Ask a Pharmacist Anything: September 24, 2018



  • @Forum_Moderator
    We did have a couple of questions about restrictions on filling prescriptions, I assume from people with pain who are taking opioids. Some of these restrictions are due to the strict requirements for checking previous prescriptions against the dosage prescribed, so that pharmacists are not filling new prescriptions or providing refills until the person SHOULD need a new supply. Other restrictions, such as daily dispensing, may be required for safety reasons, but these reasons should be explained to you clearly. If you feel that these restrictions are unnecessary for your safety, you are entitled to a frank discussion with your doctor and to negotiate something that is fair, and necessary. These requirements could be a standard statement on an opioid agreement, but these agreements should be adjusted based on your individual needs.
    Thank you all for your interesting and challenging questions!
    I hope this has been helpful to you.



  • The live discussion is now closed. Thanks everyone!



  • Great! Thanks so much for taking time out of your day to be here with us today, Terri. Our live discussion has offered great insight on some pharmacological options that are available for people in pain.



  • @Forum_Moderator
    I wanted to respond to a question I saw on the discussion forum that was posted recently, about acid reflux problems while taking cannabis oils. The reflux might be due to the oil used to make the drops (usually coconut, I think), and possibly due to the plant terpenes in the extract, that might be irritating to your stomach. I have it on good authority (a family member) that an antacid usually gives adequate relief. She uses Tums Ultra!
    Taking the oil with food, especially starchy foods that empty from the stomach quickly, might help. But food also tends to delay the absorption of the helpful compounds in cannabis (CBD and THC). As long as you are consistent in taking it with food, you can adjust your dosing times to allow for slower absorption if you experience this.



  • Terri, as we near the end of this live chat is there anything else you'd like to share on the topic of pharmacy as it relates to people with chronic pain?



  • Thank you. Here's another question we received from a person in pain: My pharmacist is withholding my prescription. What are my options?



  • @Forum_Moderator
    I can certainly understand the discomfort some people may feel about discussing their use of medical cannabis! Unfortunately, there is still some stigma surrounding it, even directed at those who have authorization under the Health Canada program. The risk of being judged for using it doesn’t encourage open communication between those who use it with good effect, and their health professionals. It is good to hear, though, that your doctor was willing to authorize it for you!
    Having said all this, it is most definitely worthwhile to advise your pharmacist about your medical cannabis use because we know of a few potential interactions between cannabis and other medications. These are more of a concern if you are already on medications at doses that seem right for you. If you begin using medical cannabis, it can increase or decrease the effects of some other medications (examples – estrogens, some antidepressants and medications for epilepsy) by changing the rate at which your body clears them out. If they become less effective, or side effects suddenly appear, doses may need to be adjusted. If your pharmacist knows you use medical cannabis, they can help you identify potential drug interactions and can discuss with your doctor how to adjust your medications.



  • @Fred8
    Yes, and some pharmacists may be better informed on the usefulness of supplements than others!
    There is a lot well-meaning discussion out there about various supplements, but it is good to ask if there is objective evidence to back up the claims for them. Many pharmacists will have access to on-line resources such as the Natural Medicines database, or will know of websites that provide unbiased information on the usefulness of commonly used supplements based on properly conducted studies.
    A couple of examples I can give you - studies of glucosamine don't strongly support its use, except for one, I think, that found some benefit (less pain) for osteoarthritis of the knee. There have been some limited studies that showed some effect of turmeric supplements for pain due to inflammatory conditions (things like rheumatoid arthritis).
    Most have very few side effects except maybe some stomach upset, but ensure you get some sound advice on effectiveness and safety before you try any of them. Some of them are also quite expensive, and it's best to save your money for things that work!



  • Great! Going back to your discussion around cannabis for pain, here's a question we received in advance: I use medical cannabis to help manage my pain and I don’t feel comfortable talking to my pharmacist about it. Do I need to? Are there possible interactions it could have with some prescribed medications?



  • @Forum_Moderator
    Over the counter medications that can be helpful in alleviating pain include acetaminophen (Tylenol, Tylenol Arthritis & other generic brands), ibuprofen (Motrin & generics), naproxen (Aleve & generics). Acetaminophen is safe in recommended doses – no more than 4000 mg a day for adults; no more than 3000 mg a day for those over 65 years old; and no more than 2000 mg a day for people with serious liver disease. Ibuprofen and naproxen (which are NSAIDs) should not be used by anyone with heart failure, kidney disease, or a history of stomach or intestinal ulcers, and should only be taken infrequently by anyone with high blood pressure.
    There are also products that can be applied to the skin, and can be helpful for specific painful areas, such as diclofenac gel (Voltaren), menthol and wintergreen creams and ointments (e.g. Rub A-535) and capsaicin creams. These cannot be applied to areas of broken skin, or to large areas of skin, and can be irritating. A pharmacist can help you select the best product for your situation



  • Can a pharmacist advise me on supplements for pain?



  • @Forum_Moderator
    The most common non-opioid medications that can be helpful in managing chronic pain include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) like celecoxib (Celebrex and generics) and many other prescription drugs in this category, and over the counter ibuprofen and naproxen (Motrin, Aleve, and generics). Some patients may benefit from adding antidepressants such as amitriptyline or venlafaxine; others may find adding gabapentin or pregabalin is helpful for nerve pain. There are others that are generally only used if none of the above are helpful or have caused intolerable side effects. Medical cannabis (marijuana), as we just mentioned, also fits in this category, and is helpful for chronic pain in some patients. We are learning much more about cannabis with new research.



  • Terri, are there any alternative medications to opioids, whether prescription or over the counter medications, that can be helpful for some people with chronic pain?



  • @Fred8
    This is a difficult situation, for sure. Some of the newer opioids that have other actions than the usual opioid effects might be more helpful, but this is hard to predict. The ones I have in mind here are tramadol and tapentadol, that have some minor effects that are similar to some of the antidepressants. Having said that, for some people the side effects may be worse, or just as bad, but different - in other words not any better.
    It has certainly become more common, especially in the last year or so, for people in pain who don't tolerate opioids very well to look into medical marijuana as an option. It can be a challenge to find physicians who are comfortable with recommending and authorizing it, and experienced in prescribing it so they can advise you on how to choose products and what doses to start with. But, if trying new opioids has not been helpful, this may be worth considering if you can get access to good medical advice.



  • How long should I keep trying different opioids? It's hard to know whether I just have to put up with the side effects or if there's another, better opioid I could be using?



  • @Clearwater

    1. Opioids are mostly quite similar in their overall effects. However, in practical terms, some individuals find they tolerate some medications in this group much better than others! This probably reflects differences between people in how these medications are cleared out of the body and how quickly, whether they are broken down by the liver, filtered out by the kidneys, etc. For example, some people have no pain relief from codeine, because they do not break it down to its active form, morphine. Others have a very rapid peak effect from codeine because they are very efficient at breaking it down; others are in the middle somewhere! Elderly people generally have less capacity to break down and clear drugs from the body, and often have more trouble with side effects as a result.
      There are newer opioids available which have some unique effects, and may be more helpful for pain and better tolerated by some. Others may have more side effects because of these differences. Choosing the right medication from any group of drugs, including opioids, may be a process of trial and error.


  • Are there any opioid medications with fewer side effects?



  • @Forum_Moderator

    1. The most common side effects of opioids include:
      a. Constipation – those who take opioids on a daily basis should always be taking an effective laxative regularly; your pharmacist can provide advice
      b. Sedation – feeling sleepy and having difficulty concentrating, which may interfere with daily activities. If you notice these effects, wait until they pass before attempting anything that requires awareness and concentration e.g. driving.
      c. Nausea (sometimes with vomiting) – may be worse when opioids are first started, and may improve with time. Higher doses, and short acting opioids (those that must be taken every 3-4 hours) may also make this problem worse. Sticking with the minimal effective dose, and perhaps switching to long-acting (every 12 hour) products may help.
      d. Sweating – try to avoid overheating, e.g. dress in layers. Sweating may also be due to poorly controlled pain, so can be difficult to sort out, unfortunately
      e. Withdrawal effects if dose is reduced too quickly
      f. Mood changes, hallucinations can occur but are less common


  • Great, thanks for answering the first 2 questions Terri. Another question we received in advance asks if you can go over some of the common side effects of opioid medications.



  • @Clearwater

    1. Finding a good pharmacist is a very worthwhile goal, for all the reasons just described in the response to the first question! It can be helpful to ask friends and relatives who have health care needs, and attitudes toward their health care, that are similar in some ways to your own. If they are happy with their pharmacist(s), they will be willing to recommend them to you.
      Also consider any personal preferences, e.g. if you are more comfortable talking with a pharmacist who is of the same gender or in your own age group.
      Many people have used this approach successfully to locate a good family doctor, and it applies just as well to pharmacists. The advantage you have with pharmacists is that they are always able to take on new patients, and a good one will always find a time to talk with you later if they are very busy when you are at the pharmacy.

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