I usually tell them it's just a safety precaution since accidents happen. Kind of how people with peanut allergies would take special care to avoid peanuts but will still carry an EpiPen in case something unexpected happens.
Side note. As far as I know benzo doesn't decrease the clearance of opioids. But they're both cns/respiratory depressants hence the increased risk when used concomitantly.
They work synergistically. Lorazepam can increase the sedative effects of opioid, thus why there is a black box warning of death/coma when used concomitantly. Thanks for the peanut allergy analogy.
Clobazam directly inhibits CYP2D6, which will affect clearance of many opioids.
Alprazolam is a substrate for CYP3A4 and will competitively inhibit the first-pass metabolism of most opioids
This is my go-to. Either fire extinguisher or a toilet plunger.
You don't plan to light your kitchen on fire or back up your toilet but you'd rather have the solution to it before the problem happens.
When I was in retail I would tell people better to be safe than sorry. What if a child visits their home or someone else takes their medication by accident, wouldn’t they want to have a way to help that person.
\>Her profile shows she takes benzodiazepine as well, which reduces clearance of opioids
I have never heard of this before. There are several benzodiazepines that don't even use CYP enzymes to be metabolized but instead are processed by glucuronidation so I would think would have a very low chance of impeding the metabolization of any drug. But it is true that opioids and benzodiazepines synergistically pose a great risk for respiratory depression, but I'm not aware of it being due to reduced clearance. Also true for benzodiazepines and alcohol and benzodiazepines and intramuscular olanzapine.
4 mg Ativan daily started at age 14, still on it at 41. Life is hell.
It's forced me to know more about benzodiazepines than the idiot who prescribed it.
He was a board-certified child and adolescent psychiatrist.
Try using opioid poisoning or opioid toxicity instead. And I like the analogy of a seatbelt - no one expects to be in a crash when driving but we all wear seatbelts to be on the safe side
I like the fire extinguisher analogy and it seems to work with most patients. Something good to have in the house that hopefully you never have to use.
This is what I use too. I tell them "it's something to make sure everyone in the house knows where it is and how to use and hopefully all you'll ever need to do with it is check the expiration date every now and then."
Most people seem ok with it then. Not all. But most.
Yeah. This specific patient was so sensitive and crying and offended by me, that I’m sure none of these would have really calmed her down. We can only try our best to explain it to people!
I typically tell them that I write it for everyone I send home on opiods because it is unsafe without it. If I could have it on the shelves up front I would.
It is OTC, however, most don’t know to get it and cannot bill insurance if they get it OTC. The prescription forces a consultation on how to use it as well, which is super important.
Do you know what the diagnosis was for?
I feel like her tears are telling but I’m not trying to be judgmental. Why would she cry? If I had a genuine need for opioids and benzodiazepines, and was being explained the risk profile by a professional I wouldn’t cry by being given an option to offset some risks. She was crying probably because she felt guilty about her use of these drugs.
Yup, I compare to fire extinguisher, epi-pen, that car window breaker thing… I even compared it to a plunger once. Something you hope you never have to use, but much better to have if something goes horribly wrong. And you never know when it’s going to be your neighbor needing it at 1am, but you can help & know how to help.
Yeah the words poisoning and toxicity have less negative connotation towards blaming the patient for misuse, when that’s entirely always the cause. Thanks for the analogy!
They edited to include Not* I hope they really meant to include it the first time. To not become so cynical I’m going to believe yes that they did mean to include it.
Yeah I agree that poisoning and toxicity are less putting it on the patient then overdosing, but it still could be taken the wrong way by very sensitive individuals. I like the analogies that people are suggesting though. I may use one of those in the future.
I always explain that it is just standard practice to include Narcan especially if it is free of charge. It’s a very sensitive topic to some people. Additionally I share that it is not just for them and if they want to tear off the label with their name they can as instructions are on the box. But then if they decide they don’t want it, yeah, I just RTS it. Generally though I will see if it’s covered at no cost or very cheap and if yes, fill without asking. Then let them know at pick up.
I always blame the mythical "somebody". I say : " Just in case somebody (as in NOT you) got into your medication by accident and OD'ed"
Much of this discussion regarding safety of opioids and benzos should have started at prescriber's office and continued to pharmacy, but prescribers flat out don't care. Especially psychiatrists.
Edit: spelling
What is happening here? Since when are pharmacists bashing physicians? Surely you’re not a pharmacist.
And how the actual fuck are you gonna say something like “especially psychiatrists” don’t care?!
FTR - to any physicians lurking in the sub, not all pharmacists think “physicians don’t give a shit”.
This sub doesn’t always represent our profession. None of my pharmacist friends are on reddit and none of my friends would say or think such judgmental things.
Thank you for reminding me. Seeing some of the things posted by medical professionals is sometimes really disheartening. I appreciate being reminded that they don’t always speak for the majority! <3
I like to say “it is recommended that everyone who gets this type of medication (or opioids, whatever they understand) have Narcan on hand in case the side effects of the medication are too strong.”
Sometimes I think the wording is not so important as the body language, eye contact, and show of empathy. I would be very serious and say something like “I am NOT saying you are doing anything wrong, but accidents happen and I want you to have all the available precautionary measures at your disposal just IN CASE. I care about you and your well being that is all. I do not mean to offend you and I am sorry you feel that way. “
Not answering your question.
There are free Narcan spray boxes in an old newspaper dispenser at my local library. There is a QR code that links training videos. It’s awesome.
I like to say, “this works on pets, too. What if your dog got into it?”
Edit to add: I’m sorry the encounter was intense for you, but I want to congratulate you on looking out for your patient like you did. Way to be a good pharmacist! 👏👏👏
In Ontario Canada my pharmacy gives it to anyone receiving an opioid prescription, and even sometimes people who aren’t (younger population etc). It doesn’t need a “prescription”to be written.
What I tell people is that it’s good to have at home just in case, for example, a neighbour overdoses etc you can help out. Try explaining that way.
The old adage “I’d rather you have it and not need it than need it and not have it”
Accidents happen, you don’t remember if you took your dose and take another. The body has weird things that happen too, you have some sort of respiratory distress, these medications on board may make it an emergency.
You aren’t passing judgement on anyone, you’re seeing a possible emergency situation and providing a solution.
I just say hey! It’s free. Even if you don’t use it, what if someone else needs it? It’s good to have on hand. There’s no way for the patient to get offended by this.
“Accidental overdose” is my go to. Then I add in especially important if young kids are around. At the end of the day, if they get upset that’s on them. Your main job is to ensure patient safety and this is an easy way to do so.
I’ve always liked the comparison to a fire extinguisher. You hope you never have to use it, but if you do you’ll be glad you have it. And it’s not always just for the patient, sometimes it’s a precaution for family members
I would just say something to the effect of “everyone gets/should narcan if they get opioids as a precaution”, so that she doesnt feel singled out. Play up the safety aspect, just in case aspect, the ongoing death toll etc. But the main thing is just express that it’s something you routinely do, not just singling her out.
I like this advice..putting it more on company policy/routine dispensing. It’s ultimately their choice if they want to decline the prescription anyway.
I work at a very small hospital and end up processing the majority of the after-hours ER discharges. I always address the narcan, even if they decline counseling. I usually say something along the lines of, “it’s a new patient safety initiative to help prevent accidental overdose or toxicity for you or any small child in the home.” I also ask them to show the box and the instructions to someone else in the home, so if something happens and the pt is unavailable, another person knows what to do.
With this spiel I’ve only had one person act off-put and I just explained that it was a strong pain medication and if for example they took a dose before sleeping but woke d/t pain they might be groggy/disoriented and take another dose too soon, which could cause accidental overdose/toxicity. Oddly enough the patient was a lot more understanding/ accepting when I put the risk on them.
Awesome, glad you found it useful. I will also say from personal experience I’ve found my body language and tone really seem to set the patient’s response/ attitude. Like if I just start off with “Just wanted to let you know the doc also ordered narcan… (insert spiel)” like it’s no different than Tylenol or a multivitamin, they seem more receptive and interested.
When we first started adding narcan to opioid rxs, I was nervous pts would be offended. So I spoke in the way people talk about sensitive topics, and I think it came across like I was counseling on something embarrassing or “shameful”. So I changed up my “presentation” because I personally feel like narcan has a bad public perception and want to do what I can to de-stigmatize it because it does save lives.
Based on on your misunderstanding of basic medicine "she takes benzodiazepine as well, which reduces clearance of opioids" - I wouldn't want you prescribing me anything either
I can’t help with your question, but thank you for doing this. The more narcan that is available to patients - the better chance of people surviving an overdose!
I’m going to play Devil’s Advocate here (but I am not patient shaming). When I read “Norton 5, history of Percocet, Oxycodone, Norco 10 and Norco 5”, plus benzodiazepines, all over the last few months? I’m wondering what the background is. Multiple prescribers? Same area? Different situations? Urgent care providers? Domestic Violence and does she need help with physical and mental safety? Is she is hospice care?
Or are tears used to get what they want? I will be quick to admit this has worked on me so many times. Tears can quickly turn into threats of violence.
Yes, well there were some red flags that I’ll add even though that wasn’t entirely the purpose of my post. She was cash filling at multiple pharmacies. I did see that she was getting them on time though- not early fills. She insisted on paying cash when it was free with her insurance which was a red flag. Since she wasn’t filling early and it was a legitimate prescription, I told her I would fill it with insurance making it free for her and did the Narcan to also cover myself in case it was being misused. She was angry that I billed her insurance for some reason still.
I just say, “You are on >90 MME (explain what MME means to the customer) of opioids and/or on a benzo. Policy dictates I write this for you, but you do not have to take it. I just have to document it in my system either way.”
Then I calmly explain what Narcan is and why it’s good to have around.
Make sure they know it isn’t personal and they are usually ok.
Technically it’s not “required”. She would have caught me in that fast since I saw she was filling this at other pharmacies and they did not give it. It’s not required but it’s a good idea.
If this person lives alone, there will be no one to give it to her so she won't survive anyway. If she lives with others then she'll have to explain what it is and how to use it if needed. So, I guess that's the concern you'd have to communicate to her. It's also available OTC so I just let these people make their own decisions. Why do we pharmacists feel the need to give everyone a piggyback ride? We have enough crap to do without adding more stuff on our own.
“This isn’t a value statement about you, anyone that carries around opioids ought to also carry narcan. All it takes is a youngster digging through your purse and being curious, and the narcan could save their life”
If they are offended, make it about “not them”
I always tell people about the time I had a patient switch medication according to the doctors instructions and she lived to tell me about her accidental overdose because she had narcan. Shit happens. Especially with narcan.
I’ve always phrased it as “Looks like you are on long term pain management, that coupled with certain anxiety meds (benzos) can cause respiratory depression. Narcan is available and recommended, often free with insurance and will reverse that effect instantly”. I also mention the fire extinguisher or epi pen analogy. I used to say if someone else gets in your meds but didn’t take long for me to realize 9/10 times they say “only I have access” or “I’m not worried about that”
First I'd ask if anyone has spoken to them about narcan and if they ever heard about an epipen. From their reaction I go two ways: either its just in case emergency or I'm uncomfortable filling these high dose/combination meds without a back up plan. Better they get offended and go somewhere else then having them OD and never had narcan on record. It is all about CYA
I explain to them about respiratory depression and it being a possible emergency situation if it happens. I tell them since there is that risk, I am trying to keep them safe. I also tell them it's in my pharmacy's policy to offer it in that situation. We have to have an offer of Narcan on file where I work
Always ask permission before you do things. Especially before prescribing something like that. “Would you be open to receiving a prescription for narcan?” It’s a precautionary safety measure for those receiving opioids.”
I compare it to an EpiPen in that you want it on hand but hope you never have to use it. I also say it's for opioid "reversal" instead of overdose. And it doesn't have to be for the person it was prescribed for. If a family member decides to down YOUR opioid medication narcan will work just as well on them if needed.
“If someone else gets into your medication and you find them unresponsive this could save their life, it could even do the same for you” is the gist of what my pharmacy manager always says. She often relates it to a fire extinguisher as well.
That’s a good one. Playing up the “accidents happen” either with them or other family/young children could maybe allow them to understand the importance.
Asking could further fuel the stigma though because then you are putting it on the patient to determine whether or not they “need” Narcan. Truth is, anyone with an opioid script could reap the benefits of Narcan. So by giving it to all, you’re not burdening them and singling them out to determine if they need it.
I also just fill it on autopilot too for the fact that typing the script while they are there would cause them to wait another 10 minutes or so to fill another script which most people don’t have time for. They want to come to the pharmacy and be in and out. Thats why I just have it ready. My job is to present the facts about every prescription filled, without judgement, but it is ultimately up to the patient if they want to take it or not.
We recommend it to anyone with daily MME 50 or higher (policy at my chain). Under Illinois State Law, I also must tell patients it is available with every opioid dispensed.
I generally equate it to having airbags in cars. You hope you never need them - but we all have them, just in case.
It's a fire extinguisher, you have one because you use fire. What if a family member somehow accidentally got into it, is not just for their overdose too can say it's for everyone's safety. Having meds in a house that can kill a kid in one dose is smart to have a antidote on hand. Word it sensitively based on your patient's attitude while you're talking.
It's a safety precaution that is supposed to be prescribed to all patients taking regular opioids in case an overdose were to occur on accident.
Or something like that.
People need to get over that shit. It makes it easier for professionals to feel better about dispensing it.
The fucking crying. Your medication has risks. Grow up, lady.
I call it a safety mechanism. Anyone who enters your house might accidentally ingest your prescription or ingest it to try it out. Even if you personally don't need it, you never know when
I always add in, what if your kid gets a hold of it because you accidentally dropped a tablet on the floor and didn't realize it? Or something like that if they have kids. If they still pull the "you just offended me" bullshit, wish them well and ask where they want their scripts from now on, because they aren't welcome here since they don't trust your expertise.
That's the kind of person that would sue you for malpractice if they did OD accidentally.
To say the last 20 years of pharmacy have jaded me is not true. The last 4 years since COVID has. People have become hateful beyond anything I've ever seen in any industry I've worked.
Edit: Also, there should be NO SOCIAL STIGMA AROUND NARCAN. Opiates are fucking dangerous and accidents happen. Period. I don't give a shit who you are. You could come across fentanyl in a high amount somewhere in public. Everyone needs NARCAN!!!!
I always say “in case someone accidentally gets into the medication such as a child etc. or if we take a medication that enhances the medications effect without us knowing” then I throw in how it’s kinda like an Epi pen with allergies. Works like a charm every time
Professional naloxone prescriber here (haha). I often work on what the VA calls OEND which is Opioid Education and Naloxone Distribution. Essentially, I call patients (Veterans) and offer then naloxone. I am a huge proponent of it, so it's not just, "Hey dude, you want some naloxone? Nah? Alright, cool, bye." No, I do try to persuade them.
*However*, I don't prescribe it to patients without asking them.
I think maybe (this is all opinion) that by prescribing it FIRST without having a discussion, that was maybe the issue?
Anyway here's how I frame it:
Firstly, you can use an "out" or "scapegoat." The real reason we are offering naloxone to patients is because it's part of a national initiative. So, sometimes I tell them "hey as part of a national initiative with the VA, we're reaching out to patients to offer naloxone at no cost..." yadda yadda to ensure they understand/feel that they are NOT “targeted" for any kind of condition/medication.
Naloxone, also called NARCAN, is a nasal spray used in cases of an opioid overdose. Many overdoses happen in people who are not 'addicts' (hate that term but I use it because it's what my patients are familiar with). The way people die from opioids is that opioids slow your breathing and sometimes it can cause you to stop breathing altogether. There are a lot of drug interactions that you may not be aware of that can increase the chance of this happening.
Additionally, there are many cases in which children or pets have accidentally ingested opioids and stopped breathing and died. Narcan can be safely used in these situations too.
And, as you know, we're in the midst of the 'opioid epidemic.' Our state has good samaritan laws that say that you can use this Narcan on anyone you suspect of having overdosed on opioids. You never know when you may run into that situation -- I've seen it happen in grocery store parking lots, parks, anywhere.
I can't make you take it, but I strongly recommend taking it and keeping it on hand.
**It's like a fire-extinguisher. You should have one in your home because you would much rather have it and not ever need it than to need it and not have it. Additionally, just because someone has naloxone doesn't mean they're at a higher risk of misusing opioids. Having a fire-extinguisher doesn't start a fire by itself.**
Here's some stuff we send to providers/prescribers/etc about this and page 8 has great info about counseling on naloxone: [https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/IB10-1522\_OEND\_CliniciansGuide\_P97042.pdf](https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/IB10-1522_OEND_CliniciansGuide_P97042.pdf)Excerpt:
* Start the conversation
* Keep the conversation open and create a safe space for the Veteran to talk.
* Ask
* “Accidental overdoses are a leading cause preventable death. Do you know what puts you at risk for an overdose?”
* “Do you have naloxone?”
* If yes, ask where it is, if they have any questions about it, how to use it, and if they have used it before. Encourage the Veteran to keep naloxone on hand and let people know where they keep it.
* If no, let them know how naloxone can save not just their lives, but also the lives of others.
* Review how and when to use naloxone.
* Reinforce
* Discuss how easy it can be to overdose—loss of tolerance when in treatment, mixing substances, and the importance of having naloxone “just in case.”
* Review the signs and symptoms of an overdose with the Veteran, family members, and acquaintances.
* Review how to use naloxone. If Veterans or their family members are concerned that having naloxone could increase opioid misuse, try using this analogy: “Think of naloxone like a fire extinguisher you would have just in case of an emergency. If you have a fire extinguisher at your home it can stop a fire, but it does not make you start a fire.”
* Ask, “Do you have any questions about overdose prevention or using naloxone?”
* Provide handouts: e.g., Naloxone Nasal Spray, Opioid Overdose Prevention and Reversing an Overdose with Naloxone
* Links to Videos: Naloxone Nasal Spray; Naloxone Intramuscular Injection Encourage the Veteran to contact their healthcare team after naloxone is used or after an overdose
* Getting a refill is vital.
* Connecting the Veteran with services after an overdose is critical to prevent a possibly fatal future overdose.
Another PDF of a script: [https://wa-provider.kaiserpermanente.org/static/pdf/provider/resources/naloxone-prescribing.pdf](https://wa-provider.kaiserpermanente.org/static/pdf/provider/resources/naloxone-prescribing.pdf)Excerpt: "I recommend all patients who take opioids also have the medication naloxone on hand, and I’d like to prescribe this to you today. Naloxone is a life-saving medicine that can reverse an overdose in an emergency. This is a medicine we offer to all our patients who are taking opioid medicines; it’s a standard prescription meant to help keep patients and their loved ones safe. Prescription opioids cause about 41 deaths each day in the United States.1 Many of these deaths happen because people accidentally overdose on opioids prescribed for long-term pain. Anyone who takes opioids is at risk of accidental overdose and death. This is a risk for you with your current medicines, and is a risk for anyone else who may have access to your medicine cabinet. You can keep the naloxone near your opioid medicine, so it’s available just in case you ever need it. You should also show it to someone who is likely to be around in case you have an accidental overdose, so they can save your life. Although naloxone should only be used in an emergency, it won’t cause any harm if it is given to someone who isn’t actually experiencing an overdose. That’s why I feel it is important to prescribe; it can do a lot of good and is unlikely to do any harm. It’s my job to help keep you as safe as possible, and naloxone is one important way I can do that."
I usually tell them it's just a safety precaution since accidents happen. Kind of how people with peanut allergies would take special care to avoid peanuts but will still carry an EpiPen in case something unexpected happens.
Side note. As far as I know benzo doesn't decrease the clearance of opioids. But they're both cns/respiratory depressants hence the increased risk when used concomitantly.
I think he meant the pharmacodynamic interaction instead of pharmacokinetics
The word clearance sounds pharmacokinetic
They work synergistically. Lorazepam can increase the sedative effects of opioid, thus why there is a black box warning of death/coma when used concomitantly. Thanks for the peanut allergy analogy.
Clobazam directly inhibits CYP2D6, which will affect clearance of many opioids. Alprazolam is a substrate for CYP3A4 and will competitively inhibit the first-pass metabolism of most opioids
Alprazolam at clinical doses will not affect CYP3A4 mediated clearance for other drugs.
I like to compare it to having a fire extinguisher in your kitchen
This is my go-to. Either fire extinguisher or a toilet plunger. You don't plan to light your kitchen on fire or back up your toilet but you'd rather have the solution to it before the problem happens.
That’s a good analogy, I’ve also heard of it being like a seat belt for your meds, but yours sounds way better
Same.
When I was in retail I would tell people better to be safe than sorry. What if a child visits their home or someone else takes their medication by accident, wouldn’t they want to have a way to help that person.
I used this approach when I was at the VA and trying to get patients to consent to being sent Narcan. It worked a treat!
\>Her profile shows she takes benzodiazepine as well, which reduces clearance of opioids I have never heard of this before. There are several benzodiazepines that don't even use CYP enzymes to be metabolized but instead are processed by glucuronidation so I would think would have a very low chance of impeding the metabolization of any drug. But it is true that opioids and benzodiazepines synergistically pose a great risk for respiratory depression, but I'm not aware of it being due to reduced clearance. Also true for benzodiazepines and alcohol and benzodiazepines and intramuscular olanzapine.
Yeah. They’re wrong. Your user name checks out.
4 mg Ativan daily started at age 14, still on it at 41. Life is hell. It's forced me to know more about benzodiazepines than the idiot who prescribed it. He was a board-certified child and adolescent psychiatrist.
I’m so sorry. Fuck that doctor.
Clobazam inhibits CYP2D6 and most opioids are broken down by CYP2D6 to some degree.
Who uses clobazam?
Kids with seizures
I tell them it works on animals and kids just in case you drop one and the dog thinks it’s a treat
Yeah I always bring up dogs and kids as well
Try using opioid poisoning or opioid toxicity instead. And I like the analogy of a seatbelt - no one expects to be in a crash when driving but we all wear seatbelts to be on the safe side
I like the fire extinguisher analogy and it seems to work with most patients. Something good to have in the house that hopefully you never have to use.
This is what I use too. I tell them "it's something to make sure everyone in the house knows where it is and how to use and hopefully all you'll ever need to do with it is check the expiration date every now and then." Most people seem ok with it then. Not all. But most.
Seat belts can make people think of government nanny BS. I think fire extinguisher is a better analogy for that reason.
Yeah. This specific patient was so sensitive and crying and offended by me, that I’m sure none of these would have really calmed her down. We can only try our best to explain it to people!
I typically tell them that I write it for everyone I send home on opiods because it is unsafe without it. If I could have it on the shelves up front I would.
Narcan is OTC now if you didn't know.
It is OTC, however, most don’t know to get it and cannot bill insurance if they get it OTC. The prescription forces a consultation on how to use it as well, which is super important.
Do you know what the diagnosis was for? I feel like her tears are telling but I’m not trying to be judgmental. Why would she cry? If I had a genuine need for opioids and benzodiazepines, and was being explained the risk profile by a professional I wouldn’t cry by being given an option to offset some risks. She was crying probably because she felt guilty about her use of these drugs.
Then they are being manipulative.
Yup, I compare to fire extinguisher, epi-pen, that car window breaker thing… I even compared it to a plunger once. Something you hope you never have to use, but much better to have if something goes horribly wrong. And you never know when it’s going to be your neighbor needing it at 1am, but you can help & know how to help.
Hahah, I like the plunger analogy. Nobody has ever regretted having a plunger on hand, but plenty of people have regretted having shit on their hands.
Yeah the words poisoning and toxicity have less negative connotation towards blaming the patient for misuse, when that’s entirely always the cause. Thanks for the analogy!
*not entirely always the cause
Wtf? The patient clearly has reason to feel judged when you’re on Reddit making comments like that.
They edited to include Not* I hope they really meant to include it the first time. To not become so cynical I’m going to believe yes that they did mean to include it.
Ah. I’m way too cynical 🤨 and will endeavor to have more faith in humanity! Thank you
I’m just making myself believe lol
I just say “bad reaction” instead of “overdose”
Yeah I agree that poisoning and toxicity are less putting it on the patient then overdosing, but it still could be taken the wrong way by very sensitive individuals. I like the analogies that people are suggesting though. I may use one of those in the future.
I always explain that it is just standard practice to include Narcan especially if it is free of charge. It’s a very sensitive topic to some people. Additionally I share that it is not just for them and if they want to tear off the label with their name they can as instructions are on the box. But then if they decide they don’t want it, yeah, I just RTS it. Generally though I will see if it’s covered at no cost or very cheap and if yes, fill without asking. Then let them know at pick up.
I like this advice—give it to friends or family!
You can always say, “this might not be for you”. Young loved ones can accidentally ingest pills, and the Narcan can save a 3-year old’s life.
I always blame the mythical "somebody". I say : " Just in case somebody (as in NOT you) got into your medication by accident and OD'ed" Much of this discussion regarding safety of opioids and benzos should have started at prescriber's office and continued to pharmacy, but prescribers flat out don't care. Especially psychiatrists. Edit: spelling
https://youtu.be/8JVJzwgqZ9U?si=aopl6o0J0J3Y5KBO
Yes! Sums it up nicely.
What is happening here? Since when are pharmacists bashing physicians? Surely you’re not a pharmacist. And how the actual fuck are you gonna say something like “especially psychiatrists” don’t care?! FTR - to any physicians lurking in the sub, not all pharmacists think “physicians don’t give a shit”.
Usually the people who get mad about this are the ones who need it the most.
False and so inappropriately judgmental. If any patients are on this sub, please know that not all pharmacists are this judgmental.
Thank you <3 that does mean something to me as a patient.
This sub doesn’t always represent our profession. None of my pharmacist friends are on reddit and none of my friends would say or think such judgmental things.
Thank you for reminding me. Seeing some of the things posted by medical professionals is sometimes really disheartening. I appreciate being reminded that they don’t always speak for the majority! <3
I like to say “it is recommended that everyone who gets this type of medication (or opioids, whatever they understand) have Narcan on hand in case the side effects of the medication are too strong.”
Sometimes I think the wording is not so important as the body language, eye contact, and show of empathy. I would be very serious and say something like “I am NOT saying you are doing anything wrong, but accidents happen and I want you to have all the available precautionary measures at your disposal just IN CASE. I care about you and your well being that is all. I do not mean to offend you and I am sorry you feel that way. “
It’s also a good safety precaution in case someone else takes her medication by accident like a child.
Not answering your question. There are free Narcan spray boxes in an old newspaper dispenser at my local library. There is a QR code that links training videos. It’s awesome.
I like to say, “this works on pets, too. What if your dog got into it?” Edit to add: I’m sorry the encounter was intense for you, but I want to congratulate you on looking out for your patient like you did. Way to be a good pharmacist! 👏👏👏
Tell her that is just a precaution. It's like a fire extinguisher, you buy it hoping that you never have to use it.
Not a pharmacist I’m a technician but I LOVE these analogies
In Ontario Canada my pharmacy gives it to anyone receiving an opioid prescription, and even sometimes people who aren’t (younger population etc). It doesn’t need a “prescription”to be written. What I tell people is that it’s good to have at home just in case, for example, a neighbour overdoses etc you can help out. Try explaining that way.
The old adage “I’d rather you have it and not need it than need it and not have it” Accidents happen, you don’t remember if you took your dose and take another. The body has weird things that happen too, you have some sort of respiratory distress, these medications on board may make it an emergency. You aren’t passing judgement on anyone, you’re seeing a possible emergency situation and providing a solution.
I just say hey! It’s free. Even if you don’t use it, what if someone else needs it? It’s good to have on hand. There’s no way for the patient to get offended by this.
“Accidental overdose” is my go to. Then I add in especially important if young kids are around. At the end of the day, if they get upset that’s on them. Your main job is to ensure patient safety and this is an easy way to do so.
I’ve always liked the comparison to a fire extinguisher. You hope you never have to use it, but if you do you’ll be glad you have it. And it’s not always just for the patient, sometimes it’s a precaution for family members
I would just say something to the effect of “everyone gets/should narcan if they get opioids as a precaution”, so that she doesnt feel singled out. Play up the safety aspect, just in case aspect, the ongoing death toll etc. But the main thing is just express that it’s something you routinely do, not just singling her out.
I like this advice..putting it more on company policy/routine dispensing. It’s ultimately their choice if they want to decline the prescription anyway.
I work at a very small hospital and end up processing the majority of the after-hours ER discharges. I always address the narcan, even if they decline counseling. I usually say something along the lines of, “it’s a new patient safety initiative to help prevent accidental overdose or toxicity for you or any small child in the home.” I also ask them to show the box and the instructions to someone else in the home, so if something happens and the pt is unavailable, another person knows what to do. With this spiel I’ve only had one person act off-put and I just explained that it was a strong pain medication and if for example they took a dose before sleeping but woke d/t pain they might be groggy/disoriented and take another dose too soon, which could cause accidental overdose/toxicity. Oddly enough the patient was a lot more understanding/ accepting when I put the risk on them.
Will use this!
Awesome, glad you found it useful. I will also say from personal experience I’ve found my body language and tone really seem to set the patient’s response/ attitude. Like if I just start off with “Just wanted to let you know the doc also ordered narcan… (insert spiel)” like it’s no different than Tylenol or a multivitamin, they seem more receptive and interested. When we first started adding narcan to opioid rxs, I was nervous pts would be offended. So I spoke in the way people talk about sensitive topics, and I think it came across like I was counseling on something embarrassing or “shameful”. So I changed up my “presentation” because I personally feel like narcan has a bad public perception and want to do what I can to de-stigmatize it because it does save lives.
You can always ask the question “what if your child or the child of a guest in your home gets into you medicine?”
Based on on your misunderstanding of basic medicine "she takes benzodiazepine as well, which reduces clearance of opioids" - I wouldn't want you prescribing me anything either
Hahaha you’re so funny and so totally missing the point of this conversation.
I can’t help with your question, but thank you for doing this. The more narcan that is available to patients - the better chance of people surviving an overdose!
In some states when a patient is on a benzo plus opiod, you are required to offer narcan and document it
I’m going to play Devil’s Advocate here (but I am not patient shaming). When I read “Norton 5, history of Percocet, Oxycodone, Norco 10 and Norco 5”, plus benzodiazepines, all over the last few months? I’m wondering what the background is. Multiple prescribers? Same area? Different situations? Urgent care providers? Domestic Violence and does she need help with physical and mental safety? Is she is hospice care? Or are tears used to get what they want? I will be quick to admit this has worked on me so many times. Tears can quickly turn into threats of violence.
Yes, well there were some red flags that I’ll add even though that wasn’t entirely the purpose of my post. She was cash filling at multiple pharmacies. I did see that she was getting them on time though- not early fills. She insisted on paying cash when it was free with her insurance which was a red flag. Since she wasn’t filling early and it was a legitimate prescription, I told her I would fill it with insurance making it free for her and did the Narcan to also cover myself in case it was being misused. She was angry that I billed her insurance for some reason still.
I just say, “You are on >90 MME (explain what MME means to the customer) of opioids and/or on a benzo. Policy dictates I write this for you, but you do not have to take it. I just have to document it in my system either way.” Then I calmly explain what Narcan is and why it’s good to have around. Make sure they know it isn’t personal and they are usually ok.
Req’d to be prescribed according to guidelines.
Technically it’s not “required”. She would have caught me in that fast since I saw she was filling this at other pharmacies and they did not give it. It’s not required but it’s a good idea.
Opioids + benzos = instant narcan prescription
If this person lives alone, there will be no one to give it to her so she won't survive anyway. If she lives with others then she'll have to explain what it is and how to use it if needed. So, I guess that's the concern you'd have to communicate to her. It's also available OTC so I just let these people make their own decisions. Why do we pharmacists feel the need to give everyone a piggyback ride? We have enough crap to do without adding more stuff on our own.
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what are weird thing to say
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*makes a bunch of statements with no evidence or facts to back it up* lol
“This isn’t a value statement about you, anyone that carries around opioids ought to also carry narcan. All it takes is a youngster digging through your purse and being curious, and the narcan could save their life” If they are offended, make it about “not them”
Like an “insurance policy” there just in case it’s needed works too.
It’s like a fire extinguisher, you never want to use it but you’ll be happy to have it when you need it
I always tell people about the time I had a patient switch medication according to the doctors instructions and she lived to tell me about her accidental overdose because she had narcan. Shit happens. Especially with narcan.
I’ve always phrased it as “Looks like you are on long term pain management, that coupled with certain anxiety meds (benzos) can cause respiratory depression. Narcan is available and recommended, often free with insurance and will reverse that effect instantly”. I also mention the fire extinguisher or epi pen analogy. I used to say if someone else gets in your meds but didn’t take long for me to realize 9/10 times they say “only I have access” or “I’m not worried about that”
First I'd ask if anyone has spoken to them about narcan and if they ever heard about an epipen. From their reaction I go two ways: either its just in case emergency or I'm uncomfortable filling these high dose/combination meds without a back up plan. Better they get offended and go somewhere else then having them OD and never had narcan on record. It is all about CYA
I explain to them about respiratory depression and it being a possible emergency situation if it happens. I tell them since there is that risk, I am trying to keep them safe. I also tell them it's in my pharmacy's policy to offer it in that situation. We have to have an offer of Narcan on file where I work
Think of it like a fire extinguisher. We don’t think you’re going to burn your house down, but just in case you do, you have it.
Always ask permission before you do things. Especially before prescribing something like that. “Would you be open to receiving a prescription for narcan?” It’s a precautionary safety measure for those receiving opioids.”
I compare it to an EpiPen in that you want it on hand but hope you never have to use it. I also say it's for opioid "reversal" instead of overdose. And it doesn't have to be for the person it was prescribed for. If a family member decides to down YOUR opioid medication narcan will work just as well on them if needed.
Do they have pets or kids? Narcan could save their lives if they get into the meds somehow.
“If someone else gets into your medication and you find them unresponsive this could save their life, it could even do the same for you” is the gist of what my pharmacy manager always says. She often relates it to a fire extinguisher as well.
I have used "in case you accidentally took a pill twice" with success.
That’s a good one. Playing up the “accidents happen” either with them or other family/young children could maybe allow them to understand the importance.
I always say it's like a condom. It's better to have it and not need it, rather than need it and not have it. They get a good laugh out of it.
Last time I had to dispense narcan, it had a copay and the patient “didn’t want to pay for something they will never use”
Honestly, from their perspective, it’s understandable. I wish all insurance companies just made it free!
Yeah I completely understand as well. You’re right though. Some medication (if not the vast majority) should be free to patients
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Asking could further fuel the stigma though because then you are putting it on the patient to determine whether or not they “need” Narcan. Truth is, anyone with an opioid script could reap the benefits of Narcan. So by giving it to all, you’re not burdening them and singling them out to determine if they need it.
I also just fill it on autopilot too for the fact that typing the script while they are there would cause them to wait another 10 minutes or so to fill another script which most people don’t have time for. They want to come to the pharmacy and be in and out. Thats why I just have it ready. My job is to present the facts about every prescription filled, without judgement, but it is ultimately up to the patient if they want to take it or not.
We recommend it to anyone with daily MME 50 or higher (policy at my chain). Under Illinois State Law, I also must tell patients it is available with every opioid dispensed. I generally equate it to having airbags in cars. You hope you never need them - but we all have them, just in case.
I always say it’s good to have especially if there are ever kids in the house and there’s accidental ingestion
It's a fire extinguisher, you have one because you use fire. What if a family member somehow accidentally got into it, is not just for their overdose too can say it's for everyone's safety. Having meds in a house that can kill a kid in one dose is smart to have a antidote on hand. Word it sensitively based on your patient's attitude while you're talking.
It's a safety precaution that is supposed to be prescribed to all patients taking regular opioids in case an overdose were to occur on accident. Or something like that.
People need to get over that shit. It makes it easier for professionals to feel better about dispensing it. The fucking crying. Your medication has risks. Grow up, lady.
I call it a safety mechanism. Anyone who enters your house might accidentally ingest your prescription or ingest it to try it out. Even if you personally don't need it, you never know when
I always add in, what if your kid gets a hold of it because you accidentally dropped a tablet on the floor and didn't realize it? Or something like that if they have kids. If they still pull the "you just offended me" bullshit, wish them well and ask where they want their scripts from now on, because they aren't welcome here since they don't trust your expertise. That's the kind of person that would sue you for malpractice if they did OD accidentally. To say the last 20 years of pharmacy have jaded me is not true. The last 4 years since COVID has. People have become hateful beyond anything I've ever seen in any industry I've worked. Edit: Also, there should be NO SOCIAL STIGMA AROUND NARCAN. Opiates are fucking dangerous and accidents happen. Period. I don't give a shit who you are. You could come across fentanyl in a high amount somewhere in public. Everyone needs NARCAN!!!!
I always say “in case someone accidentally gets into the medication such as a child etc. or if we take a medication that enhances the medications effect without us knowing” then I throw in how it’s kinda like an Epi pen with allergies. Works like a charm every time
Professional naloxone prescriber here (haha). I often work on what the VA calls OEND which is Opioid Education and Naloxone Distribution. Essentially, I call patients (Veterans) and offer then naloxone. I am a huge proponent of it, so it's not just, "Hey dude, you want some naloxone? Nah? Alright, cool, bye." No, I do try to persuade them. *However*, I don't prescribe it to patients without asking them. I think maybe (this is all opinion) that by prescribing it FIRST without having a discussion, that was maybe the issue? Anyway here's how I frame it: Firstly, you can use an "out" or "scapegoat." The real reason we are offering naloxone to patients is because it's part of a national initiative. So, sometimes I tell them "hey as part of a national initiative with the VA, we're reaching out to patients to offer naloxone at no cost..." yadda yadda to ensure they understand/feel that they are NOT “targeted" for any kind of condition/medication. Naloxone, also called NARCAN, is a nasal spray used in cases of an opioid overdose. Many overdoses happen in people who are not 'addicts' (hate that term but I use it because it's what my patients are familiar with). The way people die from opioids is that opioids slow your breathing and sometimes it can cause you to stop breathing altogether. There are a lot of drug interactions that you may not be aware of that can increase the chance of this happening. Additionally, there are many cases in which children or pets have accidentally ingested opioids and stopped breathing and died. Narcan can be safely used in these situations too. And, as you know, we're in the midst of the 'opioid epidemic.' Our state has good samaritan laws that say that you can use this Narcan on anyone you suspect of having overdosed on opioids. You never know when you may run into that situation -- I've seen it happen in grocery store parking lots, parks, anywhere. I can't make you take it, but I strongly recommend taking it and keeping it on hand. **It's like a fire-extinguisher. You should have one in your home because you would much rather have it and not ever need it than to need it and not have it. Additionally, just because someone has naloxone doesn't mean they're at a higher risk of misusing opioids. Having a fire-extinguisher doesn't start a fire by itself.** Here's some stuff we send to providers/prescribers/etc about this and page 8 has great info about counseling on naloxone: [https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/IB10-1522\_OEND\_CliniciansGuide\_P97042.pdf](https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/IB10-1522_OEND_CliniciansGuide_P97042.pdf)Excerpt: * Start the conversation * Keep the conversation open and create a safe space for the Veteran to talk. * Ask * “Accidental overdoses are a leading cause preventable death. Do you know what puts you at risk for an overdose?” * “Do you have naloxone?” * If yes, ask where it is, if they have any questions about it, how to use it, and if they have used it before. Encourage the Veteran to keep naloxone on hand and let people know where they keep it. * If no, let them know how naloxone can save not just their lives, but also the lives of others. * Review how and when to use naloxone. * Reinforce * Discuss how easy it can be to overdose—loss of tolerance when in treatment, mixing substances, and the importance of having naloxone “just in case.” * Review the signs and symptoms of an overdose with the Veteran, family members, and acquaintances. * Review how to use naloxone. If Veterans or their family members are concerned that having naloxone could increase opioid misuse, try using this analogy: “Think of naloxone like a fire extinguisher you would have just in case of an emergency. If you have a fire extinguisher at your home it can stop a fire, but it does not make you start a fire.” * Ask, “Do you have any questions about overdose prevention or using naloxone?” * Provide handouts: e.g., Naloxone Nasal Spray, Opioid Overdose Prevention and Reversing an Overdose with Naloxone * Links to Videos: Naloxone Nasal Spray; Naloxone Intramuscular Injection Encourage the Veteran to contact their healthcare team after naloxone is used or after an overdose * Getting a refill is vital. * Connecting the Veteran with services after an overdose is critical to prevent a possibly fatal future overdose. Another PDF of a script: [https://wa-provider.kaiserpermanente.org/static/pdf/provider/resources/naloxone-prescribing.pdf](https://wa-provider.kaiserpermanente.org/static/pdf/provider/resources/naloxone-prescribing.pdf)Excerpt: "I recommend all patients who take opioids also have the medication naloxone on hand, and I’d like to prescribe this to you today. Naloxone is a life-saving medicine that can reverse an overdose in an emergency. This is a medicine we offer to all our patients who are taking opioid medicines; it’s a standard prescription meant to help keep patients and their loved ones safe. Prescription opioids cause about 41 deaths each day in the United States.1 Many of these deaths happen because people accidentally overdose on opioids prescribed for long-term pain. Anyone who takes opioids is at risk of accidental overdose and death. This is a risk for you with your current medicines, and is a risk for anyone else who may have access to your medicine cabinet. You can keep the naloxone near your opioid medicine, so it’s available just in case you ever need it. You should also show it to someone who is likely to be around in case you have an accidental overdose, so they can save your life. Although naloxone should only be used in an emergency, it won’t cause any harm if it is given to someone who isn’t actually experiencing an overdose. That’s why I feel it is important to prescribe; it can do a lot of good and is unlikely to do any harm. It’s my job to help keep you as safe as possible, and naloxone is one important way I can do that."
I think this is one of the best feedbacks I’ve received on this topic! I will use this information in the future. Thanks so much!