keep oversight. I do think pbms are evil but not becaue of clinically developed formulary enforcement
If it's such an issues do a prior authorization
Agree with npage. As a consumer, I have no problem when insurance companies require that metformin be tried before Trulicity, that losartan/irbesartan/telmisartan/valsartan be tried before Edarbi, that MSER or Oxycontin be tried before Opana ER. If you truly need the expensive brand name drug, be prepared to go through the PA process. If you just want to get the latest and greatest shiny new drug, get ready to pay.
Can you articulate why the dose for Ambien would be different for a 127lb sorority sister and a 782 lb morbidly obese person?
You're a professional, not a frat boy guessing how many shots someone can take.
If you think body fat makes a difference and you accept it as justification from the MD you need to understand why.
Yes, because Belsomra is a trash drug that's more marketing than science.
The phase 4 trials aren't living up to the hype.
Just kidding, literally nothing insurance does is ethical.
BUT, not enough prescribers force their people to try trazodone + melatonin for long enough.
Especially the know it all patients who have their prescriptions decided before you walk in
How about even a simple sleep hygiene discussion? My fil thinks he has insomnia and is dependent on ambien But he takes 2 naps during the day, falls asleep on the couch at 9 after a few drinks and then complains he wakes up 5am
didn't read the whole thing but I suspect the patient is selling some of this stash.
When i see prescribing like this, that is my automatic gut reaction. Just like adderall QID...
Thanks! Just read up a bit and it appears Merck aggressively marketed it without sufficient trials. Surprise, surprise.
Trazodone is the bomb. Seriously life-changing. We need to make it cool again.
You're looking at it from a liver metabolism perspective. That is absolutely valid, but I am looking at it from a concentration perspective.
I realize that the effective dose doesn't increase linearly with weight. With that said, the studies are not done in 300 pound patients.
Surely you are aware that there are medical reason why a person would be on both of these???? (I'm assuming they are taking them at different times of the day....if they are taking them both at bedtime, then I would agree that is a problem.) Now whether or not everyone on both of these medicines needs them is debatable, but certainly there are cases where some people would benefit medically from both of these drugs.
yesterday i declined a large and high dose vicodin script. a profile lookup shows they also get Fentanyl, oxy, soma, temazepam in the past. its amazing they're still alive. these pharmacists on this forum and in this district are amazingly "reckless." no wonder many communities are being destroyed.. and it all comes from the same doctor i suspect operating a pill mill from day 1.
A non-trivial percentage of people on large quantities are selling some, using some to validate drug screening, i.e., old people with limited income. Yes most pharmacists in retail are probably culpable in ruining at least one person's life during the course of their career but I stopped caring about that. Some people don't have what it takes chemically in regard to addiction/abuse.
Have you seen a cancer patient drug list honestly? I mean how long have you worked? I mean from your posts, I wouldn't bring any script to your pharmacy.
You probably won't even fill albuterol inhaler and albuterol solution together b/c they're duplication of therapy for god sakes.
Yup. I'm just cautious with probably more things than I need to be since I have been licensed for all of one month, and still have the idealistic view that I can help people avoid over medicating if possible.
To be fair, my providers do write for Norco with oxycodone and instruct patients to take Norco for mild to moderate breakthrough pain and oxycodone for moderate to severe breakthrough pain. I see their point, but it rarely works out how they hope it will. A lot of our patients on both scripts just take both of their PRNs as scheduled doses and come in every month for all 3 opioid scripts. Unless the patient has tried every other muscle relaxer, the patient shouldn't be on Soma (my opinion).
The script wasn't necessarily written by a pill mill, but it would be a bad idea to fill it without verification and it would be a bad idea to fill if the script was written by a different provider. Not all cancer treatment requires high dose opioids. Pain management can be too aggressive and do more harm than good.
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 | MMWR
i filled it the other day for a hospice patient. and i confirmed before dispensing. thats the only exception. period. you and your kind can wait until u have cancer before coming to me with Fentanyl and oxy combo. and even then i must have confirmation you'll be dying. otherwise i have no problem declining and assuming you're from a pill mill.
Short acting and long acting combination isn't that unusual. It's a bit weird to see two types of short acting opioids, but I actually like to see a chronic opioid patient on something long acting and something PRN vs a large number of IR tablets every month.
It's tough to judge which patients should get opioids if your criteria is a terminal condition. Is it only patients on hospice, or would a patient treated with palliative intent meet your criteria? I wouldn't assume everyone prescribing large numbers of opioids is part of a pill mill, but I also wouldn't assume that every script written is appropriate for the patient. It's difficult to tell since you don't have the patient's chart in front of you.
Lol, is gonna have a field day with you.
Hope you like getting reassigned to a store 1.5 hours away from Dallas
Yeah, fentanyl with oxy. Are we degreed professionals or order takers for the illicit drug trade...geez. didn't know DFW was that bad.
am I missing something here, what is wrong with duragesic with prn oxy on top of it? in general you want a short acting PRN for breakthrough pain (provided it is being used appropriately - which is a big assumption)
and @sosoo your woute "you and your kind can wait until u have cancer before coming to me with Fentanyl and oxy combo. and even then i must have confirmation you'll be dying" seriously? you are not that heartless are you? You must being dying? wow -
to be heartless is to be a reckless drug dealer. to be the main cause of the opioid epidemic. i just think if i don't give them pills out like M&Ms, then no one will die. in all things ethics, i've done no harm. heartless is when u cause harm, and continue as if theres nothing wrong with reckless dispensing of opioids.
Heartless is when you don't look at the patient as a person, but look at the scripts/drugs and determine what kind of person/patient they are. That's negligence and ignorant. You should be ashamed of yourself.