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Are there any RxP psychologist out there from the prescribing states that would care to share their experience with us??
RxP for Psychologist
- Thread starter gzaky
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I had to go head to head with one before, to get a patient off of an inappropriate drug. I can tell you about my experience with her. I don't think she is typical though.
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I am a pharmacy student from Washington state. The prescriber is from Oregon.
I was asked to review my grandmother-in-law's prescriptions after her husband, who took care of them for her, was hospitalized. The family wanted me to tell them what everything used was for and any special instructions that might not be on the bottle. I started the process over instant messenger with my father-in-law.
When I looked at her medications, I discovered that she was taking thioridazine (generic for Mellaril) and paroxetine (generic for Paxil) concurrently. These two medications are considered to be contraindicated together - absolutely. (Paroxetine inhibits the metabolism of thioridazine, raising the serum levels. Since thioridazine is associated with fatal arrythmias, with risk increasing with elevated doses, making the combination potentially fatal.) I noticed the interaction and told my father-in-law to talk to her doctor or pharmacist. He told me that she had been taking them together for a long time and that he would talk to her doctor the next time he saw him.
In the meantime, I went online and started pouring through hardcore drug references and finding out what I could about the interaction. At work, I looked over more references. What I found was shocking. Every single other medication that my grandmother-in-law was taking appeared to treat a side effect of thioridazine use, long term thioridazine use, or cover up signs of toxicity. The symptoms she was experiencing included pseudo-Parkinsonism (long term-use @ high dose), incontinence, passing episodes of blurred vision (toxicity), and cardiac arrythmia (toxicity). Her incontinence had started in the past month and the eye problems had been present for 3-4 months. I was pretty worried.
I also found out that 8 years ago my grandmother-in law had contacted over 200 providers before she found one who would see her and continue to prescribe the paroxetine and thioridazine together. Her previous provider had been prescribing the combination for about a year. At that time, thioridazine had an indication for short term (~1 month?) treatment of depression. In 2000, the FDA put a black box warning on thioridazine stating that it was only indicated for use in complicated cases of schizophrenia where the patient had failed other therapy. It is advised that monitoring for arrythmias and other symptoms of toxicity be routine and that use be limited to controlled inpatient environments. My grandmother-in-law does not suffer from schizophrenia, nor was anyone monitoring for adverse effects. The therapist had been supplying both medications through the office with no pharmacist there to make the connection between the thioridazine and her other ailments.
So, in I stepped. I wrote a letter to her therapist explaining the symptoms which were occurring, how they negatively impacted her quality of life, that they were symptoms of toxicity, that thioridazine was not indicated for anything but complicated cases of schizophrenia, and suggested discontinuation of therapy. I did this all fromt he standpoint of one concerned healthcare professional contacting another. My husband was visiting his grandfather in the hospital and took a copy of the letter to his dad to pass on to her therapist. I also CC'd a copy to the PCP.
The PCP wanted to stay out of it. The therapist did not want to discontinue therapy, since my grandmother-in-law was not happy with the idea of giving up her "miracle pill". Plus, my grandmother-in-law was always on her best behavior at appointments and had convinced the therapist that everything was going ok - as long as she had her thioridazine and paroxetine. I considered writing another letter to the therapist explaining that is she were to continue inappropriate and life-threatening therapy then I would have no choice but to write a letter to her state board of health asking for intervention. I really did not want to be the bad guy, but there was a life at stake.
It turned out that I didn't need to write the letter. Three days later, my grandmothe in-law suffered a series of small strokes. These strokes were likely a result of the cardiac arrythmias caused by thioridazine. While she was disoriented, she called her therapist's office and babbled incoherently. Consequently, the therapist was able to realize that the medication was life-threatening and began to taper the dose. My grandmother-in-law has now discontinued thioridazine and says that she feels like a new person.
I realize that this experience is not at all representative. But, it does show what a large responsibility prescriptive authority is. And it shows that dispensing directly out of the office is not the best idea.
I was asked to review my grandmother-in-law's prescriptions after her husband, who took care of them for her, was hospitalized. The family wanted me to tell them what everything used was for and any special instructions that might not be on the bottle. I started the process over instant messenger with my father-in-law.
When I looked at her medications, I discovered that she was taking thioridazine (generic for Mellaril) and paroxetine (generic for Paxil) concurrently. These two medications are considered to be contraindicated together - absolutely. (Paroxetine inhibits the metabolism of thioridazine, raising the serum levels. Since thioridazine is associated with fatal arrythmias, with risk increasing with elevated doses, making the combination potentially fatal.) I noticed the interaction and told my father-in-law to talk to her doctor or pharmacist. He told me that she had been taking them together for a long time and that he would talk to her doctor the next time he saw him.
In the meantime, I went online and started pouring through hardcore drug references and finding out what I could about the interaction. At work, I looked over more references. What I found was shocking. Every single other medication that my grandmother-in-law was taking appeared to treat a side effect of thioridazine use, long term thioridazine use, or cover up signs of toxicity. The symptoms she was experiencing included pseudo-Parkinsonism (long term-use @ high dose), incontinence, passing episodes of blurred vision (toxicity), and cardiac arrythmia (toxicity). Her incontinence had started in the past month and the eye problems had been present for 3-4 months. I was pretty worried.
I also found out that 8 years ago my grandmother-in law had contacted over 200 providers before she found one who would see her and continue to prescribe the paroxetine and thioridazine together. Her previous provider had been prescribing the combination for about a year. At that time, thioridazine had an indication for short term (~1 month?) treatment of depression. In 2000, the FDA put a black box warning on thioridazine stating that it was only indicated for use in complicated cases of schizophrenia where the patient had failed other therapy. It is advised that monitoring for arrythmias and other symptoms of toxicity be routine and that use be limited to controlled inpatient environments. My grandmother-in-law does not suffer from schizophrenia, nor was anyone monitoring for adverse effects. The therapist had been supplying both medications through the office with no pharmacist there to make the connection between the thioridazine and her other ailments.
So, in I stepped. I wrote a letter to her therapist explaining the symptoms which were occurring, how they negatively impacted her quality of life, that they were symptoms of toxicity, that thioridazine was not indicated for anything but complicated cases of schizophrenia, and suggested discontinuation of therapy. I did this all fromt he standpoint of one concerned healthcare professional contacting another. My husband was visiting his grandfather in the hospital and took a copy of the letter to his dad to pass on to her therapist. I also CC'd a copy to the PCP.
The PCP wanted to stay out of it. The therapist did not want to discontinue therapy, since my grandmother-in-law was not happy with the idea of giving up her "miracle pill". Plus, my grandmother-in-law was always on her best behavior at appointments and had convinced the therapist that everything was going ok - as long as she had her thioridazine and paroxetine. I considered writing another letter to the therapist explaining that is she were to continue inappropriate and life-threatening therapy then I would have no choice but to write a letter to her state board of health asking for intervention. I really did not want to be the bad guy, but there was a life at stake.
It turned out that I didn't need to write the letter. Three days later, my grandmothe in-law suffered a series of small strokes. These strokes were likely a result of the cardiac arrythmias caused by thioridazine. While she was disoriented, she called her therapist's office and babbled incoherently. Consequently, the therapist was able to realize that the medication was life-threatening and began to taper the dose. My grandmother-in-law has now discontinued thioridazine and says that she feels like a new person.
I realize that this experience is not at all representative. But, it does show what a large responsibility prescriptive authority is. And it shows that dispensing directly out of the office is not the best idea.
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An unfortunate encounter but I wonder, was the "therapist" a psychologist with prescription rights? Additionally, I am sure not all Rx prscribers are that stubborn comes to patient safety.
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No, I don't think most prescribers are that stubborn. But, they can be pretty darn stubborn about changing the med they prescribe when it conflicts with a med prescribed by another provider.
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The prescriber is from Oregon.
You keep saying this person was a therapist and prescriber - what do you mean? My understanding is that psychologists have the right to prescribe only in Louisiana and New Mexico...and not Oregon....
You keep saying this person was a therapist and prescriber - what do you mean? My understanding is that psychologists have the right to prescribe only in Louisiana and New Mexico...and not Oregon....
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I looked her up on Google and it looks like she is actually a psychiatrist. So the family was mixed up when they told me she was a psychologist. If psychologists recieve prescriptive authority, I am not sure exactly how you would distinguish them from psychiatrists, based on the scope of their practice.
You would think that in this case with the prescriber's medical background she would have a decent appreciation for the phrase "life-threatening prolongation of the Q-T interval". Some psych drugs are really nasty, even the newer ones. How is monitoring supposed to happen in patients without a PCP if a psychologist hasn't covered the monitoring parameters in their PhD program? Wouldn't it be better to have a nurse practitioner or someone with more medical background as a partner to help with monitoring? I would be worried about the potential for things to go awry without sufficient monitoring.
You would think that in this case with the prescriber's medical background she would have a decent appreciation for the phrase "life-threatening prolongation of the Q-T interval". Some psych drugs are really nasty, even the newer ones. How is monitoring supposed to happen in patients without a PCP if a psychologist hasn't covered the monitoring parameters in their PhD program? Wouldn't it be better to have a nurse practitioner or someone with more medical background as a partner to help with monitoring? I would be worried about the potential for things to go awry without sufficient monitoring.
