If the anthrax attacks of 2001 had been as bad as many feared, the country would have needed not only a public response to the lethal bacteria, but also to the potentially dangerous adverse effects of the antibiotic ciprofloxacin.
“If we were all on [ciprofloxacin], maybe one in 100 would have pretty bad anxiety—on top of the anxiety that an anthrax attack would cause,” explained Jose A. Rey, MS, PharmD, BCCP. “People have had seizures on this antibiotic, and it can make you anxious, agitated, and aggressive.”
This is just one of the lesser known adverse effects that Rey trains Florida law enforcement and emergency medical personnel to handle. As a psychopharmacologist, he prepares police officers, first responders, and hostage negotiators for situations in which prescription or illicit drugs, nonadherence, or withdrawal might be involved.
“They might want to know what they can expect if a guy’s on Paxil [paroxetine—GlaxoSmithKline], for example, or supposed to be on Paxil but he’s nonadherent. Or if the person of interest says ‘Don’t come in or I’m going to take all my meds,’ the police need to know which meds they should actually worry about,” Rey told Pharmacy Today. “They might be dealing with someone whose prescription medication has been recently changed or discontinued. Alcohol and illicit drugs have a withdrawal syndrome, but so do antidepressants, anxiolytics, and hypnotics.”
Board-certified in psychiatric pharmacy practice, Rey is a an associate professor of pharmaceutical sciences at Nova Southeastern University College of Pharmacy in Fort Lauderdale, FL, and a clinical psychopharmacologist and residency preceptor at South Florida State Hospital, a 335-bed psychiatric facility in Pembroke Pines, FL. As a public service, he gives presentations on current psychotropics, drug-induced psychoses, withdrawal syndromes, and psychotropics’ potential influence on crisis situations at quarterly trainings for members of the Broward County Crisis Intervention Team, annual meetings of the Florida Hostage Negotiators Association, and invited speaking engagements for other law enforcement and first responder organizations around the state.
Rey starts these talks by presenting a list of the top 100 psychotropic medications prescribed to those with mental illnesses.
“So many individuals with mental illness are involved with the law,” Rey said. “The jails and prisons actually house more of our mentally ill patients than our state or psychiatric hospitals do. And that, unfortunately, is no place for them.”
Rey explains to his audience which conditions and behaviors may have led to a prescription for a psychotropic drug, what behaviors these drugs may cause, and what behaviors nonadherence could bring about.
“You can’t assume the psychiatric diagnosis based on the drug,” Rey told Today. “But this at least gives you a short list of what you might be dealing with. There could be a variety of reasons to be on an antipsychotic or mood stabilizer.”
When a crisis situation brings up further questions, first responders call Rey as they rush to the scene or afterwards to determine if a medication discovered might have influenced the suspect or the suspect’s testimony. Soon, Rey will complete the training and vetting that will allow him to be stationed on the scene during crises and hostage negotiations for certain police departments.
Some Florida law enforcement officials came to know Rey from his court appearances as an expert witness. He has occasionally testified for patients who suffered damages due to medication errors, and he has defended pharmacies as well. Rey has also testified in murder and other criminal trials when prescription drug adverse effects or drug interactions offered the only plausible explanation for the behavior resulting in or affecting the crime.
“When I’m involved, these people usually have no criminal background, and someone’s trying to come up with a reason this occurred—for example, due to an [adverse] effect of a prescription drug,” Rey explained.
This is how Rey learned of the slight potential for violence in patients taking ciprofloxacin. He will include several of these cases in a literature review he is currently writing with colleagues on antibiotic-induced psychoses.
“I had a case where a mild-mannered, nice guy struck and threw his small child against the wall in a rage reaction, and he had no history of violence whatsoever,” Rey said. “He had just been given [ciprofloxacin] for a sinus infection.”
Rey explained that ciprofloxacin blocks gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter that keeps a person from having seizures or flying into a rage. It’s not necessary to block GABA to fight infection; it’s an unwanted, secondary adverse effect.
As a psychiatric pharmacist and clinical psychopharmacologist, Rey prepares first responders for far more than the adverse effects of psychotropic drugs.
For example, corticosteroids, which treat poison ivy, arthritis, allergic reactions, or breathing problems, can cause manic or aggressive behavior in some patients. Rey has consulted on cases in which drugs for Parkinson disease led to risk-taking criminal vice behaviors. These drugs can incite a person to gamble or be sexually promiscuous because they help produce or mimic dopamine, which heightens the pleasure felt when these risks yield rewards, Rey explained.
Lately, Rey has seen an uptick in criminal cases in which the defendant is accused of a heinous crime he or she has no recollection of committing. What these cases usually have in common is a prescription for zolpidem (e.g., Ambien—Sanofi) or another sedative hypnotic, usually a benzodiazepine.
“You could pull someone over on a traffic stop and have what you think is a complete conversation with the individual, and the next day they have no recall of the events,” Rey told Today. “People are acting out in a disinhibited way—‘sleep driving,’ ‘sleep sex’—and they can’t remember [what happened] in order to give a proper statement.”
These agents can cause anterograde amnesia while at the same time lowering inhibitions. Rey has seen defendants charged with murder end up convicted of manslaughter instead because a benzodiazepine was involved.
Recently, Rey testified for an 80-year-old man on trial for murdering his longtime girlfriend in her sleep. The defense argued that one drug for depression, recently switched from another by a general practitioner and dosed too high for someone his age, had made the defendant paranoid that his girlfriend was stealing from him, while another drug to help him sleep had lowered his inhibitions and caused disrupted sleep. As a result, the defense argued, the defendant killed the woman and did not remember it the next day.
While Rey’s public service emphasizes unwanted effects of pharmaceuticals, his research examines the exploitation of their desirable effects.
“Cosmetic neuropharmacology is a bit a of soapbox for me, something I’m going to spend the rest of my career following,” Rey told Today.
Rey said he has seen a rise in unnecessary, or cosmetic, use of stimulants such as methylphenidate (e.g., Ritalin—Novartis) and mixed amphetamine salts (e.g., Adderall—Teva). High school and college students who are not diagnosed with ADHD are taking these medications in order to do better in school, he said, though there is little to no evidence to support the practice. Rey and his colleagues researched this trend in amateur and professional poker players and presented a poster on it at the 2010 annual meeting of the College of Psychiatric and Neurologic Pharmacists.
“It was an astonishing list of things some of them were taking to manage their behaviors, to hide a tell, to stay focused on a poker game for 10 hours straight, or manage their anxiety,” Rey noted. “They love energy drinks, then they may use marijuana to calm themselves down, but they use a lot of Ritalin, Adderall, Dexedrine [dextroamphetamine—GlaxoSmithKline], and other stimulants when they play poker.”
Rey called these psychostimulants “cousins of cocaine.” He is concerned about what he perceives as a cultural phenomenon that’s driving this trend.
“I’m concerned about our society’s threshold for using medications to achieve ‘better living through chemistry,’” Rey explained. “I’m concerned about the way our parents, our society, and our system have pushed people into competition. For kids in school trying to have the highest GPA and get to the next level of education, every test is now a high-stakes test. It’s interesting that athletes aren’t allowed to use anabolic steroids or stimulants to build their muscle and boost their physical speed, but you’re allowed to use [drugs] to ‘boost’ your brain.”
Rey believes some parents and adolescents are acquiring prescriptions without cause and that some physicians may be willing to go along with it. Thus, there are most likely many more cases of cosmetic use of psychostimulants than the medical and pharmacy fields may know. He called this situation “one of society’s dirty little secrets” and said he hopes his research will shine a light on it.
With research interests spanning geropsychiatry, psychotropic polypharmacy, pain management, communication disorders, and beyond, Rey is drawn to psychiatric pharmacy because no two days are alike. What attracted him to psychiatry is what he suspects might drive others away: the subjective nature of the field. There is no blood test for schizophrenia, he explained.
“The heart is a pump and the kidneys are a filter,” he joked. “The brain is where it’s at. I’ve found it easy to stay interested in my specialty.”