Should she be allowed to stay "hooked" on her pills? - (5/3/2022)

By Dr. Ron Gasbarro

As with any job, profession, or vocation, one learns as one goes along. And we make mistakes along the way. For example, the pharmacist has occasionally quoted an incorrect drug price to a patient. Usually, this can be resolved with a sincere apology. But what about a mistake that is only realized after the damage has been done? 

When the pharmacist was much younger and more of an unbendable stickler for the rules, he committed a blunder. This goof, made with the patient's best intentions, took place in a nursing home that had its own pharmacy. The patient in question was a pleasant 87-year retired schoolteacher, who had been a resident for almost 8 years. During that time, she received a mild barbiturate 3 times a day. The pharmacist, who was a new employee at the time, scanned through the resident's voluminous clinical notes to review her medication history. 

The pharmacist concluded that the barbiturate prescription had been carried over from her physician while she was still living at home. He asked the resident's nurse about the drug. The nurse said, "She's been on them for many years with no problem." Nevertheless, the pharmacist was convinced she was addicted to the drug. He proceeded to discontinue the barbiturates slowly over the next 2 weeks. During that time, the retired teacher became increasingly agitated and had difficulty sleeping – new behaviors for this resident. 

Three weeks after the drug was removed entirely from the patient, a nurse found her drinking mouthwash. The mouthwash, which contained alcohol, was the resident's way of self-medicating herself. Back then, many types of mouthwash had over 20% alcohol – equivalent to that of many liqueurs. So, for the resident, it probably had a punch to it. The pharmacist was mortified. However, he was more concerned about the jeopardy in which he placed this person. 
To be clear, barbiturates are controlled substances used for conditions ranging from seizures to insomnia. They are rarely used today since newer, safer drugs are available. However, this patient was completely stable on her medication. The pharmacist learned, "If it ain't broke, don't fix it." 

These days, with decades of experience under his belt, the pharmacist would have handled the situation differently. First, the resident was under the supervision of the nursing staff. She was doled out her medication only as directed. There was no chance of overuse. Second, she had likely built up a tolerance to the drug over the decades, meaning that the placebo effect potentially could have been more substantial than the pharmacologic effect of the drug. Third, he would have consulted with the prescriber as to whether the medication should be continued. He would then document that discussion.

Pharmacists are often torn between what is lawful and what makes common sense. True, medication errors are made despite the efforts made to avoid them. Yet, in community practice, the pharmacist has no control over the patient's actions once that patient leaves the pharmacy with a prescription. If the patient decides to swallow all her pills and wash them down with a quart of vodka, who's fault is it? The pharmacist is not there to police the use of drugs. Instead, his role is to make sure the patient is in no danger and maintains a quality of life that is beneficial to her. We will make mistakes until the sweet end of our days. Accept these judgment flaws as lessons – and pray they do no harm.  

Ron Gasbarro, PharmD, is a recovering pharmacist and writer-in-residence at Rx-Press.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.


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