BETHESDA, MD, 23 Apr 2002—Since the arrest last August of a Kansas City, Missouri, pharmacist who was charged with purposely weakening doses of cancer drugs, many pharmacists in this Midwestern city and elsewhere have found themselves having to defend the pharmacy profession.
Robert R. Courtney and his corporation, Courtney Pharmacy Inc., pleaded guilty at a federal hearing on February 26 to eight counts of tampering with consumer products, six counts of adulterating drugs, and six counts of misbranding drugs (see box).
Tampering, Adulterating, and Misbranding Drugs
Robert R. Courtney, 49, of Kansas City, Missouri, and his corporation, Courtney Pharmacy Inc., pleaded guilty on February 26 to 20 felony criminal charges related to the incorrect preparation and dispensing of cancer drugs.a
Courtney and his corporation have admitted to the following crimes:
Through his plea agreement, Courtney has admitted that he also diluted and tampered with paclitaxel and gemcitabine solutions administered to 26 additional patients, for a total of 34 persons. He also admitted that he diluted and tampered with cisplatin and carboplatin on an unspecified number of occasions. In addition, he admitted that he conspired to traffic in stolen drugs and that, by tampering and diluting drugs but not informing the treating physician, he caused that physician to file false Medicare claims.
An ongoing investigation into the Courtney case has resulted in at least four other people confessing to dealing in stolen prescription drug products.
Two of those cases involved retired pharmaceutical salesmen who admitted to buying stolen drugs from a man who worked in the pharmacy storeroom of the University of Colorado Hospital in Denver. The former hospital worker confessed in April to stealing drugs from the facility and selling them.
The investigation also netted a Kansas City pharmacist who, through a plea agreement, surrendered his pharmacy license to state authorities in Kansas and Missouri.
Gary S. Ravis, 58, pleaded guilty to knowingly buying stolen drugs from one of the salesmen. Ravis was sentenced in April to five years of probation, 2500 hours of community service, and a $250,000 fine. He must spend the first six months of his probation under electronic monitoring in his home.
aSource: Office of the United States Attorney for the Western District of Missouri.
As part of his plea agreement, Courtney faces 1730 years in prison without the possibility of parole. He remains in jail without bond, pending sentencing. A sentencing hearing has not yet been scheduled.
Courtney has been sued in civil court by more than 300 patients or their family members.
A federal judge will decide how to disperse about $8 million of Courtneys assets that were frozen last fall.
Standing in February before a U.S. District Court judge, Courtney said he had no "rational explanation" for his criminal actions, was "extremely sorry," and would "accept full responsibility."
But Dan Novovesky, a clinical pharmacist at Research Medical Center, the hospital located next door to one of the independent pharmacies owned by Courtney, wants him to apologize to all pharmacists for "placing a blemish on the entire profession."
"I want to know why he did it," Novovesky said. "He hasnt explained that yet. Out of greed, he has hurt our image as pharmacists."
Novovesky said he has known Courtney for more than 20 years, beginning with a month-long experiential rotation in Courtneys Research Medical Tower Pharmacy, shortly after it opened in the late 1970s.
"He was a mentor to me," Novovesky said. "I dont understand how he could have put his patients at harm."
Novovesky said he has had to confront negative comments from patients, visitors, and staff members at his hospital about whether his pharmacy correctly mixes drug products.
"Its a terrible feeling to have your fellow health care workers and patients lose trust in you," Novovesky said. "They will see my name tag and see that Im a pharmacist, and then they will say things like, You dont mix stuff like Robert Courtney, do you? All I can do is try to reassure them that we are doing our job correctly and that not all pharmacists are like Courtney."
More communication is needed about pharmacists who, Novovesky said, "do their jobs correctly everyday."
"Nobody seems to be asking how many lives a day pharmacists save," he said. "Pharmacists correct things like dosing errors, and not enough focus has been placed on things like that. I really like my job. I know that Im making an impact for the good. But Im afraid its going to be a slow road getting back to normal, and only time will heal this wound."
Novoveskys wife, Denoya, a pharmacist at Saint Lukes Hospital in Kansas City, said she and her colleagues have been "stunned and in shock" by the Courtney case.
"Its just been so hard getting over the fact that any pharmacist would do this," she said.
Saint Lukes, a 650-bed hospital, is within a few miles of where Courtneys Research Medical Tower Pharmacy was located.
Jennifer Quinlan, a Saint Lukes clinical pharmacist, said her pharmacy has received numerous calls from concerned patients and their family members, asking questions about how i.v. drugs are prepared at the hospital and whether Courtneys pharmacy had supplied any drugs to the hospital or its patients.
Saint Lukes, Quinlan said, did not obtain any drugs from Courtney.
"Im proud that our policy was designed to prevent purposeful errors," she said. "We have four to five people involved in mixing and checking our [cancer] chemotherapy drugs. We can reassure our patients that there is no way that what happened at Courtneys pharmacy could happen here."
Janet Haskin, also a clinical pharmacist at Saint Lukes, said the Courtney case has yielded some positive outcomes. It has prompted physicians and nurses to ask how the pharmacy prepares i.v. admixtures, particularly cancer chemotherapy drugs.
"Some of them didnt realize how the process worked," she said. "And this has been an opportunity for them to learn more about it."
Haskin said she has always been proud that pharmacy is considered one of the most trusted professions.
For 10 consecutive years (1989 through 1998), pharmacists held the top spot in the CNN/USA Today/Gallup annual honesty and ethics in professions poll.
Pharmacists dropped to fourth place in the most recent poll, but the percentage of respondents who perceived the pharmacy profession as highly or very highly honest and ethical has stayed about the same, around 68%, for the past three years.
"I would hate to see a survey done locally now," Haskin said. "Im still proud to be a pharmacist, but this has been such a bad thing for all of us."
Pharmacist Sue J. Bliss said that, even though she practices institutional pharmacy in Oregon, hundreds of miles away from Kansas City, she has felt the added pressures the Courtney case has created for pharmacists.
"It makes every pharmacists workday harder," she said. "One person has created such a large breach of trust that it will take a lot of people doing a lot of things right to fix this."
Bliss said she was so "fired up" about the Courtney case that she contacted a Kansas City Star business-news columnist to argue in favor of pharmacists who, to ensure patients have the correct medications when needed, cover double shifts, skip lunch, and work late hours.
The columnist responded by publishing an article about pharmacists that quoted Bliss.
"Im not one of those people who can just sit back and complain and worry about something. I have to do something about it," she said.
One of the reasons the public has reacted "so emotionally" to the Courtney case, Bliss said, is because pharmacists are "the most accessible group of health care providers."
"People can walk right up to the counter and ask questions," she said. "No other health care professional provides that [service]. People feel like they know their pharmacist. So when a pharmacist like Courtney does what he did, people are shocked and hurt because they feel their personal trust and relationship has been violated."
Bliss hopes the Courtney case will not dampen the market for pharmacists who want to set up cancer chemotherapy laboratories and compounding rooms in community pharmacies.
"Pharmacy needs innovators and entrepreneurs," she said. But, she added, as the pharmacy profession grows and the use of automation increases, the profession needs to make changes and continue to establish ethical guidelines to prevent other cases like Courtneys from occurring.
"It takes courage to make those changes," she said.
Within weeks after a federal judge ordered Courtneys assets frozen, pharmacist Howard Stark bought the Research Medical Tower Pharmacy. By November 2001, he had opened it under its new name, Stark Professional Pharmacy.
Stark said he was strongly encouraged by a local health system to buy the pharmacy to help "change the image" and "clean up the mess."
Stark is a past president of the American College of Apothecaries and owns three other pharmacies in Kansas and Missouri.
He said he changed the interior of his new pharmacy, installing glass walls for the compounding area and a large picture window for the cancer chemotherapy laboratorya design he uses in his other pharmacies.
"We want the public to have access so that we can show them the art of pharmacy," he said. "We are showing them that we are not hiding anything, and they can trust us. But Im afraid, locally at least, it is going to take awhile for that trust to come back."