Girl's death stirs debate over psychiatric meds

[MountainPharmD]

http://www.msnbc.msn.com/id/17758170/

Read and discuss. Students this is the real world. What would you do if you were the pharmacist filling these childrens medications? Is our responsibility simple to dispense medications? How far would you go to stop something you felt was inappropriate?

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[sdn1977]

There was a discussion on the psych forum a month or so ago when this story first broke.

I've had the very unpleasant circumstance of being in this position (of feeling as though the child was being overmedicated - not that the parents were trying to overmedicate deliberately).

Fortunately, for me, the child did not die & she is now 8 yrs old & has moved on to a specialized psychiatrist who treats only children & has many fewer medications.

But....I didn't like the position I was in at all!!!

 

[BeatrixKiddo]

In my intro to pharm class, it says that pharmacists, allied health professional s and doctors are supposed to be kept in touch and talk to each other about the patients and concerns they have.

 

[twester]

Neither valproic acid nor clonidine is indicated in the treatment of pediatric psychiatric disorders. My initial reaction, from a student perspective, is that the pharmacist wasn't doing his job - but then neither were the physician nor the parents.

I have strong feelings about using medication to control children. It doesn't seem possible to me that there's enough time to establish a diagnosis of either ADHD or bipolar disorder in a four year-old.

I expect the parents will blame the physician and the physician will blame the pharmacist with the pharmacist blaming the physician. I suspect the parents will be absolved of all responsibilty since they were apparently trusting the physician with their daughter's life (unless it can be proven beyond a reasonable doubt that they overdosed their daughter). Her school's administrators probably bear responsibility as well. I'm not sure how they would figure into legal action.

This case is a shameful example of healthcare gone wrong.

 

[MacGyver]

Neither valproic acid nor clonidine is indicated in the treatment of pediatric psychiatric disorders.

Sorry, but you are flat out wrong about this

http://www.ninds.nih.gov/news_and_events/news_articles/news_article_adhd.htm

I have strong feelings about using medication to control children. It doesn't seem possible to me that there's enough time to establish a diagnosis of either ADHD or bipolar disorder in a four year-old.

First off let me say that psychiatry is mostly bull****, but I dont think you are in a proper position to judge whether the diagnosis was made correctly or not. Pharmacists arent trained in diagnoses after all.

What you ARE qualified to do is comment on the dosage, side effects and medication interactions.

I expect the parents will blame the physician and the physician will blame the pharmacist with the pharmacist blaming the physician. I suspect the parents will be absolved of all responsibilty since they were apparently trusting the physician with their daughter's life (unless it can be proven beyond a reasonable doubt that they overdosed their daughter). Her school's administrators probably bear responsibility as well. I'm not sure how they would figure into legal action.

This case is a shameful example of healthcare gone wrong.

Its clear that the parents are at fault in this case. There is no evidence that the doc wrote for the wrong dosage or frequency, and the records from the pharmacy will bear that out. Its not the pharmacists fault becasue they filled the script as directed and there was nothing wrong about the script in terms of dose or frequency.

This is an open and shut case. They found LETHAL levels of the medications in the girl's blood. The parents deliberately overdosed her and killed her. Its got nothing to do with the doc or pharmacist.

 

[sdn1977]

Sorry, but you are flat out wrong about this

http://www.ninds.nih.gov/news_and_events/news_articles/news_article_adhd.htm



First off let me say that psychiatry is mostly bull****, but I dont think you are in a proper position to judge whether the diagnosis was made correctly or not. Pharmacists arent trained in diagnoses after all.

What you ARE qualified to do is comment on the dosage, side effects and medication interactions.



Its clear that the parents are at fault in this case. There is no evidence that the doc wrote for the wrong dosage or frequency, and the records from the pharmacy will bear that out. Its not the pharmacists fault becasue they filled the script as directed and there was nothing wrong about the script in terms of dose or frequency.

This is an open and shut case. They found LETHAL levels of the medications in the girl's blood. The parents deliberately overdosed her and killed her. Its got nothing to do with the doc or pharmacist.

MacGyver - oddly enough, I agree with you altho not with the same vehemence or perhaps language.

I agree - psych meds are some of the most often used off-label of the drugs we have & it is not at all unreasonable they be used in children. If you've not worked near an inpt child psych unit, you may not see these.

It is short-sighted to use just the FDA indications & dosage schedules without pursuing discussions with those who prescribe them & educate yourself.

After being put in this position myself, I communicated often, consistently & documented each and every time this communication took place. Remember - we CANNOT diagnose & CANNOT make the judgement that these drugs should or should not be used in these situations. Child psychiatry is a subspecialty of psychiatry itself & it is NOT in our ability to make a judgement if these drugs were appropriate or not. You are always welcome to ask for clarification or verification, but we are NOT physicians.

I also agree, the frequency of filling is not unreasonable - I've often filled psych meds on a weekly basis - which means over a 4 month period - there could be 16 refills or more, depending on the circumstance.

Yes - this is indeed the real world......you have to find a way to communicate empathetically with the patient (or parent), the prescriber & be very, very diligent in your documentation.

I'm not sure this was a deliberate overdose - these parents are frustrated & often at wits end with their own issues. It is not my place to make a judgement......but, I agree, communication is very important for us - both with the prescriber & the patient (or patient's representative).

Good luck.....real life is often hard and this case shows that clearly.

 

[Pharmguy07]

Sorry, but you are flat out wrong about this

http://www.ninds.nih.gov/news_and_events/news_articles/news_article_adhd.htm

Well, technically he/she is correct. An off-label use is not the same thing as an indication.

 

[sdn1977]

Well, technically he/she is correct. An off-label use is not the same thing as an indication.

splitting hairs here.....

 

[honeykrown]

this quote taken from the article "And a pharmacist complained that Rebecca’s mother kept coming up with excuses for why her daughter needed more and more medication." seems to me looks likt Munchausen syndrome by proxywhere the parents keep bringing reason why the child should be on medications just to get attention.

I was n clinical at childrens hospital in DC where msot of the medications were not for use in kids but the doctor could prescribe it to kids based on certain factors.

Its sad news but u cant just blame the health care workers.

 

[BMBiology]

I don't think you can legally blame the physician or the pharmacist. If you work in a retail setting, you see this pretty often. I think some pharmacists are not bold enough to just say I refuse to fill this medication and some physicians are too willing to please their patients.

 

[MacGyver]

What so now pharmacists have the authority to reject all off-label uses? Thats a load of crap. Off-label usage is a necessary evil in the system at this point; obviously not ideal but nevertheless necessary because it takes the FDA forever to study all the potential uses of a medication despite the fact that many off-label uses are backed by good science.

 

[twester]

Sorry, but you are flat out wrong about this

http://www.ninds.nih.gov/news_and_events/news_articles/news_article_adhd.htm

This news bite is five years old. I started poking around in Pubmed and can't find any studies that show any non-anecdotal evidence that valproate is either safe or effective for use in pre-school children (didn't look at clonidine since I have an exam on Monday that requires my attention). I found one open case series from 2001 in which the psychiatrists admitted that "use of valproate in this - and older child - populations is not established with proper controlled investigation" (Journal of Affective Disorders, Volume 67, Issues 1-3 , December 2001, Pages 193-197). Yet they felt it appropriate to prescribe anyway.

First off let me say that psychiatry is mostly bull****, but I dont think you are in a proper position to judge whether the diagnosis was made correctly or not. Pharmacists arent trained in diagnoses after all.

What you ARE qualified to do is comment on the dosage, side effects and medication interactions.

Personally, I have a bias against psychiatry as well. My comment about childhood bipolar/mania was probably naive. However...

I did not represent myself as a pharmacist. I am a student (first year, at that). As a student it is my job to question everything. I will continue to do so as I work to educate myself about various issues.

My streak of naivete may be continuing, but the scope of a pharmacist's responsibility extends beyond dosage, side effects and medication interactions. It's hard to imagine that I would presume to tell an expert how to do her job, but if I saw something going on that raised my eyebrows you'd better believe she'd get a phone call from me expressing concern. I'm sophisticated and mature enough to phrase my concerns in a non-threatening, professional and respectful manner.

Its clear that the parents are at fault in this case. There is no evidence that the doc wrote for the wrong dosage or frequency, and the records from the pharmacy will bear that out. Its not the pharmacists fault becasue they filled the script as directed and there was nothing wrong about the script in terms of dose or frequency.

This is an open and shut case. They found LETHAL levels of the medications in the girl's blood. The parents deliberately overdosed her and killed her. Its got nothing to do with the doc or pharmacist.

I agree with you that the parents are probably at fault. Honeykrown mentioned Munchausen's and I wondered about that myself. I guess the jury will decide. At the same time, though, maybe it's time that the public start demanding some evidence beyond the anecdotal for medicating kids with powerful psychotropic drugs.

Most of the children in the open-case series that I cited had parents with substance abuse issues and/or psychiatric disorders. Is there a connection? Is the child's problem genetic or is it environmental? If you have some citations you could point me towards that show evidence for one or the other, I'd really like to see them. That's not a challenge, it's a request.

Thank you.

 

[VCU2011]

I would be very interested to know what the psychitrist said to the pharmacist over those two phone conversations to convince the pharmacist that they were necessary refills. I can maybe understand not pushing the parents on the case but if RTS warnings are coming up every time you go to fill the script and the doctor isn't giving you adequate reasoning for why they keep coming back so early that would raise a huge concern. I'm also surprised that everyone else saw that the girl was a walking zombie except the psychitrist...it obviously didn't take people more than 10 seconds to know something was wrong with the girl, and if the parents were people who thought "the doctor is god", this seems like it should have been a very easy problem resolve.

 

[BMBiology]

What so now pharmacists have the authority to reject all off-label uses? Thats a load of crap. Off-label usage is a necessary evil in the system at this point; obviously not ideal but nevertheless necessary because it takes the FDA forever to study all the potential uses of a medication despite the fact that many off-label uses are backed by good science.

First, you need to get your fact right before you post. It's not the FDA but the pharmaceutical companies that are responsible to fund the study and file for an FDA approved indication. Don't blame it on the FDA.

Second, pharmacists are given the authority to reject prescriptions by the board of pharmacy. It has nothing to do with off label prescriptions. I don't think I need to explain this to you since this case clearly explains the need for this authority. Don't reply yet. Let this concept swirl in your head first.

 

[sdn1977]

First, you need to get your fact right before you post. It's not the FDA but the pharmaceutical companies that are responsible to fund the study and file for an FDA approved indication. Don't blame it on the FDA.

Second, pharmacists are given the authority to reject prescriptions by the board of pharmacy. It has nothing to do with off label prescriptions. I don't think I need to explain this to you since this case clearly explains the need for this authority. Don't reply yet. Let this concept swirl in your head first.

Sorry - given the circumstance of this case - its hard to dispute the fact that this child was prescribed a valid medication with valid indications, in spite of labeling advice.

We don't know actually there were early refills - there is just suspicion there were frequent refills - two different things.

Just my opinion, there is much more we don't know about this case than there is we do know - negilence, malpractice or just poor judgement on any or all of the particpants can come into play. It is easy to be a Monday morning quarterback - but, we all make the best judgement we have at the time. The rest is left up to those in the judicial system.

I have been in this exact same situation & have seen the "zombie-like" little girl I have given medication to. It is very, very hard - but I feel that each time I have asked for clarification of the rx & each time I counseled the parent made a difference.

Even now - I have an adult pt - he is about 35 yo - he is on enough antipsychotics which would floor any other adult - his psychiatrist agrees. But - that is all that keeps him in this world. We both agree it is not a good circumstance - it just is.

Be careful not to judge too harshly & too soon!

 

[All4MyDaughter]

I have strong, albeit mixed emotions about this case. On one hand, it all seems so simple, cut and dried sitting here discussing it in retrospect. But hindsight is always 20/20.

I think this child's death represents a multi-level failure on the part of many different individuals, to notice something was wrong. And that, unfortunately, happens all the time to, I'd imagine, thousands of children every year. Not every case will be as spectactular and sensational as this one, for sure but it's a sad fact: parents hurt and neglect their children. A lot. Too frequently. People don't always notice. I'd say that at least half the time, no one notices.

In this particular case, I want to say the majority of the blame lies with the parents. They seem, to me anyway, to want to substitute pharmacotherapy for parenting. That's how the article reads anyway. But then again, we don't know what these parents were going through. It sounds like they had issues of their own and other children with problems. I doubt they were trying to kill their child. More likely, they were ill-equipped to deal with the stresses of life and parenthood and viewed medication as a way to take a short-cut, if you will.

I'd also question a doctor who'd prescribe these types of medications in this quantity to a four-year old for behavioral reasons. But it is not unprecedented. There are some very young children with some major problems...so it's unusual but not unheard of. I've seen it...my pharmacy is within walking distance of two major child psych clinics.

It sounds like the pharmacists were aware of the refill too soon issue, but if there was a reasonable explanation it's hard to say that you or I would have done any differently, given the circumstances.

See how there are so many sides to this? It is a tragedy, for sure. One that will change the way every person involved in it views the world, probably for the rest of their lives. But no one will pay a price as big as that child, an innocent child who died a horrific death because all of the adults, all of the people who were supposed to protect her, let her down.

And now, I'm officially:

 

[BMBiology]

I am harsh but I think I need to be harsh in this situation. A child died as a result. I don't think I can live with myself knowing that I played a role in the death of an innocent child.

I am not questioning the validity of the prescription. But I wonder if the pharmacist knew the mother was abusing the medication and if that is the case, did the pharmacist convey it to the physician? I don't think telling the physician that the mother is making excuses to get more refills is enough considering the magnitude of the consequence.

 

[Jeddevil]

What so now pharmacists have the authority to reject all off-label uses? Thats a load of crap. Off-label usage is a necessary evil in the system at this point; obviously not ideal but nevertheless necessary because it takes the FDA forever to study all the potential uses of a medication despite the fact that many off-label uses are backed by good science.

Yes, I have the authority to not fill any prescription that I am not comfortable with. Pretty cool, isn't it.

 

[MacGyver]

it obviously didn't take people more than 10 seconds to know something was wrong with the girl, and if the parents were people who thought "the doctor is god", this seems like it should have been a very easy problem resolve.

Oh come on dont take seriously what the defense lawyer says. He's obviously desperate to defend his client and will outright lie or make **** up to make them appear in a positive light. Lying comes with teh code of conduct for such a slimeball profession.

 

[pkpd]

Yes, I have the authority to not fill any prescription that I am not comfortable with. Pretty cool, isn't it.

How do u guys tell the pt or parent when u do not want to fill their prescriptions? I always try to make something up like I have to contact your doctor and hope that they will take their prescriptions back because they do not want to wait.
any input anyone? So I know what to do in the future

 

[sdn1977]

How do u guys tell the pt or parent when u do not want to fill their prescriptions? I always try to make something up like I have to contact your doctor and hope that they will take their prescriptions back because they do not want to wait.
any input anyone? So I know what to do in the future

If I'm going to make a decision to not fill a valid rx, I have a very good reason. Usually, it is because of a language barrier, the complexity of the sig, and the age of the pt. I will get someone to translate that to the pt/parent & ask they go to another pharmacist who speaks their language (I know the several in the area with languague skills other than mine).

In other circumstances....I tell the truth.

 

[VCU2011]

Oh come on dont take seriously what the defense lawyer says. He's obviously desperate to defend his client and will outright lie or make **** up to make them appear in a positive light. Lying comes with teh code of conduct for such a slimeball profession.

dont by any means think im defending the defense laywer in this case, but I find it pretty difficult that a trained child psychitrist cant pick out an overdosed 4 year old.

This case is tragic and it is not something im looking forward to dealing with once i enter the professional world, which by the way im not in yet if you couldn't tell from my name, but just my tech experience we have had to deal with and its tough.

We had a 5 year old patient just a little while ago perscribed an ADD med *dont remember which one* and we took the info sheet out on the drug and the clinical trials didn't even go back to patients her age. Calling to verify we find out the pt had already been on a bunch of different strengths of adderall for over a year and they weren't working anymore. I dont think it was an easy dispense for our pharm. manager.

 

[12345]

Not sure how I feel. I currently have a psychiatry rotation at a VA clinic and one thing I have heard a few different pharmacists say is to cite sources or quote what evidence you are using to treat a patient. They have said a few times that if a lawyer reads this they should know where you were coming from and you should do that to protect yourself. I haven't read the study but a BMS MSL recently told me about a study on schizophrenic patients and psych docs watched videos of the children when they were younger and other children and asked to try and pick out the schizophrenic one. He said they were correct about 100% of the time indicating that they could diagnose schizo at a young age, but of course there were limitations of the study so not sure.

 

[rxcrystal]

Where is Tom Cruise when you need him?

 

[MountainPharmD]

How do u guys tell the pt or parent when u do not want to fill their prescriptions? I always try to make something up like I have to contact your doctor and hope that they will take their prescriptions back because they do not want to wait.
any input anyone? So I know what to do in the future

The best plan is to be honest. The other day we had a mother come in with a script for her son who was 8 years old. The prescription was for Imitrex nasel spray. The package insert specifically says it is not to be used in patients under 18 years of age. I did a quick google search and could not find any information to support its use in pediatric patients. I told this to the mother and explained to her that I did not feel comfortable filling the prescription until I talked to the doctor. The mother reluctantly agreed and I told her I would call her after I talked to the MD. Long story short, the doctor was out of town for a few days and the mother did not care to wait any longer. She came in, took the script and went to Walgreens across the street and filled it there right away with no objection from the Walgreens pharmacist.

The reason I started this thread was to get everyone thinking about how they would react in a similar situation. The story of that little girl is tragic but there were numerous opportunites for someone to intervene, including the pharmacist.