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Pharmacy switching my caree from fentanyl to zoromorph

Posted: Fri Jan 04, 2019 9:08 pm
by Colin _1706
I will try and explain as clearly as possible.
My caree has been on fentanyl patches for about 2 years now and it's quite tricky to manage.
Her fentanyl prescription is for chronic pain in her spine, head and pelvis. She has several chronic health problems and has been under the neurology team and pain management clinic recently. She has to pop back to the pain management clinic every year or so for a review and tuning of her pain meds as and when she feels the need.

But today she had a phone call from the pharmacy that is near to our GP practice and they said that the GP has asked for her fentanyl to be changed to zomorph for purely cost saving reasons. A name of GP was not given by the pharmacy and she does have an assigned GP at the practice.
The pharmacist said she will be coming off fentanyl; at the end of this month and be going onto zomorph immediately after 3 days which is the normal patch day as we cal it.

Now I feel unhappy about the pharmacy chaning her drugs in this way and they have changed my prescriptions before now in the name of saving money by one of the pharmacy staff just popping over to the GP reception and getting the reception to change my prescription and take it over. I have let it go before now with one of my minor meds but now I am very concerned.

The pharmacist said it was ok and that the gp had asked them to change her pain meds to something cheaper.
Obviously when anyone has several very serious health problems which require complex balancing of her meds this requires more careful consideration than a pharmacist wanting to save costs. I had my cheaper latanoprost eye drops changed to the Pfizer brand after being told it was cheaper by the pharmacy when in fact my GP had previously turned down the Pfizer eye drops on the grounds of them being much more expensive than the basic latanaprost whom Pfizer buy the basic product from and add their own content and labels.

On the first online page of drugs it states that one of the contraindications of Zomorph is raised cranial hypertension of which my caree has suffered for many years and historically it has been very difficult to manage. The pressure in her head can become intolerable and she can become quite irrational as a result, apart from the chronic pressue4 she can experience in her head.

So my alarms bells are jangling very loudly.
Has there been any consultation with her assigned GP?
Any changes and certainly any changes of a very serious nature should be discussed between both of us and her GP and instructions should be on her GP file, but not in a phone call from the pharmacy who claims to have been instructed by the GP practice. Was there in fact any discussion with the GP practice? or her assigned GP?

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Fri Jan 04, 2019 9:41 pm
by Colin _1706
Minor correction.
The pharmacist who called is working for the gp practise not the independent pharmacy which supplies our meds.
I didn't know the GP practise had a pharmacist so perhaps this is a new staff appointment.

The situation is that this change needs to be discussed between all four of us. The GP, the pharmacist, the caree and me the carer.

I am still not happy that this pharmacist has missed a clear contraindication for a serious health issue. That's just me looking quickly online as a non medically trained person. So I wonder what else has the pharmacist missed?
Here we go again.

My caree agreed to the change over the phone but after a difficult discussion she now realised she was ill advised. The pharmacist said she would contact my partner 2 weeks after the changeover to see if she was OK.
Err no that is not how it should be done in medical legal terms and not without anything in writing or any discussion between us and the assigned gp.
I went through 6 years of my own medical legal claim post accident so I know the pitfalls and also how things work and don't work.

My partner is already over the safe doseage of fentanyl, so any change over must be done properly and with adequate safeguarding and protection. Ie: she might need withdrawal meds.

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Fri Jan 04, 2019 10:06 pm
by bowlingbun
Colin, I understood that Fentanyl was strong than Oramorph?
Surely they are entirely different medicines? I would have thought this pharmacist was "exceeding his authority"?
Maybe discuss it with the CCCG Complaints Officer?

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Fri Jan 04, 2019 11:08 pm
by Colin _1706
bowlingbun wrote:
Fri Jan 04, 2019 10:06 pm
Colin, I understood that Fentanyl was strong than Oramorph?
Surely they are entirely different medicines? I would have thought this pharmacist was "exceeding his authority"?
Maybe discuss it with the CCCG Complaints Officer?
Thanks bowlingbun, that's certainly a consideration.
I know that due to her medical problems my partner can be quite irrational and sometimes a little naive. So I get concerned about her vulnerability when someone or anyone tries to bluff something past her. My partner has agreed to call the surgery next week and withdraw her consent and explain that we need a meeting and not a normal ten minute consultation with a GP.

Yes fentanyl is very strong and the pharmacist said to my partner they would initially put her on just over 300 mcg of zomorph or zoromorph. I do get very concerned about aspects of the medical professions from my life experiences.

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 05, 2019 5:53 am
by bowlingbun
Me too, my husband died because the GP thought he had arthritis, in fact he'd had one heart attack that was never recognised and was about to have another, fatal attack.

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 05, 2019 11:38 am
by Melly1
BB, that is terrible. I didn't realise that.

Colin, it's my understanding that pharmacists just look at all the meds someone is on and look for contradictions/ reactions between meds. It sounds like the GP surgery has employed a pharmacist to go through all the repeat prescriptions looking for ways to make savings etc but without knowledge of people's medical history.

Good job you are alert and on the case. When S was in hospital they tried to give him something contradicted for those with epilepsy ( he has epilepsy,) it was only because I read the leaflet in the box whilst she went to get something, that I was able to raise this with her.

If the pain clinic are in charge of reviewing her meds, I don't see how the GP surgery can contradict their decisions?

I hope you sort this out quickly, I'm sure you will. They probably aren't used to being challenged!

Melly1

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 05, 2019 12:54 pm
by Colin _1706
bowlingbun wrote:
Sat Jan 05, 2019 5:53 am
Me too, my husband died because the GP thought he had arthritis, in fact he'd had one heart attack that was never recognised and was about to have another, fatal attack.
That's very sad to hear. I'm really sorry about what happened to your husband.
I have been there for two people who would have died if it had not been for my direct and blunt intervention.
I had no idea until a few years ago about how dangerous the NHS is.

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 05, 2019 1:07 pm
by Colin _1706
Melly1 wrote:
Sat Jan 05, 2019 11:38 am
BB, that is terrible. I didn't realise that.

Colin, it's my understanding that pharmacists just look at all the meds someone is on and look for contradictions/ reactions between meds. It sounds like the GP surgery has employed a pharmacist to go through all the repeat prescriptions looking for ways to make savings etc but without knowledge of people's medical history.

Good job you are alert and on the case. When S was in hospital they tried to give him something contradicted for those with epilepsy ( he has epilepsy,) it was only because I read the leaflet in the box whilst she went to get something, that I was able to raise this with her.

If the pain clinic are in charge of reviewing her meds, I don't see how the GP surgery can contradict their decisions?

I hope you sort this out quickly, I'm sure you will. They probably aren't used to being challenged!

Melly1
I will not let this pass, thank you Melly1.
When it comes to complex multiple health issues, not only is the DWP incapable of recognising the issues, the NHS on occasion is too. You are right they aren't used to being challenged, but I will not let my partner come to any harm through incompetence or negligence. I could convey some horrific stories about my partner and my treatment by the NHS, but i am not going to because it will not help others and may cause them to worry and i don't want that.
The bottom line is with the NHS, you have to question everything whether they like it or not.

I have been accused of being blunt in the way i talk to people in some situations. But it was part of my training to speak very directly through my career as a construction project manager. That was a very technically difficult job with a massive amount of stress where the client and the program require direct action. Construction is very hands on and direct. ;)

Could do without this nonsense from professionals who should know better, but this is the way of things now.

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 05, 2019 4:03 pm
by bowlingbun
Colin, my OH was an engineer, my brother was an aircraft engineer, and my son is an engineer too. Engineers are very direct and very logical. I wish Social Workers could be the same!!

Re: Pharmacy switching my caree from fentanyl to zoromorph

Posted: Sat Jan 12, 2019 5:26 pm
by Colin _1706
Took a while to get through to the GP surgery, but we now have a ten minute patient slot for this Friday.
Apparently they don't do patient meetings. Personally i don't think ten minutes is enough time to even scratch the surface.
But we will take some notes for them to read and make a decision later ie; not on Friday.
The new surgery pharmacist is only there two days a week.

Some interesting and relevant notes here.
https://www.rcoa.ac.uk/node/21126

* Switching from one opioid to another should only be recommended or supervised by a healthcare practitioner with adequate competence and sufficient experience. If uncertain, ask for advice from a more experienced practitioner.
* Opioid rotation or switching may be considered if a patient obtains pain relief with one opioid and is suffering severe adverse effects.
* When converting from one opioid to another, the initial dose depends on the relative potency of the two drugs and route of administration.
* An individualised approach is necessary.
* Conversion factors are an approximate guide only because comprehensive data are lacking and there is significant inter-individual variation.
* In most cases, when switching between different opioids, the calculated dose-equivalent must be reduced to ensure safety. The starting point for dose reduction from the calculated equi-analgesic dose is around 25-50%.
* A dose reduction of at least 50% is recommended when switching at high doses (eg, oral morphine or equivalent doses of 500mg/24 hours or more), in elderly or frail patients, or because of intolerable undesirable effects.
* The half-life and time to onset of action of the two drugs needs to be considered when converting so that the patient does not experience breakthrough pain or receive too much opioid during the conversion period.
* Once the conversion has occurred, the dose of new opioid should be titrated carefully according to individual response and the patient monitored closely for side effects and efficacy, especially when switching at high doses.
* Withdrawal symptoms (eg, sweating, yawning and abdominal cramps, restlessness, anxiety) occur if an opioid is stopped/dose reduced abruptly.