Scary

I had a scary experience today with a new drug that I am supposed to be taking.  No one got hurt and everything is being dealth with.  But this mistake could have had fatal consequences if I hadn’t been more on the ball.

I have ADD, and it’s be a godsend to find out that I could get treated. It started just before my wife and I got married, and seeing how different I am now from then is amazing. I still struggle daily with staying on track, spontaneous impulses and ‘speeding’ at times, but it’s much better than it was. Having my Treo to keep me organized helped, too.

Recently, my doctor wanted me to try out something new and different to see how I responded. It’s a newer drug that supposedly has fewer side effects and a gentler ‘coming down’ period than what I am on now, and he thought I might be a good candidate. I’m always up for something that will help me stay focused, even and get stuff done so I figured I’d give it a try (especially since I got a free 30-day trial that wouldn’t need insurance approval). However, it took me a while to get the Rx dropped off so that I could get the drug. And then another couple of weeks before I was ready to try it out.

Then I noticed something odd with the prescription bottle I got from our pharmacy. I was fairly sure that the drug I was getting was an XR (extended release – all-day release) – since I need to have it work throughout my day and not have the ups and downs of the shorter-acting varieties. But my prescription bottle said to take it every 6 hours. That seemed odd because of what I had been told and also because these drugs are stimulants – meaning that taking one after a certain time is almost certainly going to affect my sleep. I checked the brochure that came with the free sample, and it too spoke about a ‘once-a-day treatment that lasts the full day’. Now I was concerned.

I called my neurologist and asked if I had misunderstood him when he told me about this – but I hadn’t. In fact, he was really concerned about the prescription. I figured that 1 of 2 things had happened: either they had misread the Rx and had given me a shorter-acting version of the drug (i.e. the wrong drug) or they had mislabeled my prescription. After some phone calls back and forth between me, the neurologist and the pharmacy, we finally got the answer – the pill bottle had been mislabeled.

First, the pharmacy said that the pharmacist said that he was having a hard time reading the prescription and thought it said QAM (or AQM, I can’t remember – either way it meant 4x per day). However, pharmacy systems are supposed to have safety features that prevent this time of manual labeling mistakes. They are also supposed to have a second set of eyes reviewing the prescriptions to make sure that the right thing is in the bottle and is going to the right person. Neither of these happened, and worse, when I talked to someone at the pharmacy she stated that being a new drug, it must have “slipped between the cracks”.

This frightens me on many levels. At its most basic, had I not already known what to expect, there is a good chance that I would have been taking FOUR TIMES the correct dosage for this drug. If this had been a parent of a child who wasn’t familiar with this drug – remember, it’s a new one – they might have given a child this dosage. According to my neurologist, the most likely end result of that would be a heart attack. That seems to me, at least, to be a little bigger than ‘slipping through the cracks’. Heck, I’m lucky that I knew what to expect or it could have happened to me. I know that pharmacists have a lot to do and that drugs and drug-drug interactions are getting more and more complex, but this one is really scary. I’m just glad I caught it and that this is probably a new enough drug that many people haven’t gotten it yet. I’ll be stopping there today on my way home, and letting the Pharmacy Manager know what happened – because I would hate to think of the consequences of this mislabeling occurring again.