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Psychiatric
Pharmacy Options
LT Anna Stevenson PharmD
Federal Bureau of Prisons
Federal Medical Center Devens
Objectives
• At the end of this presentation, participants will
be able to
• Describe the role a pharmacist can play in the
management of psychiatric inmates
• Have a better understanding of how to design a
monitoring plan for patients on psychiatric
medications
• Understand appropriate
use of psychiatric
medications in a
correctional setting
Clinical Pharmacy In the BOP
•
•
•
•
93 Collaborative Practice Agreements (CPAs)
57 pharmacists involved
12 distinct areas of medicine
DUE Outcome Measures for most CPAs
• Clinical Pharmacist Protocol Review
• In 2011, the Clinical Psychiatric Pharmacy Clinic was
opened at FMC Devens marking the first formalized
psychiatric clinic in the BOP.
Is there a need?
Clinical Psychiatric Pharmacy Clinic
• What do I do?
• Promote appropriate, safe, and cost-effective drug therapy
in order to achieve outcomes that improve
• Functioning within a correctional facility
• Ability to successfully transition back into society upon
completion of their sentence.
• Primary functions
• Assessing and monitoring response to drug therapy
• Work collaboratively with treatment teams to optimize
pharmacotherapy
• Providing drug information
• Counseling patients on the proper use of medications
• Formulary management
Assessment
• Indication for use
• Efficacy
• Safety
• Adverse effects
• Drug interactions
• Adherence
• Comprehensive
Medication
Management
Comprehensive Medication
Management Defined
• Review all Medications
• Are they compliant?
• Review
appropriateness of
medications in relation
to other chronic
diseases the patient
may have
• Ensure appropriate
monitoring has been
completed and is within range
Medication Monitoring
• Compliance
• Counsel inmates who have
missed more than 10 doses
• High risk medications
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Clozapine
Lithium
Valproic Acid
Carbamazapine
Phenytoin
• High dose medications
• Multiple psychotropic medications in the same class
• The prevention, identification, and management of side
effects, including Tardive Dyskinesia
Medication Compliance
• “Drugs don’t work in patients
who don’t take them”
C. Everett Koop, M.D.
• The most expensive pill is that
which is not taken or taken
inappropriately.
• Patients are often non-compliant with their antipsychotic
regimen.
• Simplify the regimen
• Some medications could be consolidated into once-a-day
scheduling
• Utilize depot formulations when available
• Side effects need to be watched for and treated as soon as
possible
Important considerations
• Many patients take subtherapeutic trials of medications.
• Inadequate dose
• Inadequate duration (6-8 weeks)
• Antipsychotic medications are slower to take clinical
effect than the onset of side effects.
• Newer (atypical) Second Generation Antipsychotics
(SGAs) cost roughly 10 times as much as the older
(typical) FGAs
• CATIE trial (2005) showed comparable efficacy between
First generation antipsychotics (FGAs) and SGAs.
Antipsychotics
• Side effects form a critical
aspect of treatment because
they frequently affect
medication choice, and
decisions to discontinue
them.
• SGAs and TGAs, in low doses,
are less likely than FGAs to
cause significant extra
pyramidal symptoms (EPS).
• There is some evidence to
support that at least one SGA,
clozapine, may actually improve
TD.
• However, many SGAs have their
own troublesome side effects
that make them less acceptable
than FGAs for some patients.
Medications at risk for abuse
• Lifetime prevalence of
substance abuse in 74%
of mentally ill criminal
offenders (Putkonen)
• Trihexypehnidyl
• Gabapentin
• Benzodiazepines
• Buspirone
• TCAs
Wellbutrin
• DA/NE reuptake inhibitor (unique mechanism)
• Few side effects and lack of weight gain
• Lowers seizure threshold
• Only antidepressant that does not appear to increase the risk
of mania in susceptible patients
• Within the BOP only to be used for anergic depression,
depression with bipolar, ADHD symptoms, and cardiac disease
• Security concern
• Structurally similar to stimulants such as methamphetamine and
amphetamine
• Can be crushed and snorted or taken in large doses to obtain a
high
• Has been reported that 1 tablet can be exchanged for 1 book of
stamps
Seroquel (Quetiapine)
• Use in psychotic disorder, bipolar disorder,
or borderline personality disorders only
• Concerns
• Cases of abuse (including oral, intranasal, and intravenous) have
been documented in the literature, and multiple BOP institutions
have reported incidents of inmates selling their quetiapine
• Should be reserved for those cases refractory to other SGAs and
TGAs
• Should be administered crushed or in liquid formulation to
reduce diversion.
• An extended-release formulation of quetiapine is now available
that is less abusable and better tolerated than the immediaterelease version. (preferred in the BOP)
Value
• Improves patient
outcomes
• Improves access to
care
• Decreases resource
utilization
• Admissions to lock-up
units
• Suicide-watch
• Improves patient
satisfaction
• Increase safety for
both inmates and staff
Case #1
• Schizophrenic inmate taking quetiapine ER
• Complaining of migraines
• Previously managed on sumatriptan
• Increasing in frequency and no-longer adequately managed on
sumatriptan
• Providers administering off-label IV metoclopramide with good
effect
• Increasing use up to 2-3 times per day
• When non-formulary request submitted, request was not approved
• Upon medication review, it was found that migraine frequency
positively correlated to increased dosing of quetiapine
• Quetiapine dose was lowered and psychiatric medication was
augmented. Migraines subsided and inmate is now managed only
with occasional sumatriptan use.
Case #2
• Inmate housed in Mental Health secure housing due to behavioral
issues from psychiatric disorders and medication non-compliance
• Schizoaffective disorder- bipolar, HepC, COPD, Heart Failure
• Non-compliant with all medications
• Pharmacy Encounter to discuss medications with inmate
• Stated non-compliance because he didn’t want to take that many pills
• Discovered that he had about 7 medications for GI/constipation but
inmate was not having any GI problems. Able to eliminate these meds
• Had standing orders for APAP and Ibuprofen (able to d/c)
• Contacted medical provider and able to narrow down cardiac
medications from 4 to 2 medications.
• After encounter, inmate became compliant and psychiatric symptoms
began to become controlled.
• Inmate was then able to participate in behavioral treatment
• Decreased number of incident reports for behavioral issues
Case #3
• Psychiatric Inmate presented complaining of increased anxiety
over past month.
• Symptoms: chest tightness, shortness of breath, headache,
trouble sleeping
• Psychiatrist was prescribing benzodiazepine for short-term use
as management.
• During medication review it was discovered that inmate had
been non-compliant with asthma medications.
• After pharmacist counseling, inmate began using inhalers
again and symptoms subsided.
Thank you !
Questions & Comments?
Contact Information:
LT Anna Stevenson
Federal Bureau of Prisons
FMC Devens
[email protected]
978-796-1000 ext 4457
References
• BOP Clinical Practice Guidelines: Pharmacologic Management of
Schizophrenia. June 2010.
• Putkonen A. Comorbid personality disorders & substance use of
mentally ill homicide offenders. Schizophr Bull 2008;30:59-72.
• National Institute of Mental Health [homepage on the internet].
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE):
NIMH Study To Guide Treatment Choices for Schizophrenia. Available
at:
http://www.nimh.nih.gov/health/trials/practical/catie/index.shtml.
Accessed March 1, 2011.
• Swartz, M.S., Swanson, J.W., Hiday, V.A., Borum, R., Wagner, R., &
Burns, B.J. (1998). Taking the wrong drugs: the role of substance
abuse and medication noncompliance in violence among severely
mentally ill individuals. Social Psychiatry and Psychiatric
Epidemiology (supplement), 33, S75-S80.