Prescription Drugs, Verde Valley Guidance Clinic - Dr. Collins, Phone Interview
Q: It looks from my interpretation, that one of the reasons that you had him [Jeremy] admitted [for treatment in jail], is that you wanted to wean him off some of these medications, and wanted to make sure that it was medically safe to do so? Am I interpreting that correct?
Dr. Collins: Well, I think we wanted to get the medical clearance at first to get him medically stabilized … I really tried to remain neutral, and stay away from the legal stuff, because if I do that, it really clouds what I am seeing in patients under my care; the people in detention. When he [Jeremy] came into detention, I was made aware immediately what was going on, what happened, and that would have been the first thing I am told. They don’t call me and say, its Joe-Blow here and he committed homicide, or alleged homicide, and this is what’s going on. When people call me, the nurses call me, and they give me a list of medicines, the medicines the person is on … they give me a brief, a mental state of what’s going on, and what they think - because I don’t see them [the patients] immediately; usually within couple of days. When they gave me the list of the medicines he [Jeremy] was on; number one, I was really worried, and then number two, when they told me that there was alleged drug abuse, I was really worried, and then when they told me what happened, it was really concerning - that I had a concern- that the medicine he [Jeremy] was on, which it seems to me there were five or six, that’s five or six Psychotropics [emphasis added] maybe not, but at least four, that combined with illicit substances, whether be it an amphetamine or something else, I was really concerned about his metal status, and the possibility of a delirium. So, I believe this is the reason I went for a medical clearance.
Q: What role, were you concerned, the Psychotropic medications were playing in this?
Dr. Collins: […] I was concerned that he was in a delirium. A delirium is different than a psychosis. You can have psychosis with delirium, and you can have just psychosis on its own. But, a delirium is where you have really lost your ability for orientation, you have lost your ability to form a clear thought process, you don’t know where you are, you don’t know what date it is, you don’t know what happened. [emphasis added] And that was my concern […] put some drugs on the top of that, he was in a state delirium […] You have to make sure that somebody is medically stable before I can treat the psychiatric issues. I was worried that what was going on with him [Jeremy], was medication-induced, in addition to drug withdrawal on top of it.
Q: Ok, so psychosis is a psychological term, and delirium is a medical term?
Dr. Collins: It is. And that is what we all try to sort out when somebody comes in. Are they in a delirium; because if they are in a delirium, this is a medical issue, and I’ve got a get to the bottom of what’s going on medically, before I can treat them from the psychiatric perspective.
Q: Now, the records show that he [Jeremy] was, like, seeing, squirrels, or something coming out of toilets, and …
Dr. Collins: Yes
Q: There were definitely some hallucinations, and you were aware that he had attempted an overdose, so his prescribed medications … See, he was in that kind of mental state when he got to the jail. What [do you] sense was causing it?
Dr. Collins: I kind a eluded to that, and again, my concern was that the state that he was in; when he came to the jail, and that’s all I can say, [his mental state] at that time, that when he was in a delirium, that this delirium was induced by psychotropic medications on top of drugs. [emphasis added …]
Q: The information to us, and based on his records at Verde Valley [Guidance Clinic] is that he probably had been clean of meth like about thirteen months, but he was on a lot of psychotropic meds. [emphasis added]
Dr. Collins: A lot! A lot!
Q: I am trying to see if it is possible to distinguish his metal state when he showed up at the jail, whether the ethology was that medications that he took to overdose himself […] to what degree the medications that he took on daily basis was causing his mental state? […]
Dr. Collins: I was really, really, really concerned about the number of Psychotropics he was on […] I was appalled. Appalled by how many Psychotropics this kid was on. [emphasis added] He is sick, Bob. He is sick. He’s got a real significant psychiatric disorder. I have been; what we had done in the jail, he is on Clozaril right now, which is essentially, in our treatment algorithm, the last medicine that we can use for psychosis and schizoaffec[ive] disorder […] I was so upset by what had happened to this young man, and not excusing what he did, and I am not a bleeding-heart leftist, or anything like that, or a liberal, I am not at all, but I am so upset that he had been on all of these medicines, nobody had been watching drugs for him, and that there is a loss of a life. And, and you know, I am not making any comments about, that’s not my business; there is bad things that happen with the combination of legal drugs and illegal [drugs]. And I was just pissed off about [this], to be honest with you. [emphasis added]
Q: This mixture of drugs can cause problems with aggression, impulse control, things like that? [emphasis added]
Dr. Collins: It sure can! It sure can! [emphasis added …]
Q: We left off kind a saying that this cocktail of medications that Mr. Pompeneo was on could affect his aggression and impulse control. [emphasis added] Is that right?
Dr. Collins: Yes. It is correct. [emphasis added]
Q: Why do you think that, what is it about this mixture of medications that makes you think that?
Dr. Collins: I think, me to go through over that […] He was on a mixture of mood stabilizers and antidepressants, and psychotics, and ADD [Attention Deficit Disorder] medications; that’s what I am remembering form the top of my head. And he was on … I think, two ADD meds, one antidepressant, one atypical psychotic, and one mood stabilizer. While back ago, we did a chart, long time ago. But, what happens, he was on multiple drugs, from multiple classes of medications. Antidepressants are different from psycho-stimulants, antidepressants are different than mood stabilizers, antidepressants are different than atypical anti-psychotics. And each time you add a medication on top of another, you run a risk of drug-drug interaction. You also run the risk of exacerbating a primary disorder when you trying treat maybe the secondary disorder. Jeremy’s primary diagnosis would have been schizoaffective, or bi-polar. A typical antipsychotic or mood stabilizer would have been an appropriate treatment for that. And that would have been fine. But, if he is then treated with an antidepressant, that can make the primary disorder worse, or for depression, or if he is treated for ADD with a psycho-stimulant, or Strattera, that can make the primary disorder worse. So, you run the drug-drug interaction, you run the risk of the additional medication used to treat every symptom, and Jeremy comes with a ton of symptoms. And you know, he and I have had several talks in detention. I said – “Jeremy, this is what I’m going to treat, this is how we are going to do it. We are going to get you to the best stability I can. I cannot […] and I don’t care, eradicate the 100% of the symptoms, we can treat 50 to 60 percent, that’s what about we can do.” […] What had happened, may have not happened, if he would have reasonable mental health treatment. We have a loss of life, we have a kid who is going to be in jail, at least for the rest of his life, [emphasis added] and I just said to him – “Jeremy, I will do the best I can to make you feel better, and help you to get thorough this thing while here in detention. I will not over-medicate you, I will not under-medicate you. “ And that’s where we got to the Clozaril; that’s how I look at his record, or what he’d been through; Clozaril is a difficult medicine to use, and extremely dangerous medicine at that, if not used appropriately. This is kind a end-of-the-line. And he stays on it pretty well, I mean, he has responded pretty darn well to the medicine, and you know, he has not killed himself, which I think is probably a good feat for the stress, depression, he has been under. And the psychiatric diagnosis, just his psychiatric diagnosis, runs the risk of completed suicide. And you take everything else, you know, you are doing reasonably well. And he is better, and I have told him every time – “Jeremy, I’m not going to make you worse, I am not going to give you extra medicine, and you know, if I get you to 50 to 60-percent better, that’s all I can do. And he is pretty accepting of that. You know, he has been accepting; I did rework his meds a little bit recently for, a … at the trial, but they were going in front of the [Sherris’] family members, and he was just up-front, and we’ve got a social worker to see him too, and he said “I am just really anxious about this”, and that’s real, and this is what we can do during this time, because you know, I myself want him to be stable […]
Q: We did interview some people at the Verde Valley Guidance Clinic, regarding the treatment and care there given to Jeremy. I think there is a lawsuit against them by the victim’s family, but I think there is also, some Tarasoff [duty to warn] issues going on there. But, what we are told is that, it is the nurse practitioners that are prescribing the medications […]
Dr. Collins: Nurse practitioners must practice within their boundaries, within their expertise, and their level of ability. Jeremy should’ve never, ever been treated by nurse practitioner; with his issues he should have had treatment by a psychiatrist […] With his level of pathology, he should have never seen a nurse practitioner. Once you got two, three meds on Jeremy, there should have been a consultation with the psychiatrist – with the medical director. And, there should have been ongoing consultation; he is on four, five, six different meds, that should have set off a warning sign, a flag, somewhere – you know we’ve got a really complex case, we better get a board-certified psychiatrist to take a look at that. And I know Lisa [Sims], and I know Frank [Gagliardi], and I like them, but it is a bad, bad thing that happened. [emphasis added]
Q: You know, I appreciate your perspective. In my job I’ve interviewed other nurse practitioners who practice unsupervised [… When] I interview a nurse practitioner – one, they don’t have any idea what they don’t know, they operate based on the law that says they can, therefore they do. I had a nurse practitioner who [once] told me “I could do a brain surgery, if I wanted to.”
Dr. Collins: Yeah, and that’s kind a separate issue, but it is an important issue, that they suppose to practice within the bounds of their ability.
Q: But they don’t think of it this way; they think of it is, “I practice under the limits of my licensing.”
Dr. Collins: And they didn’t go to the medical school.
Q: Do you think it is O.K?
Dr. Collins: Well, and we have physicians like that to. They physician community is not immune, that we have people practicing outside of their boundaries. But Verde Valley [Guidance Clinic] should have had; even if Lisa [Sims] was practicing outside of … as she was practicing outside of her ability, there should have been an internal mechanism within Verde Valley Guidance Center [Guidance Clinic], to identify hi-risk cases. And that’s what pisses me off! [ … emphasis added]
Q: So, the way you think the system works, that it [Jeremy’s treatment plan] was never brought to him [Francis Gagliardi] to review […]
Dr. Collins: I don’t know if it was ever brought to him or not brought to him, but I don’t think there were enough internal mechanisms to identify what could have, or what did go wrong, because they should have identified this earlier. I can’t [imagine] somebody on two, three Psychotropic medications not come to the attention of the medical director. And there should be some supervision going on. Once you get to five six medications, and with the psycho-stimulant there, and with somebody with methamphetamine abuse, that should have definitely go in front of the doc [medical doctor] who was trained to deal with this […] [emphasis added]
Q: We have a Dr. Potts, I don’t know if you know Jack Potts at all?
Dr. Collins: You know, I met him, he’s out of Phoenix?
Q: Yeah, yeah.
Dr. Collins: I met him just quickly, when he was in detention seeing Jeremy one day, and I met him for five minutes.
Q: We had him look at this case, and we gave him all Verde’s [Verde Valley Guidance Clinic] records, his [Jeremy’s] list of meds, and the Mingus records. And his main concern is that at his level of expertise, was specific to the Concerta.
Dr. Collins: And that’s the psycho-stimulant.
Q: O.K., because he says, “look, I got his [Jeremy’s] Mingus records and I got his Verde [Valley Guidance Clinic] records, and every time you put him on Concerta, there he is at Mingus self-reporting [a patient admits himself for treatment], because he can’t control his rage”. And he goes “Three times is a charm, once is a third time, its clear this guy’s got a problem with this medication, why are you giving it to him again?” [emphasis added]
Dr. Collins: Yeah, and he’s [Dr. Potts] is talking about the psycho-stimulant. You are treating bi-polar, than you’re adding something anti-depressant on top of the routine bi-polar medicine, and than you add Strattera, and than you add Concerta, which is a psycho-stimulant, and it’s a cocktail anyone would go crazy on. But, you know Jeremy [was] methamphetamine abuser, and you’ve got history that he uses, and that he also gets psychotic maniac, that is a no brainer! I mean, a third-year resident wouldn’t have given him Concerta. [emphasis added] He would just have said, you know what … and that’s what I say to him – “Jeremy, ADD is not gonna kill you. You’re gonna live through it. Yeah, you’re little bit impulsive, you’ve got poor concentration – voices, mood instability, mania, and depression, that will kill you Jeremy”.
--- End of Phone Interview ---
Jeremy was murdered in prison on May 31, 2011.
