The GoodRx Prescription Savings Blog

It’s tough enough to have pain severe enough to be treated with opioid pain medications like Vicodin or Oxycontin—but the side effects can make things even more difficult. Constipation from taking opioid medications can be debilitating and is estimated to affect 40 – 86% of patients using these drugs.

Why do opioids cause constipation?

Constipation from opioid pain meds occurs because of how these medications work. Opioids relieve pain due to direct effects on µ-opioid receptors, which is how they can relieve pain—but these receptors are also plentiful throughout the GI tract (your digestive system). This means a slower transit time through the gut, increased fluid absorption (harder stools) and increased sphincter tone.

What should I do first on my own, before I ask my doctor for help?

Start with dietary measures like more water and fiber, increased physical activity, and over-the-counter laxatives. Laxatives recommended as first-line therapy for opioid induced constipation include stimulant laxatives like Senna, Dulcolax (bisacodyl), or Cascara. There is insufficient evidence from clinical trials to recommend one over another, so pick one to see if it will work for you.

What won’t work?

For opioid induced constipation, bulk forming agents won’t work and may cause more discomfort. Bulk forming agents include psyllium, Metamucil, Citrucel, or Fibercon. These act to increase stool bulk and stimulate peristalsis—movements that push stuff through the colon. Not only will these options not help with opioid induced constipation (because opioids prevent peristalsis) but they may result in worse abdominal pain.

Over the counter options didn’t work, now what?

At this point, see your doctor. Constipation that doesn’t respond to the OTC options above needs the help of your physician. Your doctor may prescribe osmotic agents (eg, polyethylene glycol, lactulose), or newer prescription medications.

What are the “big guns”—the newer prescriptions?

• Amitiza (lubiprostone). Amitiza is a prokinetic, meaning it stimulates motility. It is a prescription medication for constipation that stimulates chloride channels and promotes intestinal fluid secretion. This adds fluid to stool and speeds up travel time through the gut, improving symptoms of constipation.
• Movantik (naloxegol). The newest kid on the block, Movantik, blocks the effects of opioids on the gut and works well in folks who have not responded to laxatives.
• Relistor (methylnaltrexone). Though effective and approved for opioid induced constipation, Relistor is an injection. Given newer pill options, Relistor may be phased out. Relistor is a subcutaneous injection given once every other day or every third day.

Hope this helps.

Dr O.

“Can I just stop my medication?” This question, frequently asked of primary care doctors, has a complicated answer. For starters, if you are taking a medication that is controlling an ongoing medical problem like high blood pressure, diabetes, or high cholesterol you should never stop it on your own—or your problem will return. Many patients do come clean though, and report that they just plain stopped their meds.

So when is stopping your medication dangerous? Abruptly stopping these 10 medications may make you sick, and lead to dangerous problems. The higher the dose and the longer you’ve been taking them, the worse the problem.

1. Catapres (clonidine). This is no joke. Catapres tablets and Catapres-TTS patches are used to treat high blood pressure. Stopping them abruptly may result in a surge of catecholamine release. Rebound very high blood pressures can occur so Clonidine should be weaned slowly. If you’ve been on higher doses of Clonidine this is more likely to occur. Don’t stop this on your own.
2. Inderal (propranolol). Beta blockers like propranolol are used to treat high blood pressure and palpitations, and are even prescribed for anxiety symptoms. While all beta blockers may have a mild effect, Inderal is a short-acting beta blocker, and stopping it abruptly may lead to a withdrawal syndrome. In addition to a rise in blood pressure, beta blocker withdrawal in patients with heart disease can lead to chest pain, heart attack, and even sudden death. Crazy thing is this can occur even in patients who have no previous history of heart issues.
3. Topamax (topiramate). Taken for epilepsy, migraine headache prevention, weight loss (as one of the active ingredients in Qsymia), and alcohol abuse disorder, this is a medication you should not abruptly discontinue. Instead, taper your dosage gradually over 2 to 8 weeks to prevent rebound effects. Why? Stopping it suddenly increases seizure frequency. This happens, I’ve seen it.
4. Effexor XR (venlafaxine ER). Used for depression, generalized anxiety disorder, and menopause symptoms, Effexor carries the nickname “Side-Effexor” partly for this reason: due to its short half-life (how long it takes for the medication to leave your system), stopping and not weaning venlafaxine may lead to horrible withdrawal symptoms. Instead, taper the dose by 37.5 mg to 75 mg per day each week, over four weeks. Abrupt discontinuation of venlafaxine may cause agitation, sweating, dizziness, fatigue, nausea, restlessness, and tremor. Not fun.
5. Paxil (paroxetine). A widely used medication prescribed for depression and anxiety, paroxetine is the most likely of the SSRI antidepressants to cause withdrawal symptoms, again due to its short half-life. Paroxetine needs to be tapered down over two to four weeks prior to stopping. If you just stop taking it, symptoms may include nausea, vomiting, diarrhea, headaches, lightheadedness, dizziness, sweating, tremors, and sleep disturbances (vivid dreams, insomnia). Wean it down.
6. Benzodiazepines. Used for anxiety symptoms, this whole class of medications including alprazolam (Xanax), lorazepam (Ativan) and diazepam (Valium) cannot be stopped abruptly IF you’ve been using them for more than a few weeks. Rebound or withdrawal symptoms, including seizures, may occur following abrupt discontinuation or even large decreases in dose. This is more common if you’ve been taking a high dose, or if you’ve been taking it for a long time The risk of seizures is greatest 24 to 72 hours after you stop, so instead, decrease your doses slowly and monitor for withdrawal symptoms.
7. Neurontin (gabapentin). Don’t just stop taking gabapentin, commonly used for neuropathic pain and seizures. Withdrawal symptoms may begin between 12 hours to 7 days after stopping, but most start between 24 and 48 hours. Agitation is the most common and is reported by half of those experiencing symptoms of withdrawal. Confusion and disorientation have also been reported along with sweating, stomach complaints, and insomnia.
8. Prednisone and other steroids. Prednisone is prescribed as a potent anti-inflammatory for a variety of conditions including asthma, allergies, hives, inflammatory arthritis, gout, and more. If you’ve been taking prednisone for more than 1-2 weeks and just stop it, you may get into trouble. Why? When you are taking prednisone tablets your own adrenal gland production of cortisol declines. When you abruptly stop taking prednisone the result may be low cortisol, causing weakness, nausea, vomiting, diarrhea and abdominal pain. It’s not fun and can be very serious. Wean it off.
9. Opioid pain medications. Opioids are prescription analgesics like codeine, morphine, and hydrocodone (an active ingredient in Vicodin) and if you’ve been taking them long term, abruptly stopping causes symptoms like diarrhea, generalized pain, restlessness and anxiety. Withdrawing from opioids is no joke, wean them down.
10. Baclofen. Baclofen is prescribed to decrease muscle cramps, spasms, and rigidity (including in folks with spinal cord injury and multiple sclerosis). Withdrawal is more common when it has been given as an injection directly into the spinal canal, but can also occur with tablets. Withdrawal symptoms include restlessness, insomnia, confusion, hallucinations, seizures, psychotic manic or paranoid states. Interestingly, Baclofen is also used to treat alcohol withdrawal.

Dr O.

Recently, the FDA approved phase 3 clinical trials using MDMA for the treatment of Post-Traumatic Stress Disorder (PTSD).

The first three phases of the clinical trials using MDMA for PTSD treatment began in 2004, and phase 3 is this final phase in the rigorous approval process. This means that MDMA is one step closer to becoming a legal therapeutic for PTSD! You can read more about the clinical trial process here.

What is PTSD?

Post Traumatic Stress Disorder (or PTSD) is a disorder that develops after a traumatic life-event. Events like war, abuse, car accidents, natural disasters, or a shooting are some of the many traumatic events that could cause some people to develop PTSD.

Typically, the symptoms of PTSD include hyperarousal, negative changes in beliefs or feelings, re-experiencing the traumatic event, and avoidance.

What is MDMA?

The chemical name 3,4-Methylenedioxy-methamphetamine, also known as MDMA, is a synthetic drug that alters a person’s mood, and their awareness.

You might be thinking that MDMA is just “Molly” or “Ecstasy.” However, they aren’t quite the same. Typically the illegal street drugs have MDMA in them, but they usually contain many other unknown and harmful substances.

How would MDMA be used?

The FDA has approved the phase three clinical trial for MDMA-assisted psychotherapy specifically. In this treatment, patients are given MDMA three times in total during therapy sessions, supplemented with weekly therapy without the drug.

Researchers have seen that MDMA has effects on the brain that make therapy more effective in treating PTSD. Essentially, the drug is allowing patients to comfortably process their pain.

The Multidisciplinary Association for Psychedelic Studies or MAPS is supporting these clinical trials. You can read more about their efforts here.

How soon could MDMA be available for PTSD treatment?

If phase 3 clinical trials go as planned, MDMA could be available for the treatment of PTSD with psychotherapy as soon as 2021.

You can read more about the previous phases here.

As you may have noticed, there have been many new hepatitis medications released recently, and we have another to add to the list! Gilead Sciences is a popular manufacturer for many hepatitis medications, and as of November 10th, they have recently gained approval for Vemlidy for hepatitis B.

Your liver is a key organ in your body that is important for removing toxins from your body and blood, aiding in digestion, and producing energy. So, it’s important to take care of it and treat it well. That is where Vemlidy comes in!

What is Vemlidy for? 

Vemlidy is indicated for the treatment of chronic hepatitis B, a viral infection that can lead to irreversible liver damage or even liver cancer. Hepatitis B is caused by contact with infected bodily fluids (from medical procedures like a blood transfusion) or through risky behaviors (like intravenous drug use or unprotected sex).

Vemlidy is specifically for adults with compensated liver disease, which means that the liver has become heavily scarred. Although the liver may still function properly, it will get worse and should be treated sooner rather than later.

Is there anything unique about Vemlidy?

Actually, yes. Vemlidy has a boxed warning, which is the FDA’s strongest warning aimed at informing patients and health care providers of a drug’s adverse effects. For Vemlidy, these serious adverse effects include:

• Lactic Acidosis: a serious condition that can result in unusual muscle pain, trouble breathing, nausea, vomiting, dizziness, or irregular heartbeat.
• Severe hepatomegaly with steatosis: the swelling of the liver beyond its normal size, with an increased build-up of fat in the liver.
• Post-treatment severe acute hepatitis B exacerbation: a “flare-up” or return of the hepatitis B virus worse than it initially was.

Is there an advantage to Vemlidy?

Despite the boxed warning, there is a big advantage. Vemlidy is similar to another Gilead product Viread, also used to treat Hepatitis B. However, Vemlidy is to be given at one tenth of the dose of Viread. This makes it better for important organs like the kidneys and the bones!

How is Vemlidy to be taken?

Vemlidy is a once-daily treatment, so patients are instructed to take one 25mg tablet daily, with food.

What are the most common side effects?

The most common side effects associated with Vemlidy are as follows:

• Headache
• Stomach Pain
• Tiredness
• Cough
• Nausea
• Back Pain

For more information, see the press announcement from Gilead Pharmaceuticals here.

Drug companies often combine two cheap generic medications, sometimes slightly altering their doses, and market them as a “new” expensive brand name medication. Don’t let this fool you—in many cases your doctor can make those combinations by prescribing two or more inexpensive drugs, and help you save a ton of dough. Here’s how:

1. Duexis. Approved in 2011, Duexis is used to treat arthritis pain. It’s expensive and guess what? Duexis is just ibuprofen (Advil) and famotidine (Pepcid) at a dose of 800 mg and 26.6 mg. You can buy ibuprofen anywhere over-the-counter, or get a prescription for 800 mg tablets of ibuprofen. Same for famotidine—you can buy it without a prescription in a 20 mg tablet. Both of these generics will cost pennies if you buy them separately. The point of the famotidine is to protect the stomach from the ibuprofen, and there is no evidence the Duexis combination pill works any better than taking ibuprofen 800 mg along with famotidine 20 mg.
2. Treximet. Approved in 2008 for the treatment of migraine headache, Treximet is taken at the onset of migraine headache and may be repeated (though this has not been shown to be helpful) after 2 hours. Guess what? Treximet is just naproxen (Aleve) and sumatriptan (Imitrex) at a dose of 500 mg + 80 mg. Naproxen is available as a very cheap generic in 500 mg tablets. Sumatriptan comes in 25 mg, 50 mg, or 100 mg tablets, and it does require a prescription, but it is a relatively inexpensive generic. To make your own Treximet equivalent you can take 500 mg of naproxen and 1.5 tablets of generic cheap 50 mg Sumatriptan. Does swallowing one Treximet pill work better than taking a naproxen and a sumatriptan at the same time? There is no proof that it does—and why would it really?
3. Acanya is a gel for acne that is very expensive. Acanya is just a mixture of clindamycin gel (1%) and benzoyl peroxide gel (2.5%), both of which are cheap generic prescriptions. Mix those two and you will have Acanya. Acanya may cost you hundreds for a tube, and may not be covered by your insurance, while you can fill a prescription for a tube of clindamycin 1% at as low as $4 – $10 through some generic discount programs, and a 30 gram tube of benzoyl peroxide 2.5% at as low as $15.
4. Ziana is another expensive acne gel, and another case where you can make your own version by mixing two generic gels: clindamycin 1% gel and tretinoin 0.025% gel. Ziana costs hundreds of dollars for 30 grams, and similar to Acanya, mixing 30 grams of clindamycin gel and 45 grams of tretinoin 0.025% gel will total under $30 in most cases.
5. Duac and Benzaclin, similar to Acanya, combine generic clindamycin and benzoyl peroxide. Both also have generic combinations available (clindamycin/benzoyl peroxide), but they still cost just under $100 per tube.
6. Loestrin Fe (birth control with iron). This brand name oral contraceptive may cost you a ton. The difference between Loestrin Fe and less expensive options? Loestrin Fe includes iron in some of the pills in your pill packet—ferrous fumarate 75 mg on days 22 – 28. Please don’t pay extra money for this brand name oral contraceptive just because it includes a few pills when you can buy an equivalent over-the-counter iron supplement. If you do really want the added convenience, generic equivalents of Loestrin Fe include Gildess Fe and Junel Fe, and you’ll still save a ton of money by using the generic instead of the brand.
7. Beyaz. There is no generic alternative to Beyaz but know this: Beyaz is 0.02 milligrams ethinyl estradiol + 3 milligrams of drospirenone (a type of progestin)—the exact same thing as Yaz and generic Gianvi. What’s different about Beyaz? It has folic acid in it (0.451 milligrams of levomefolate calcium, a metabolite of folic acid). You can buy a folic acid supplement over-the-counter for pennies, at at the dose recommended to prevent neural tube defects: 400 mcg a day.
8. Contrave is the new weight loss medication, and it will cost you. Contrave is a mixture of naltrexone and bupropion at a dose of 8 mg / 90 mg. Now, I’ll be honest, this one isn’t as easy to replicate. Generic naltrexone comes in a 50 mg dose so you’ll be breaking that tablet into very small pieces. The bupropion part is easier as it comes as a generic 100 mg tablet—almost exactly the 90 mg in Contrave.
9. Qsymia is another weight loss medication that mixes two existing generics, phentermine and topiramate (generic Topamax). Qsymia capsules come in several dosages: 7.5 mg phentermine with 6 mg topiramate, or 15 mg phentermine with 92 mg topiramate capsules. You can closely approximate these with cheap generic tablets: phentermine 15 mg and topiramate 50 mg or 100 mg.
10. Solodyn. While not a technically combination drug, this is another case where taking more pills could save you a bunch. Minocycline is often prescribed for acne over doxycycline because it is less photosensitizing (less likely to cause a rash when in the sun) and is available as a cheap generic. Generic minocycline 50 mg or 100 mg capsules can be found for as low as $12 – $30 for a 30-day supply (60 capsules, in this case—it’s taken twice a day). Solodyn is an extended release version of minocycline, so it’s more convenient at once daily dosing, but it’s really expensive. Even the extended release generic minocycline ER is pricey. Regular minocycline capsules may be hundreds of dollars cheaper than Solodyn or minocycline ER, so know there are options before you pay the big bucks.

Hope this helps . . .

Dr O.