Scared of meds, even more scared to not take meds...has anyone had this combination of medications?

[NovaCain]

I am on Zoloft just starting out, no negative side effects as of yet, clonazepam for panic attacks and prazosin at night for nightmares. I have neurocardiogenic syncope aka vasovagal syncope (low blood pressure) and am scared that these combined may not do well. I constantly have shortness of breath (from anxiety) and want to take a clonazepam to calm it down before it becomes a panic attack but I don't want to black out. I would like to know if anyone else has low blood pressure and takes these medications without issue. I am sure it will be okay because the doctors assured me that they would not negatively effect me but I have never taken meds before and want to make sure. I might just be psyching myself out here...who knows.

 

[Friday]

Not those specific meds, but whenever I'm uncertain about taking meds together or singly I usually do 2 things;

1. check with my pharmacist.
2. bring a book & take the meds IN an ER.

I used to work in an ER. It's just something some people do. You tell triage you're taking a new medication combo, don't expect any problems (or these are the problems you're possibly expecting) but if there are want to be on hand for immediate intervention & observation, and then go read a book in the lobby for a few hours. That way they already have your medical history & what you've taken pulled up for easy access if things go badly, but you're not charged a few grand for sitting in their waiting room.

 

[NovaCain]

Wow, that is a great idea, I may just have to do that. Thank you so much for your response I may also look to see if there is something that helps panic attacks without lowering blood pressure. Of course I feel like your blood pressure raises during a panic attack. Either way your ER idea sounds great and I have insurance that will cover anything that does happen if I do need to be treated.

 

[EveHarrington]

Definitely check with a pharmacist. They will be able to tell you so much more than a doctor when it comes to drug interactions.

 

[ParalyzedMind]

A pharmacist knows the facts about medications, but they are not capable of reading your clinical picture.

They operate more on theorems and statistics, so they will be little help in your individual situation. One easy thing to do here is to follow the money. A pharmacist has nowhere close to the liability of the physician who prescribes your individual medication.

When I was practicing, it was much more often a pharmacist was erroneous in pointing out adverse effects/interactions than they picked up any faults from my side. This is why they answer generic statistical advice about medications when they dispense the medications on first pick-up. Hospital pharmacists operate the same way, they screen any drugs ordered and then page on-call or prescribing physician to confirm this or that interaction, but donor have clinical picture.

Yes, theoretically any alpha-blocker (prazosin example here) will lower BP and are often excellent for people with prostrate problems for that reason. Likewise, any benzodiazepines are likely to increase propensity of dizziness, but I think it is exceedingly rare for blood pressure to drop so much that it leads to clinical deterioration, or hypotensive emergency, as long as dosing is adhered to.

Sorry, but I had to defend my previous profession here a bit. If it was up to them to determine prescription of medications and we should adhere to all their statistical warnings, while they do NOT know neither your medical history nor clinical state, I don't know how many medication would be used and especially not "trickier" combinations that are needed in "trickier" cases.

We both have roles to play in different settings. It is very sad to see how they also have become a part of the physician-bashing in many cases. I know excellent pharmacists I used to work with, but we were never antagonists or competitors.

Finally: If a pharmacist "misses" a certain degree of drug interaction, who do you think will get sued?

 

[Neverthesame]

Good thinking Friday. Love that idea.
You don't see people do that here because of healthcare plans. But damn that's clever.

@NovaCain Friday's idea is better than anything I'd have thought of.
I haven't been on those meds all at once, nor do I have issues with hypotension.
But I do remember the Prazosin damn near made me faint the first couple times I took it.
I can see why you'd be wary of the mix.

Like your username as well. When at the dentist, my best friend is Mr. Lido Cain. ;)

 

[EmmaOwl]

I would like to know if anyone else has low blood pressure and takes these medications without issue.

I have ridiculously low blood pressure, I mean, like 85/65 low. But it still varies. Today I was at the doctor (unrelated problem), and even with the beta blocker that my psychiatrist prescribes for PTSD, I was *extremely* anxious and BP was all the way up to 108 /70. So..careful but ... Well, just be careful. I am probably a bad example because I've taken such a sh*tload of medication over the years and some of the meds have built up to physical tolerance levels.
but I've been taking a beta-blocker that's supposed to ease nightmares - propranolol - which is comparable to prazosin that so many people mention. I understand that one is an alpha-blocker but I expected and experienced similar effects on both of these meds. I've been on for a couple years now and have not fainted.

I take the betablocker "as needed" - usually I choose not to during the day, so I generally spread my 3 doses throughout the night, it helps me sleep and then I just have to be careful not to jump out of bed too quickly. (Although, now that I think about it, I haven't jumped out of bed too quickly for a very long time, medication or no.) Don't take and dive into the driver's seat. Maybe try not to take the prazosin and clonazepam at the same times? But I'm not a doctor, blah blah, all medications have risks and everyone reacts differently. To me, the Zoloft is the wild card - it seems like everyone really does react differently to that one.

(@NovaCain and @Neverthesame: The username throws me off a little b/c my physical therapy is at NovaCare (hey, free advertising!). Now the name makes more sense. :) )

 

[EmmaOwl]

Sorry, but I had to defend my previous profession here a bit. If it was up to them to determine prescription of medications and we should adhere to all their statistical warnings, while they do NOT know neither your medical history nor clinical state, I don't know how many medication would be used and especially not "trickier" combinations that are needed in "trickier" cases.

@ParalyzedMind since I have "tricky" combinations I've gotten to know a couple of pharmacists pretty well - more accurately, they've gotten to know my medical history. I hold my breath and take the step and say, "this is what I've got going on all at once" and I really appreciate what an even more difficult job it is when people DON'T ask their pharmacists... All of my medications interact with one another and it's basically a disaster but both the main guy at my local chain, and the owner of my local spot know my medical history fairly well and I'm confident in them - often feeling embarrassed, but better than the alternative of a bad interaction that could've been prevented. Meanwhile, a doctor and/or hospital chart appear with vague lists that I always have to stay on top of. Pharmacists do not have an easy time of it and IME they are much more likely to catch potential problems, and quicker to fix them, too.

 

[ParalyzedMind]

I understand what you are saying, but I must still wonder:

Why do you go to "your pharmacist" if you are concerned about medications prescribed you?

Furthermore, do you really think they know your medications (and the effects upon you) better than your prescribing physician? I can simply reiterate what I have said before: They are not clinicians and have never been responsible for healing a single person, as that is not their role.

Maybe I was just used to my patients feeling comfortable with me, because I cannot recall many episodes when a pharmacist came and "saved the day" because I missed something.

Finally, if you think about psychiatrists alone, it is really not that many different drugs they deal with. I think they are quite capable of knowing the interactions if he few ones they give out.

 

[Neverthesame]

Finally, if you think about psychiatrists alone, it is really not that many different drugs they deal with. I think they are quite capable of knowing the interactions if he few ones they give out.

True. But the psychiatrist is most likely not the only one prescribing a patient medication.

A patient may not think to mention to a prescribing psychiatrist what other medications they have been prescribed by their physician. Or what over the counter medication they may be taking.

Since most people go to the same pharmacy for all prescribed drugs, it's likely the pharmacist will have a fairly complete list of meds currently and recently prescribed by the patient\customer including any drugs which are non-script recorded sale. For example analgesics such as codeine are recorded sale here in Canada. No script required. Only recently have information systems been put into use that link your pharmacy and GP.

Nowadays my doctor can look up any recorded sale meds I have purchased, but only a few years ago she'd have had to rely on my memory.
Even that isn't infallible. Every time I need to be prescribed something from my doctor, she has to verify that I am not taking Wellbutrin. I've never been prescribed Wellbutrin, or given it as even a sample. For some reason a pharmacy I went to once erroneously entered into my file that I am prescribed that drug. The doctor couldn't get it removed, so I had to physically go to this pharmacy to remove it from my file. Funny thing is, they have no record of me filing a script for Wellbutrin on site. So it's not even the pharmacists fault.
Oh, Alberta Health Services, how I love you... :banghead:

Obviously this doesn't mean that the pharmacist is a 100% reliable safety net, for the reasons you already mentioned. However if there is a possible drug interaction that was for whatever reason missed by the Psyc and or GP, the pharmacist is one more person who may catch it before the patient suffers it. They're also more likely to be aware of minor interactions that affect quality of life, as most people (especially when they have to pay out of pocket) won't book a follow-up with a psychiatrist because of excess mucous production or other seemingly minor things.

I used to be an EMT (long time ago now). I know from experience that patients don't always tell you everything you need to know about their medication history. Either they forget, fail to understand the relevance of medication for unrelated ailments or are unconscious.... <----that was a joke.
Nor does a physician, psychiatrist, nurse practitioner, paramedic or pharmacist know everything about all medication. It just isn't reasonable to expect the prescribing psychiatrist to catch everything. I think having a layer cake of professionals between the patient and the drugs to be a good thing for patient safety.
Even if all pharmacists were totally useless, if one catches an interaction before the patient ends up in the ER I think that it would have been worthwhile that the patient spoke with them.

I'm a firm believer in researching ones own medication. I also know you have a point in the lower requirements of education and lack of legal culpability for misinformation from a pharmacist. I still feel that it's better a patient be as informed as possible from as broad a source as possible.

That is my reason for suggesting a person consult with a pharmacist.

Figures, I try to keep it brief and it turns into a novel. I try to write a novel, you could fit it on a post card.

 

[ParalyzedMind]

First of all, I cannot comment on the Canadian healthcare system as specific as you are, but clearly a few things seem odd from what you say.

*Codeine is an "analgesic" in Canada and also over the counter?! You have opiates over the counter? Not sure if this is what you meant, but it seems odd.

*A psychiatrist is a physician. He surely is capable of deciphering interactions with his meds and whatever else the patient is on. Again, maybe it is different in Canada, but here a physician will tend to both want awareness of all other drugs and have to take it into consideration. Since there are plenty comirbidities in people with mental health, this is more a norm than an exception.

*I don't know what the entire Wellbutrin issue comes from, but it seems amazing to me that this is such a problem. In any case, this is all on the pharmacist, but I cannot see how that is an issue at all. Medication list is as standard in USA as blood pressure and social history. Seems very odd, to say the least.

*That a pharmacist is more aware of "minor interactions" with regards to medications prescribed than the prescribing physician is something I have never heard about. Mostly, since they deal with ALL drugs of different kinds, my experience is that it is the other way. Especially with regards to mental health and the fact that there often are many adverse effects, some even beneficial, this is not something a decent physician will ignore and especially not s psychiatrist.

*Patients call and address us if there are any concerns with medications. If they don't return because of a perceived adverse effect of a medication, the physician-patient relationship cannot have been very strong to begin with. Again, maybe the Canadian healthcare system is more assembly line with shorter visits, but I personally am not sure if I have lost many patients to such.

*You are correct that patients don't always tell everything about their medical history, but who do you think they are more likely to disclose it all to? Their physician whose job it is to comprehensively assess and plan treatment with; or the pharmacist who dispenses the medication in an open setting for all to hear? Neither do pharmacists have any medical records, so they are only capable of responding to what patient says and whatever medication list they have at hand.

*The liability is a major issue and an everpresent reminder of who is REALLY in charge and has the gun to the head. The notion that physicians are insensitive and ignorant, while pharmacists is the empathic and rigorous cavalry that comes to the rescue, has unfortunately become an ingrained "factoid" for many.

*Finally, if a pharmacist mentions an adverse effect, it will never sound quite similar to how it was mentioned in the physicians office. Is there a risk of harm if the patient gets focused on a minor adverse effect and simply stops taking the medication due to that and THEN don't return to physician? Absolutely.

 

[Neverthesame]

Canadian healthcare system as specific as you are, but clearly a few things seem odd from what you say.

This is entirely possible. It is a very different system. Not necessarily a better one. Cheaper for the patient, not necessarily the same quality of care.

Codeine is an "analgesic" in Canada and also over the counter?! You have opiates over the counter?

I apologise, I am at work, so I'm writing this in bits as I have time. So I might miss a detail here and there.
It is sold over the counter without prescription, in the forms of an oral analgesic with caffeine and acetaminophen. Also as we as a respiratory suppressant in cough syrup. Again, sold over the counter without prescription. Recorded sale is the only restriction. I agree it's baffling.
Especially considering until recently you couldn't get napproxen without script. Which I'm sure you know is an NSAID. Again baffling.

A psychiatrist is a physician. He surely is capable of deciphering interactions with his meds and whatever else the patient is on.

Of course. I didn't mean to suggest otherwise. But as I mentioned, information isn't always available to the physician in a timely manner. At least not here.

a physician will tend to both want awareness of all other drugs and have to take it into consideration.

Again, I understand this. Moreover this is what I would expect from anyone who holds a licence to practice medicine. We are in agreement here.
I'm speaking less of policy, more of real world scenarios in which patients are not always forthcoming in regards to relevant information. Either due to ignorance or deliberate choice.
It happens. Remember all those people who got sick from mixing Rx with herbal supplements back in the 90's. That's the sort of thing I'm referring to.

I don't know what the entire Wellbutrin issue comes from, but it seems amazing to me that this is such a problem.

That's what I said.

That a pharmacist is more aware of "minor interactions" with regards to medications prescribed than the prescribing physician is something I have never heard about.

I'm referring to the idea of what a person who has a minor complaint about a medication is likely to say to a pharmacist when they are being given the list of possible side effects the first time, or asked if they have questions on refilling a script. A pharmacist is likely to hear alot of complaints about minor annoyances caused by their prescription drugs.

this is not something a decent physician will ignore and especially not s psychiatrist.

Of course not. I wouldn't suggest otherwise. But they have to be made aware of it in order to deal with it. Which in a short rushed visit, which unfortunately is often the case here, minor issues aren't likely to be, in favour of larger issues or concerns.

Patients call and address us if there are any concerns with medications. If they don't return because of a perceived adverse effect of a medication, the physician-patient relationship cannot have been very strong to begin with.

This is probably another one of those geographic discrepancies of patient care. I have never been given a phone number to call about a serious problem with meds. If a person here feels that they are suffering from any serious complications of treatment. They are instructed to call poison control or go into the ER for assessment. The days of phoning the doctor for anything other than booking an appt, are long over.

maybe the Canadian healthcare system is more assembly line with shorter visits

It certainly seems that way, yes. Sadly.

You are correct that patients don't always tell everything about their medical history, but who do you think they are more likely to disclose it all to?

I think that ties in with the last quote. Plus I want to make clear that I I'm not suggesting that a pharmacist, their training, or experience is in any way superior to that of qualified physician.
If I were suggesting otherwise, you would be safe in assuming I was dipping into the codeine.

Neither do pharmacists have any medical records, so they are only capable of responding to what patient says and whatever medication list they have at hand.

Again true. But even the medication list is useful, not as a replacement for the advice of a physician, but as an additional source of patient information on top of what the patient received from the physician. That's the point I'm trying to make.

The liability is a major issue and an everpresent reminder of who is REALLY in charge and has the gun to the head. The notion that physicians are insensitive and ignorant, while pharmacists is the empathic and rigorous cavalry

Not suggesting that at all. I'm just suggesting that pharmacists aren't useless.

Finally, if a pharmacist mentions an adverse effect, it will never sound quite similar to how it was mentioned in the physicians office. Is there a risk of harm if the patient gets focused on a minor adverse effect and simply stops taking the medication due to that and THEN don't return to physician? Absolutely.

This is a very good point. Of which you are absolutely correct. It is also something pharmacists tell their customers here, as well as written in the literature package that is given with a medication. You should cease a medication based on a pharmacist's advice. As yes, that would be very irresponsible advice for any patient psychiatric or otherwise. They should either book a new appointment with their prescribing physician, or go to the ER, if they feel that a current medication is causing them harm.
But, this is not what is being discussed here.

In the case of starting a new medication on top of what is already prescribed, getting some information about what to expect, isn't a terrible idea in my opinion. A pharmacist is more accessible than a physician in most circumstances. I honestly like the idea of going to the waiting room of an ER far better than seeing a pharmacist.
I just don't think a pharmacist is totally useless is all.