Distributing Over The Counter Medications To Clients
Wazaify et al. surveyed members of the public in Northern Ireland and described almost one-third of participants as having personally encountered OTC abuse (based on either personal experience, knowledge or observation). The most recent study identified (Nielsen et al., 2010) involved an on-line survey of 909 Australian individuals who used codeine and identified 138 (17.3%) as being “likely to be codeine dependent” using a severity of dependence scale. Two studies sampled pharmacy customers: in France, Orriols et al. questioned 53 pharmacy customers using surveys about their codeine use in the previous month and identified 15% as misusing, 7.5% as abusing and 7.5% as being dependent. Major and Vincze randomly surveyed pharmacy customers in Hungary and reported that almost one-third had personally experienced OTC abuse. With a specific focus on analgesic use, Agaba et al. randomly sampled an area in Nigeria and reported analgesic abuse in 22.6% of respondents. They collected data on patients’ self-reported weekly use and overall duration and defined abuse as being a cumulative lifetime use exceeding 5000 “pills”.
A total of 53 publications were identified, including 25 empirical studies, 11 case reports, 11 reviews articles, 1 book chapter, 1 doctoral thesis, 1 parliamentary enquiry and 3 key publications from organisations. The empirical studies represented 10 countries, with the United Kingdom (England, Wales, Scotland and Northern Ireland) being the most studied, followed by the United States (Table I). The earliest identified study was conducted in 1996. A range of methods had been used in empirical studies, with various scales of surveys being most commonly used, as well as primary data collection of treatment centres and secondary data collection of emergency department presentations. Qualitative methods were identified in only two empirical studies and several studies reported on findings from pilot stages only (Fleming et al., 2004; Sweileh et al., 2004; Orriols et al., 2009). The findings are now described in more detail, organised in relation to the objectives described earlier – types of medicine implicated, scale of OTC abuse, associated harms, characteristics of those affected and approaches to dealing with OTC abuse – with an additional theme relating to terminology also being included.
A range of problems and harms associated with OTC medicine abuse were identified and these comprised three broad categories (Fig. 1). First, there were direct harms related to the pharmacological or psychological effects of the drug of abuse or misuse. Second, there were physiological harms related to the adverse effects of another active ingredient in a compound formulation. Both these types of harm led to concerns about overdoses and presentation at emergency services. Third, there were those harms related to other consequences, such as progression to abuse of other substances, economic costs and effects on personal and social life. Direct harms included addiction and dependence to an opiate such as codeine (Mattoo et al., 1997; Orriols et al., 2009; Nielsen et al., 2010). Other direct problems included convulsions and acidosis due to a codeine and antihistamine (diphenhydramine) containing antitussive medicine (Murao et al., 2008) and tachycardia, hypertension and lethargy due to abuse of Coricidin cough and cold tablets (dextromethorphan and chlorphenamine) (Banerji & Anderson, 2001). Lessenger and Feinberg produced a comprehensive list of physical findings of nonmedical use of abused OTC products, noting agitation with nicotine gum, caffeine and ephedra, priapism with ephedrine and pseudoephedrine, psychiatric effects with dextromethorphan, euphoric psychosis with Coricidin and chlorphenamine and gastrointestinal disturbances with laxatives. Also within this category of direct harms were concerns raised about chronic rebound headache associated with repeated use of analgesics.
Whilst customers want more engagement with pharmacists regarding CM issues, some customers currently feel that pharmacists are ill-equipped to counsel them about CMs and many do not refer to pharmacists as an information source. This correlates with pharmacists' own discomfort dealing with CM queries and feeling insufficiently informed about CMs . It is possible that customer's interest in having access to a natural medicine practitioner within the pharmacy premises is a consequence of their current dissatisfaction with pharmacy practice, however this remains to be further investigated.
A total of 53 publications were identified, including 25 empirical studies, 11 case reports, 11 reviews articles, 1 book chapter, 1 doctoral thesis, 1 parliamentary enquiry and 3 key publications from organisations. The empirical studies represented 10 countries, with the United Kingdom (England, Wales, Scotland and Northern Ireland) being the most studied, followed by the United States (Table I). The earliest identified study was conducted in 1996. A range of methods had been used in empirical studies, with various scales of surveys being most commonly used, as well as primary data collection of treatment centres and secondary data collection of emergency department presentations. Qualitative methods were identified in only two empirical studies and several studies reported on findings from pilot stages only (Fleming et al., 2004; Sweileh et al., 2004; Orriols et al., 2009). The findings are now described in more detail, organised in relation to the objectives described earlier – types of medicine implicated, scale of OTC abuse, associated harms, characteristics of those affected and approaches to dealing with OTC abuse – with an additional theme relating to terminology also being included.
A range of problems and harms associated with OTC medicine abuse were identified and these comprised three broad categories (Fig. 1). First, there were direct harms related to the pharmacological or psychological effects of the drug of abuse or misuse. Second, there were physiological harms related to the adverse effects of another active ingredient in a compound formulation. Both these types of harm led to concerns about overdoses and presentation at emergency services. Third, there were those harms related to other consequences, such as progression to abuse of other substances, economic costs and effects on personal and social life. Direct harms included addiction and dependence to an opiate such as codeine (Mattoo et al., 1997; Orriols et al., 2009; Nielsen et al., 2010). Other direct problems included convulsions and acidosis due to a codeine and antihistamine (diphenhydramine) containing antitussive medicine (Murao et al., 2008) and tachycardia, hypertension and lethargy due to abuse of Coricidin cough and cold tablets (dextromethorphan and chlorphenamine) (Banerji & Anderson, 2001). Lessenger and Feinberg produced a comprehensive list of physical findings of nonmedical use of abused OTC products, noting agitation with nicotine gum, caffeine and ephedra, priapism with ephedrine and pseudoephedrine, psychiatric effects with dextromethorphan, euphoric psychosis with Coricidin and chlorphenamine and gastrointestinal disturbances with laxatives. Also within this category of direct harms were concerns raised about chronic rebound headache associated with repeated use of analgesics.
Whilst customers want more engagement with pharmacists regarding CM issues, some customers currently feel that pharmacists are ill-equipped to counsel them about CMs and many do not refer to pharmacists as an information source. This correlates with pharmacists' own discomfort dealing with CM queries and feeling insufficiently informed about CMs . It is possible that customer's interest in having access to a natural medicine practitioner within the pharmacy premises is a consequence of their current dissatisfaction with pharmacy practice, however this remains to be further investigated.