Tighter Control on Vicodin?

A widely prescribed painkiller


So, before reading this blog post, take a peek at this article:  http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story

I’m not going to comment on whether or not this is a good move because, truthfully, there’s a lot to be said for both sides of the coin. There would be patients–legitimate pain patients–who would suffer from this being approved. But, there would also be a lot less abuse (or so we would hope). Regardless, I’m not going to comment on whether this is good or bad. I can tell you one thing, though:  this would make life in a big chain retail pharmacy a nightmare. Can you imagine having to be the only one allowed to count out every hydrocodone-based prescription? I don’t know where we would store it all to be honest. But, I digress.

The real thing that should be focused on here is how we, as a health care community, look at “chronic pain”. There are so many chronic pain sufferers out there, and each is different. My thoughts are that instead of reclassifying the most commonly prescribed medication in the US, we should reclassify how it is prescribed. No primary care physician should be the main person writing for a chronic pain medication. Chronic pain patients should be going to a pain specialist. This should be required. This is not only to insure the prescribing is done correctly, but to help the patients find the best possible relief. Now, I’m not saying there aren’t pain doctors out there that give out narcs like candy, but they are better equipped to be writing for these patients. I feel like writing for chronic heavy duty narcotics is out of a primary care physician’s realm of practice. Primary doctors are too quick to write a chronic lower back pain patient a script for Percocet many times. Shouldn’t they be trying out other options, such as Cymbalta or gabapentin first before going to a potent opioid medication? I think people should exhaust all other options first before starting with meds like that, including things like acupuncture and physical therapy. It’s very difficult to get off opioids once you’ve been taking them for a while. You can always go forward if it’s not working, but it’s hard to go back.

The other thing that makes the world of opioids so tough is the lack of communication between physicians, sometimes due to the patient not telling the whole truth. We had a patient who is taking both Suboxone and Percocet on a daily basis. She stopped coming to our pharmacy because we questioned why she was on both and asked if we could contact her physicians about therapy modification. There is no reason she should be on both. I wonder if her two doctors know that she is on both medications. How it ever went through her insurance is beyond me. Usually, that kind of interaction requires a prior authorization, so either one of the doctors did the prior authorization without thinking or the insurance let a major drug interaction slip by. Whichever it is, it truly points to a problem with the way this nation treats chronic pain and opioid dependence/addiction.

It really saddens me. I wish that the FDA would focus on where pain killer abuse starts instead of where it ends. We need to be proactive about health care, not reactive. If we can prevent opioid misuse by better regulating how and by whom the medications are prescribed, then we won’t need to restrict them in the pharmacy as much. But, that’s just me, a lowly pharmacist who receives multiple 7 to 10 day early fill authorizations from the same primary doctors every few weeks. Who am I to argue?


Image courtesy of http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story


Puffy Eyes


So, I had an interesting phone call today. A woman who isn’t a patient of ours called to ask about her eyes. She told me they were red, puffy, and almost swollen shut. I asked if both side were equally swollen, and she told me they were. She also told me the few medications she was on, but stated that she had been on them for a while. At this point, I had come to the conclusion that is was either really bad seasonal allergies or that she had consume or used something that she was allergic to without knowing it.

I asked if she had eaten anything out of the ordinary or new recently and if she had switched soaps or detergents in her house. She answered no. I started telling her that she should take some diphenhydramine and call her doctor first thing in the morning. She interrupted me, asking if there were any interactions with that and her other medications. I told her no, and she replied back to me:  “Well, that’s good. I just wanted to make sure, since these medications are all sort of new to me.” Whoa. Back up. Rewind. Didn’t she just tell me she had been on them for a while? I asked her when she began taking the medications. She told me she started them a week ago. *facepalm*

So now, the tables have turned. Now, I’m leaning more towards a drug allergy being the cause of this. But, the question is, which one is causing the problem? She started each of them on the same day. I told her this and let her know the only way to know for sure which drug would be the cause is to discontinue all of them and restart each individually. Again, I told her to take the diphenhydramine and call the doctor first thing in the morning. I also told her if she experienced any throat tightening or trouble breathing to go to the emergency department of the nearest hospital. She agreed to do so if needed, thanked me, and hung up.

The take home point of this story is to always ask questions. Lots of questions. Ask the same thing in different ways. Use open-ended questions (when did you start these medications vs. have you been taking these medications for a while). It’s important for us to ask these questions and get to the root cause of why the patient is speaking with us. It’s how we screen them and determine what action needs to be taken next, whether it be self-treatment, a call to the doctor, or even a hospital visit. Never be afraid to ask the same thing again if you need to. When patients seek out your help and advice, they usually don’t mind the questions. Most times, they appreciate how much effort we put in to helping them. This is one of our duties to our patients. It falls under the “Do No Harm” portion of the Hippocratic and/or Pharmacist’s Oaths. And, it can make all the difference in a person’s life.


Image courtesy of http://i33.photobucket.com/albums/d76/xx_Emmeh_xx/eyeball.jpg

Mixing Flavors


We all remember how some of the liquid medications that we had to take as children tasted. There was yummy, bubble gum amoxicillin. There was disgusting, bitter Augmentin that we could barely tolerate enough to swallow. There was sweet, grape Dimetapp that soothed a sore throat and quieted a cough. Those are just a few I personally remember be given as a small child when head colds, strep throat, and walking pneumonia came my way. Unfortunately for me, the flavor of the medication was what it was. I just had to deal with it if it was nasty. Today, there is the option to flavor liquid medications if the original flavor is yucky. The brand of flavoring drops we use at my pharmacy is FLAVORx. I feel it works pretty well, and it’s a reasonable price ($2.99 USD per prescription). Having personally taste tested many of my “creations”, I feel comfortable telling my patients which flavor is their best bet to cover up the “yuckiness”.

There are some people, though, that cannot afford the service very easily. We have a high welfare population in my area, so I try to tell these people other ways to diminish the bad flavors. I also offer to flavor it at any time if they find it just too difficult to swallow it as is. The one thing I always tell people is to have a “chaser” ready for the really bad tasting things (Augmentin, Cleocin, etc). I also tell them to try sucking on an ice cube or ice pop for a few minutes prior to administration to help dull the taste buds. I always recommend keeping things in the fridge for the medications that don’t have specific storage requirements (azithromycin, prednisolone, etc). Most people find a combination of factors that works, and if they don’t, they come back in a day or two to ask for the flavoring service.

My story today is about a mother who was picking up some liquid allergy medication for her daughter. She asked me if it was okay to put it in the fridge. I told her that was fine and would help improve taste. She commented that taste isn’t a problem since they always mix the medication with whatever beverage she is having at the time of administration. She began listing off every drink you could think of–soda, milk, juice, tea…you get the picture. I asked her if someone had told her it was okay to do this with the medication. She said she came up with the idea by herself. Instead of going through each drink to see if it was okay to mix the medication in them, I asked her to refrain from doing this because I was unaware if it had any negative implications. She seemed confused, so I explained there are some medications that if mixed with or taken at the same time as some beverages could essentially be made inactive in the body. She nodded, and asked for tips on how to make the taste less bitter. I gave her my normal spiel, and she thanked me. She ended up coming back later to ask for the flavoring service just to make sure it was palatable enough.

My advice here for my readers is to never mix liquid medications with other beverages without contacting a healthcare professional (preferably a pharmacist) first. You want to make sure the drug is as effective as possible when taking it. Whether it be by finding something that is acceptable to mix it with or by flavoring the medication itself, we can help you figure out a way to make it less yucky.


Image courtesy of http://flavorx.com/wp-content/uploads/2011/09/classic_flavoring_set.jpg

No. Just NO.


Today’s entry will be very short and to the point, since I am on the go. But, it’s a very important piece of advice.

Today, I had a woman call and ask about OTC pain relievers. Before I made my recommendation, I asked her several questions. Are you pregnant? Do you have problems with stomach ulcers? Are you on any prescription pain medications? Do you have liver or kidney problems? The answers were all, “No,” until I asked my final question: “Are you on any blood thinners or anti-platelet medications?”

Turns out she was on warfarin. So, I told her Tylenol (acetaminophen) was the only OTC pain reliever she could take, but even so, she should talk to her physician if she was looking for a long term answer. She then informed me that the one night when the pharmacy was closed, one of the people working the front store recommended ibuprofen to her. I could feel my blood start to boil. Without alerting her of the massive mistake that had happened, I asked her if she took any of the ibuprofen. She said she hadn’t, so I told her to only take the Tylenol and ask her physician for advice on a long term medication. After that, she hung up.

I was so livid after the call ended. Pharmacists are the only ones allowed to give medical advice in a community pharmacy. Pharmacy interns (those currently in pharmacy school) are also allowed to do so under pharmacist supervision. Besides them, no one else should be recommending anything or counseling anyone. This is a prime example of why. Thank goodness she didn’t take any of the ibuprofen. She could have had a major bleed, which would have been a huge liability for the entire store and could have potentially cost this woman her life. When I spoke with my store manager, she agreed to have one on one discussions with each of the people working up front, reminding them WHY all questions should be directed to the pharmacist on duty.

Readers, if you ever have any questions about medications, please come directly to the pharmacy to ask them. Those working up front are not licensed to make recommendations.

Technicians and other pharmacy staff, please use this as a reminder of why it is important to double check with the pharmacist on duty for any and all questions people have. It could make the difference between help and harm.


Image courtesy of http://i1061.photobucket.com/albums/t474/Audrey-YMCMB/wrong_texture.png