You don't have any questions for the pharmacist, do you?: A fatal methadone overdose

Terry Paul Smith, a 46-year-old roofer, suffered from a disorder of the peripheral nerves (neuropathy) in his back and legs, which kept him in chronic pain. He took Oxycontin and Neurontin, but he disliked the way it made him feel, e.g., making him sometimes "drop out" in the middle of a conversation. After he mentioned the pain meds' side effects, his doctor changed the prescription to methadone, a narcotic pain reliever. The doctor wrote a prescription for Terry to take four 10-milligram pills, twice a day.

Terry filled the prescription at a local Walgreen's pharmacy in Jacksonville, Florida. In handing over the pills, the pharmacy employee asked, "You don’t have any questions for the pharmacist, do you?" They didn’t.

Though Terry didn’t know it, the label on the medication vial was incorrect; it directed him to take four tablets "as needed for chronic pain," and did not mention any limits on the frequency. Terry took the pills for the first time on July 23-24, 2001.

Within 36 hours, he was dead. An autopsy that his widow insisted found toxic levels of methadone in his blood.

The pharmacist had mislabeled the pills as "take as needed" rather than take "twice a day."

Now Terry's widow, Pearl Smith, is pursuing a lawsuit against Walgreen's. Next week, the jury will begin considering the case.

A company spokesman says Walgreen's has spent $1 billion over the last decade on pharmacy safety systems, safety training and technology. Walgreen's filled more than half a billion prescriptions in the last fiscal year.

Advice: Read the doctor's prescription and check it carefully against the label, especially for a new medicine.

Read an informed consent story, or read more from the source article by Kevin McCoy in the USA Today of Nov. 2.