Little adults? Big kids? Caring for adolescents and teens
Rachel Balick
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Skywalk Pharmacy staff members: Clayton Pope, CPhT; Jessica Araujo, CPhT; Colette Zlomaniec, CPhT; Kara Boghossian, PharmD; Lauryn Mattek, CPhT; Joyann McChesney, PharmD; Amy Hager, CPhT; Fabiola Zuniga, CPhT; Richard Dieringer, operations manager; Jelena Stojsavljevic, CPhT; Jennifer Garner, CPhT; Julie Gall, MBA; Amy Consolazione, PharmD; Jake Olson, PharmD; Stephanie Williams, CPhT.
Adolescence is an awkward time for everyone. There can even be awkward moments for pharmacists treating patients of that age.
“Oral contraceptives are an awkward thing to discuss with a teenager when their parents are nearby. They don’t want to ask questions. But we still have the responsibility to counsel them on appropriate use, including using extra protection for at least a week if they miss doses,” said Jake Olson, PharmD, owner of Skywalk Pharmacy, which has three locations in Children’s Hospital of Wisconsin in Milwaukee.
“That can be a difficult conversation if mom is standing right there. We need to be prepared for those real-life situations that didn’t come up when we were learning the art of consultation in pharmacy school,” Olson said.
It can get worse. “I’ve had a dad come storming in and say, ‘Is my daughter on birth control?’ ” he added.
A different world
“We are a pharmacy dedicated to working with children, and it’s a bit of a different world. Much of the medication information that’s out there is about adults and dealing with the health challenges that come when you’re older. Trying to find information on children and what they’re going through, especially in dealing with chronic pediatric illnesses, is a challenge,” Olson said.
But what did Olson do about that dad? “I looked at him and said, ‘That is a conversation you should have with your daughter, not me.’ My mind was racing to figure out what HIPAA says about discussing a minor’s medication with a parent. This is not addressed in fraud, waste, and abuse training,” he said. “I have also had parents say, ‘I’m paying for those medicines on my insurance, so you need to tell me.’ I have even had a parent in a divorced home ask for their year-end tax form to try to get information about the medications their child was filling that the other parent was picking up,” he said. “It’s really challenging to figure out how to respond without breaking confidentiality laws and maintaining the trust that the young adult has in me.”
What to say and to whom is a theme when it comes to treating teens and adolescents, Olson said. “Many times you think, ‘Should I talk to the parent, or should I talk to the child themselves? When is the appropriate time to transition from speaking with a parent about the child’s illness versus speaking to the child directly?’
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Boghossian; Gall; Maria Perez, sales associate; Carly Jones, student pharmacist; Brian Halm, PharmD.
“You want to include adolescents and teenagers in their own health care knowledge and treatment, but at the same time, you need to make sure that they’re actually taking their meds and being responsible,” he said. “We all know that ‘responsibility ’ is not the first word that comes to mind when you think about teenagers,” Olson said.
“If they have chronic illnesses—cystic fibrosis, juvenile rheumatoid arthritis, Crohn’s disease—there are very important medications that they need to take consistently. If they’re not taking their medications appropriately, then they end up getting sick,” Olson said. “But as a 13-year-old, is it supposed to be your job to remember to take your inhaler twice a day, or is that mom’s job to tell you that? And when does that start to transition to become your responsibility?”
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Boghossian and Olson.
Olson noted that, unfortunately, he’s seen kids as young as 5 who are forced to become their own primary health care provider because of issues in the home. “It’s eye-opening how young some children are who call in their own refills and receive their consultations when they pick up their medications.” But there’s another side to that coin. “We see 25-year-olds who are still waiting for mom to tell them when to take their pills.”
And then there’s that rebellious phase. “A child who’s 16 years old may start to experiment with alcohol,” Olson said. “A 60-year-old realizes that drinking too much alcohol with certain medications can have serious side effects. But teenagers sometimes have to learn that for themselves the hard way, and that can cause problems.”
Warning teens can be uncomfortable. “You need to say, ‘No driving with this medication and no drinking,’ and a helicopter mom is not letting you talk directly to the child,” Olson said. “Sometimes we ask mom, ‘Hey, mom, why don’t you go check out the candy over there in the corner,’ or ‘Why don’t you go next door for a second? I need to have a conversation with your child about some things.’ ”
Mental health
“Kids are really stressed out,” said Julie Dopheide, PharmD, professor of clinical pharmacy, psychiatry, and the behavioral sciences at University of Southern California and Keck School of Medicine. “Adults are stressed out, too, but adults have learned some coping strategies. Kids are figuring everything out all at once. They’re really anxious.”
Teens and adolescents might engage in self-injurious behavior and have suicidal thoughts and behaviors. “There are so many things that could make a youth think that suicide is their only way out. Some of it’s related to bullying, some of it’s related to anxiety, depression, not fitting in, gender identity issues,” Dopheide said. “They don’t have the futuristic thinking of, ‘Maybe when I’m 30, I’ll feel differently.’ ”
Dopheide said teens are highly reactive to their environment, with many variables that affect how they present from one day to the next. “They’ve got their friend group, they’ve got their parents, they’ve got their other extended family members. They tend to not be mature enough to think things through. They’re more impulsive,” Dopheide said. “It’s important to see them over time to get an accurate diagnosis.”
That can be a challenge for pharmacists. “Pharmacists only see the parents and the family members for a particular window in time,” Dopheide said. “I think the best thing practically for a pharmacist to do is to encourage the family not to jump to a diagnosis too quickly. Parents may want easy answers. Sometimes it’s a relief for them to know, ‘My child has this. So, I can just put them on that, or we can just get him this therapy, and then they’ll be fixed.’ But it’s not that simple.”
Pharmacists should encourage a systematic approach. “You have to look at what’s predominant in the child: is the anxiety predominant, the ADHD predominant, the depression predominant? And then you treat that first. Once that is better, you re-evaluate to see if the other conditions also need a medication,” she said.
“I’ve seen patients on five or six, even seven to nine meds. And they’re doing okay finally, so nobody wants to take anything off. That’s the fear: ‘Well, this combination’s working, so I don’t want to change anything,’ ” she said. “A child might be on clonidine and Risperdal, and they’ve got some aggression and they’ve got some ADHD, but they’re also anxious. And then they’re getting Benadryl for sleep and maybe they’ve also got melatonin, and then they’re adding Zoloft or Prozac, and then finally, they start to do well. But maybe it’s because they were depressed or anxious all along!”
Dopheide said that all pharmacists should learn certain principles of psychiatric pharmacotherapy. “The special thing about giving youth antidepressants is that they could potentially have a hyperarousal or activation type of reaction. They could get restless, jittery, more amped up or hyper. They could become more impulsive,” she said.
Pharmacists should refer patients experiencing activation syndrome to their psychiatrist. “It could be a sign that they might have an underlying bipolar disorder, or it could be a sign that they are at risk for acting on any suicidal thoughts.” She emphasized that this should not preclude antidepressants. “But we have to watch for that behavioral activation within the first month of starting the antidepressant,” she said.
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“Another premise for kids is that withdrawal symptoms are worse in youth than in adults. So, everything must be tapered off gradually,” she added.
Counseling teens on mental health
“While we might be talking to the parents the most, sometimes it is good to talk to the kids, especially if you’ve got someone who’s 14, 15, 16, 17. The medical model works well with those kids—they’ve had some biology, some biochemistry. You can talk to them about rebalancing chemicals in their brain and staying on a medicine to make sure their brain is healthy,” Dopheide said. She believes that message can destigmatize mental health conditions.
Sometimes cultural issues are at play. “A lot of cultures believe if you have a mental health condition, it’s embarrassing or a smear on the family, and maybe you’re a bad parent if your kid has some mental health condition. So, pharmacists can try to help develop a culture of anti-stigma,” she added. “It’s a very delicate area.”
Dopheide once treated a patient on the autism spectrum who was acting aggressively and hitting his mother when she tried to get him to eat. “Part of autism is you have particular food texture issues, and you don’t eat everything. But in that family’s culture, you’re supposed to eat! It’s a big deal if you’re not eating.”
She recommends pharmacists visit the National Alliance on Mental Illness (NAMI) website at
www.nami.org to learn more about issues in various cultures. “And I typically recommend patients and families call their local NAMI groups, which sometimes have cultural chapters. In Santa Ana there’s a large Vietnamese community, so there’re NAMI groups that specialize in cultural issues in that area.”
Birth control
Sally Rafie, PharmD, is assistant clinical professor of health sciences at the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. She is also the founder of birthcontrolpharmaci st.com and helped develop the California statewide protocol for self-administered hormonal contraceptives.
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Look out for adverse effects
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ADHD is one the most studied neuropsychiatric conditions in youth, and there are numerous ADHD formulations with different release forms that pharmacists should know about. “There’s now Jornay PM (Ironshore Pharmaceuticals), which is given at bedtime and takes effect in the morning. And there’s a recent meta-analysis that showed methylphenidate should be first-line in adolescents because of tolerability issues,” Dopheide said. She noted the availability of several new amphetamine compounds, variations of mixed amphetamine salts, and a triple-bead amphetamine, Mydayis (Shire). “Pharmacists need to stay on top of and help patients and families manage side effects and find the right ADHD medication for them.”
Dopheide urges pharmacists to scrutinize indications for antipsychotics to make sure that there is a valid indication, such as schizophrenia or bipolar disorder with psychotic features. They shouldn’t be used for anxiety, insomnia, or behavior control for conduct disorder for longer than a 3-month trial.
“Long-term use of antipsychotics like risperidone can lead to decreased bone density, and kids could be more at risk for fractures when they are playing sports or in general,” she said. She noted that there is evidence that this is a particular issue for kids with autism spectrum disorder.
“And then there’s the metabolic side effects of things like olanzapine and clozapine. You can develop diabetes, hyperlipidemia, and weight gain—it’s much harder to reverse if you develop these as a child or teenager than if you develop them as an adult.”
Emergency contraception
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Pharmacies typically stock Plan B emergency contraception (EC) products—the levonorgestrel-containing emergency contraceptives. A newer method, ulipristal acetate (Ella—Afaxys), is also available. “EC is extremely safe. There are essentially no contraindications for anyone of any age to be using those products,” Rafie said.
“Given all of the changes that happened in the last decade with the regulatory status of the Plan B products being prescription only, then OTC for 18 and over, and now fully OTC, it’s been really hard for pharmacies to keep up with all of that, especially because there isn’t targeted academic detailing or outreach to pharmacies. I think that is part of the reason why sometimes there’s misinformation out there,” said Rafie.
Rafie said pharmacies are the go-to source for EC. “We want to make sure pharmacists are knowledgeable about the products and are offering counseling, but not requiring it. Ideally, they are keeping the product out on the OTC shelves unlocked, because locking it just makes it more stigmatizing and intimidating. Then we should also be keeping some in the back in the pharmacy, because some patients will prefer to come straight to the pharmacist.”
For those times when you can’t help, “there are some really great resources out there. If a pharmacy is in a state where prescribing a birth control is available, but the pharmacy doesn’t provide that service, [pharmacists] can hop on BirthControlPharmaci es.com and find another pharmacy nearby to send the patient to. If the patient, for example, wants something like an IUD, something the pharmacy obviously can’t provide, [the pharmacist] can hop on Bedsider.org and find a clinic that can help them with that,” said Rafie.
Rafie encourages pharmacists to consider why their adolescent patients are pursuing hormonal contraceptives. “Sometimes, they may be seeking it for noncontraceptive reasons. So, they may not even be sexually active but may want to treat their acne, or maybe they have really heavy periods. So, while it’s not required in California that we get into the indications, it does allow for more patient-specific counseling and a better experience for the patient.”
Rafie advocates that pharmacists “think about making sure that we’re welcoming our younger population—so have literature that’s appropriate for youth, and have a confidential space to speak to young people so that it’s not in front of everyone.”
While some pharmacists may have personal biases toward teenagers having sex, “as long as they can acknowledge that and actively work around it to serve their patients’ needs, then I think they can still provide really respectful competent care to patients,” Rafie said. “Teens don’t want to have someone speak to them in a condescending fashion. So we want to make sure that we are respectful toward them and helpful and friendly. Our facial expressions, our tone—all of that makes an impact on their experience at the pharmacy.”
When dealing with sexually active adolescents, keep in mind that they “are typically at higher risk for STDs, so we should counsel them about safe-sex practices such as using condoms, as well as getting at least annual screenings for STDs,” Rafie said. Pharmacists should make sure that “our counseling is comprehensive, listening to the patient about their values and what they’re comfortable with. If they want a birth control method that they can hide from their parents, take that into consideration, and help them understand the importance of adherence for the effectiveness of the medication.
“There is one kind of additional counseling point when it comes to the Depo injection, which is the shot that’s good for 3 months. That does cause some reversible bone density loss in young people. We would just encourage them to use calcium and vitamin D supplements [and do] weight-bearing exercises, and then there’s a return of that bone density after they stop the medication,” Rafie added.
Opioids and other considerations
“Another challenge for pharmacists dealing with patients this age is when they stop getting weight-based doses and begin getting regular dosing for adults. When does that transition occur?” said Skywalk’s Olson.
“If you’ve got an 11-year-old who’s 5’11”, and you see there’s a weight-based dose for her, sometimes you have to think that through. Sometimes we get 18-year-olds with special needs who are really small, and you think, ‘Well, this is an adult, I should treat them as an adult.’ But no, they’re not big enough yet.”
Controlled substances for pain, ADHD, and other uses also pose consultation challenges at Skywalk. “We consult patients and families on postsurgical pain medications on a daily basis. We once again have to mention the risk of driving while taking opioids and the dangers associated with mixing it with alcohol,” Olson said. “We also have to say, ‘This is what you read about every day. This prescription is a gateway to potential abuse problems down the road.’ ”
He also tries to educate parents on the potential for abuse. “They need to know that it is important to dispose of unused medications promptly to make sure they don’t fall into the wrong hands,” Olson said. “We feel we can help combat the opioid problem with this initial education.”