Patient attitudes to over-the-counter drugs and possible professional responses to self-medication

Consumer Impressions of the Safety and Effectiveness of OTC Medicines

The public generally believes OTC medicines to be helpful for treating minor ailments. From a survey point of view, that position often originates from feedback obtained when these medicines are considered as one broad category. The objective of the study was to assess the properties of 15 categories of agents across three dimensions-effectiveness, safety, and familiarity. Data were gathered via an online non-random survey in one Canadian province, where residents were asked to consider 15 OTC medicine categories in terms of those dimensions. Five hundred and seventy-five completed surveys were obtained out of 3000 sent. On the 10-point effectiveness scale, values ranged from 5.1 (Athlete's foot cream) to 7.3 (headache medicine). For safety, the medicines were closely grouped (6.0 to 7.4). Cough syrups for children were perceived as less safe than those for adults. There was a trend in that, as product familiarity grew, so did impressions of safety and effectiveness. The results support other reports where OTC medicines are described as safe and effective, although safety ratings were not particularly high. Responders considered these medicines to generally be higher in safety than effectiveness.

Perspectives of patients and consumers on the use of generic medicines

INTRODUCTION Access to medicines constitutes a public health challenge worldwide. Promoting utilization of generic medicines is one of the strategies that has been proposed to optimize pharmaceutical spending and thus allow greater coverage. However, its use is not yet widespread enough. This study seeks to explore the perspectives and acceptability to the use of generic medicines from patients and consumers. METHODS We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a evidence synthesis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified four systematic reviews that together include 47 primary studies, of which one corresponds to a randomized trial. A low rate of patients or consumers has a negative perception regarding generic medicines, including dimensions such as risk, quality, safety, risk of adverse effects, among others.

Community pharmacy modifications to non-prescription medication requests: A simulated patient study

BACKGROUND

Self-care, and hence self-medication, is becoming an increasingly popular practice worldwide. Community pharmacies are an important destination for those seeking non-prescription medicines, and pharmacists and their staff are in a prime position to facilitate appropriate and safe self-medication.

PURPOSE

To determine what modifications (for example, a change in brand, change in drug, or non-supply) pharmacy staff make when presented with a request for a non-prescription medicine, and to determine what factors influence whether a modification is made.

METHODS

Sixty-one third year Bachelor of Pharmacy students from The University of Sydney were trained as mystery shoppers to make 9 visits once a week to 36 community pharmacies in the metropolitan region of Sydney, Australia from March-October 2015. Students presented to a different, pre-allocated pharmacy once a week with a direct product request for a non-prescription medicine relating to a common ailment (e.g. asthma, insomnia, allergic rhinitis) for 9 weeks. Student mystery shoppers audio-recorded each visit and collected the details of the interaction and product sold. Descriptive statistics, chi-squared analyses, and binary logistic regression were performed to find factors influencing modifications made by pharmacy staff to the simulated patient initial request.

RESULTS

Of 540 completed visits, 497 were eligible for analysis. Modification (change in brand, intra/interclass change, companion sale, or no product supplied) occurred in 49% (n = 245) of visits. Whether the product requested was deemed "not appropriate" given the scenario outline was the only significant predictor of whether a modification to the request occurred (42% modification, "appropriate" scenarios vs. 57% modification, "not appropriate" scenarios; χ² = 8.90; p < 0.01).

CONCLUSIONS

Modification from the original non-prescription medicine request occurred in approximately half the reported requests. A request for a product that was considered "not appropriate" was more likely to elicit a modification than a request for an "appropriate" non-prescription medicine.

Perceptions of generic medication in the general population, doctors and pharmacists: a systematic review

OBJECTIVE

To investigate negative perceptions about generic medicines and evaluate the proportions of lay people, doctors and pharmacists who hold these perceptions.

DESIGN

A systematic review of observational studies.

DATA SOURCES

MEDLINE, EMBASE, PsycInfo and Scopus.

ELIGIBILITY CRITERIA

Quantitative data from cross-sectional and prospective studies published in English after 1980, using self-report measures to evaluate perceptions about generic medicines, presented as percentages of the total sample assessed.

RESULTS

After screening 2737 articles, 52 articles were included in the final analysis. A high proportion of doctors, pharmacists and lay people had negative perceptions of generics. Lay people were significantly more likely to view generics as less effective than branded medication (35.6%, 95% CI 34.8% to 36.4%) compared to doctors (28.7%, 27.5% to 29.9%) and pharmacists (23.6%, 21.2% to 26.2%), p<0.0001. Pharmacists (33.4%, 31.0% to 35.9%) were significantly more likely to believe generics were of inferior quality compared to branded medication than were doctors (28.0%, 26.3% to 29.9%), p=0.0006, and lay people (25.1%, 24.2% to 26.0%), p<0.0001. Doctors believed generics caused more side effects than branded medication (24.4%, 22.2% to 26.9%), compared to pharmacists (17.6%, 15.3% to 20.1%) and lay people (18.8%, 17.8% to 19.8%), p<0.0001. Doctors (28.5%, 26.9% to 30.2%) and pharmacists (25.4%, 21.4% to 29.9%) had significantly more safety concerns about generics than did lay people (18.0%, 17.0% to 19.0%), p ≤ 0.0002. A greater proportion of lay people felt negatively about generic substitution (34.0%, 33.2% to 34.9%), compared to doctors (24.1%, 22.0% to 26.4%) and pharmacists (11.0%, 9.6% to 12.7%), p<0.0001. Rates of negative perceptions of generics do not appear to have changed substantially over time in the general population or among physician groups, p ≥ 0.431, but such negative beliefs show a decreasing trend in pharmacists over the study period, p=0.034.

CONCLUSIONS

A significant proportion of doctors, pharmacists and lay people hold negative perceptions of generic medicines. It is likely these attitudes present barriers to the wider use of generics.

Key information providers, channels, and characteristics of Japanese consumers’ informed choices of over-the-counter medications

People need reliable information regarding over-the-counter medications (OTCs), so that they can independently make appropriate informed choices. The study aimed to identify the information providers and channels that have an impact on the purchase of OTCs, and to demonstrate the information needs of OTC purchasers, using these providers and channels, from the viewpoint of information characteristics such as specialty, objectivity, concreteness, comprehensiveness, individuality, and availability, focusing on the efficacy of OTCs and related safety information. A questionnaire survey of randomly sampled adults aged ≥20 was conducted at the Japan Drugstore Show 2012, hosted by the Japan Association of Chain Drug Stores. In this questionnaire, information was particularly limited to the efficacy and safety of OTCs. Multivariate logistic regression analysis was performed on data from 1743 respondents (1625 purchasers and 118 non-purchasers of OTCs) who obtained information on OTCs in their daily lives, to demonstrate the associations between the use of information providers and channels (predictor variables) and the purchase of OTCs (outcome variable), as well as between information characteristics valued by purchasers (predictor variables) and their use of these information providers or channels (outcome variables). Both the use of pharmacists as information providers and consultation at pharmacies as an information channel were positively associated with the purchase of OTCs (odds ratio [OR], 3.74; 95 % confidence interval [CI], 2.46–5.68; P < 0.001 and OR, 4.55; 95 % CI 2.92–7.11, P < 0.001, respectively), whereas both the use of family or friends using OTCs as information providers and family or friends as information channels were negatively associated with the purchase of OTCs (OR, 0.60; 95 % CI 0.40–0.90; P = 0.014 and OR, 0.55; 95 % CI 0.36–0.82; P = 0.004, respectively). OTC purchasers who valued individuality of information were more likely to use pharmacists (OR 2.00; 95 % CI 1.61–2.48; P < 0.001) and consultation at pharmacies (OR 1.98; 95 % CI 1.61–2.43; P < .001). In conclusion, individualized information provided by pharmacists on the efficacy and safety of OTCs during consultation at pharmacies can play the most important role in the informed choices of OTC purchasers.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Ibuprofen-Induced Hypokalemia and Distal Renal Tubular Acidosis: A Patient's Perceptions of Over-the-Counter Medications and Their Adverse Effects

We highlight a case of distal renal tubular acidosis secondary to ibuprofen and codeine use. Of particular interest in this case are the patient's perception of over-the-counter (OTC) medication use, her own OTC use prior to admission, and her knowledge of adverse reactions or side effects of these medications prior to taking them.

Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers' attitudes toward their children's health management

BACKGROUND

Since 2009, when the revised Pharmaceutical Affairs Act was enacted in Japan, self-medication practices have increased. Because the concept of self-medication was recently introduced in Japan, few studies exist on this topic. Therefore, it is necessary to explore how self-medication is practiced. This study examined Japanese consumers' self-medication practices and attitudes toward over-the-counter (OTC) medicines based on their sex, age, and socioeconomic status (SES).

METHODS

The participants were 403 adults (Mage = 41.1 years, SD = 16.22). A quota sampling method was employed based on age group, and participants completed an online questionnaire.

RESULTS

Participants in the 20-29 age group reported medical costs as an obstacle in seeing a doctor; in contrast, transportation was a mitigating factor for elderly people. Regarding SES, people at lower SES levels chose to rest instead of seeing a doctor or purchasing over-the-counter (OTC) medicines when sick. They also placed more value on national brand OTC medicines than private brands (likely due to advertisements). This finding suggests individuals with a low SES do not select OTC medicines based on their effects or ingredients. Regarding attitudes toward OTC medicines, Japanese participants seemed to be unaware of the potential for abuse and side effects associated with OTC medicines. Finally, in relation to caregivers' self-medication practices for their children, the majority of participants reported taking their children to the hospital since children tend to receive free medical care. Furthermore, caregivers with a high educational background are more confident in being able to help manage their children's health.

CONCLUSIONS

Our results suggest that health and medical discrepancies among Japanese consumers pose new social problems. In Japan, universal health care is available, but the cost of receiving medical care is not completely free of charge. Thus, we hope that the government will attempt to meet the various needs of patients and support their well-being. Consumers also have to be more independent and aware of their health management, as self-medication practices will continue to play a more significant role in healthcare. More research is needed to find ways to teach Japanese consumers/patients of both the benefits and risks of over-the-counter (OTC) medicines.

Self-medication patterns and drug use behavior in housewives belonging to the middle income group in a city in northern India

OBJECTIVES

The objective was to assess the self-medication patterns and drug use behavior in housewives belonging to the middle income group in a city of Haryana State in Northern India.

MATERIALS AND METHODS

A detailed questionnaire designed to assess the self-medication patterns and drug use behavior and interview technique was used to elicit the requisite information. One hundred housewives of the middle income group were interviewed in Rohtak.

RESULTS

Most of the housewives were in the habit of keeping the medicines though only 73% of them were in the habit of using it without any prescription. Also it was seen that those housewives who were taking self-medication were better educated than those not indulged in self-medication. All of them were using allopathic drugs on a regular basis while other modes of medications were less used. The self-medication was most commonly based on the previous prescriptions issued by the doctors followed by the suggestions from friends, advertisement on the television, and newspapers. For most of them the reasons for self-medication were financial restraints and lack of time to go to the medical practitioner.

CONCLUSIONS

The study delineates the difference in the self-medication patterns and drug use behavior in housewives in a city of Northern India. The results emphasize the need for comprehensive measures for intervention strategies to promote rational drug therapy by improving prescribing patterns and influencing self-medication.

Non-dispensing of NHS prescriptions in community pharmacies

Objective

To explore non-dispensing of National Health Service (NHS) prescriptions in community pharmacies.

Method

Prospective study on prescription items that were presented and not dispensed. Pharmacy staff recorded reasons for non-dispensing of NHS prescription items and process outcomes, including substitution through other means.

Setting

Sixteen community pharmacies in the North of England.

Key findings

Data are available on 587 items (514 patients). Two main reasons for non-dispensing were identified: those related to the cost of the prescription charge (n=308) and those unrelated to cost (n=279). The latter generally suggested a prescribing issue involving the general practitioner's (GP's) computer system. Cost-related reasons included cheaper availability of over-the-counter (OTC) products (78.6 per cent) and incidents where customers were unwilling or unable to pay the prescription charge (20.1 per cent). Unsurprisingly, cost-related reasons were encountered almost exclusively for patients who were non-exempt from prescription charges, while non-cost reasons were more commonly seen for exempt patients. As a result of non-dispensing because of cost, 242 OTC products were sold, 97.0 per cent of which contained the same active ingredient as had been prescribed by the doctor. There were 62 incidents where a prescribed item was not dispensed, or substituted, because of cost, and more than one-third of these items (n=22) could be considered to be clinically important.

Conclusions

In addition to issues of GP prescribing, the cost of the prescription charge was identified as a major factor in non-dispensing. Many of the items were substituted by cheaper OTC products, yet some clinically important drugs were not dispensed or substituted, suggesting that a review of the UK charge system is appropriate.

Consumer over-the-counter usage and attitudes: a survey in one Canadian city

Aims and objectives

To describe general aspects of over-the-counter (OTC) product use and attitudes in the community.

Setting

One Canadian city.

Method

The approach was cross-sectional and descriptive in design. Questionnaires were mailed to 2547 residents. The questionnaire covered OTC purchases and use and experience with minor illnesses.

Key findings

The response rate was 57.2%. Respondents reported using an average of 2.7 different products within a 6-month period and were reasonably satisfied with them. The majority (78.9%) could not recall having a side effect with use. Label-reading claims were high, with 4.0 package sections accessed at first purchase. The majority (86.5%) had received OTC-related advice from pharmacists at some point in the past. The main reason for not asking was having no difficulty in selecting what they needed.

Conclusion

This report confirms the broad use of OTC medicines. Citizens appear to have reasonably healthy attitudes to these medicines and do seek pharmacists for assistance.

Factors associated with self-care activities among adults in the United Kingdom: a systematic review

Background

The Government has promoted self-care. Our aim was to review evidence about who uses self-tests and other self-care activities (over-the-counter medicine, private sector, complementary and alternative medicine (CAM), home blood pressure monitors).

Methods

During April 2007, relevant bibliographic databases (Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts, PsycINFO, British Nursing Index, Allied and Complementary Medicine Database, Sociological Abstracts, International Bibliography of the Social Sciences, Arthritis and Complementary Medicine Database, Complementary and Alternative Medicine and Pain Database) were searched, and potentially relevant studies were reviewed against eligibility criteria. Studies were included if they were published during the last 15 years and identified factors, reasons or characteristics associated with a relevant activity among UK adults. Two independent reviewers used proformas to assess the quality of eligible studies.

Results

206 potentially relevant papers were identified, 157 were excluded, and 49 papers related to 46 studies were included: 37 studies were, or used data from questionnaire surveys, 36 had quality scores of five or more out of 10, and 27 were about CAM. Available evidence suggests that users of CAM and over-the-counter medicine are female, middle-aged, affluent and/or educated with some measure of poor health, and that people who use the private sector are affluent and/or educated.

Conclusion

People who engage in these activities are likely to be affluent. Targeted promotion may, therefore, be needed to ensure that use is equitable. People who use some activities also appear to have poorer measures of health than non-users or people attending conventional services. It is, therefore, also important to ensure that self-care is not used as a second choice for people who have not had their needs met by conventional services.

Use of complementary and alternative medicine and self-tests by coronary heart disease patients

Background

Coronary heart disease patients have to learn to manage their condition to maximise quality of life and prevent recurrence or deterioration. They may develop their own informal methods of self-management in addition to the advice they receive as part of formal cardiac rehabilitation programmes. This study aimed to explore the use of complementary and alternative medicines and therapies (CAM), self-test kits and attitudes towards health of UK patients one year after referral to cardiac rehabilitation.

Method

Questionnaire given to 463 patients attending an assessment clinic for 12 month follow up in four West Midlands hospitals.

Results

91.1% completed a questionnaire. 29.1% of patients used CAM and/or self-test kits for self-management but few (8.9%) used both methods. CAM was more often used for treating other illnesses than for CHD management. Self-test kit use (77.2%,) was more common than CAM (31.7%,) with BP monitors being the most prevalent (80.0%). Patients obtained self-test kits from a wide range of sources, for the most part (89.5%) purchased entirely on their own initiative. Predictors of self-management were post revascularisation status and higher scores on 'holism', 'rejection of authority' and 'individual responsibility'. Predictors of self-test kit use were higher 'holism' and 'individual responsibility' scores.

Conclusion

Patients are independently using new technologies to monitor their cardiovascular health, a role formerly carried out only by healthcare practitioners. Post-rehabilitation patients reported using CAM for self-management less frequently than they reported using self-test kits. Reports of CAM use were less frequent than in previous surveys of similar patient groups. Automatic assumptions cannot be made by clinicians about which CHD patients are most likely to self-manage. In order to increase trust and compliance it is important for doctors to encourage all CHD patients to disclose their self-management practices and to continue to address this in follow up consultations.

Self medication with St. John's wort in depressive disorders: an observational study in community pharmacies

BACKGROUND

Depressive disorders are frequent. They are frequently unrecognised or sufferers use self help or self medication, e.g. with St. John's wort (SJW), instead of seeking professional help. The purpose of this study is to examine patients who buy SJW for the treatment of depression.

METHODS

In pharmacies from all over Germany customers who bought SJW and the pharmacists were asked to fill in a questionnaire on the cause for buying SJW, their health status and the type of counselling they received.

RESULTS

588 individuals were included, 293 purchased SJW as an OTC preparation, 230 had a prescription (65 missing answers). The majority in both groups were women (78.8% in OTC group, 74.3% in prescription group. Self medication patients were significantly younger. Subjects with a prescription took SJW longer (26.99+/-26.84 vs. 15.25+/-20.84 months). Both groups did not differ in self rated symptoms of depression (severity of depression, anxiety, endurance).

LIMITATIONS

No standardized interviews were used to establish the diagnosis of depression.

CONCLUSIONS

Patients who buy SJW for self medication report pronounced and persistent depressive symptoms. As this is a large group of patients they should get more attention in research. Pharmacists are the only professionals who come in contact with these patients and should therefore be considered as an important group of carers.

Physician-patient communication about prescription medication nonadherence: a 50-state study of America's seniors

CONTEXT

Understanding and improving the quality of medication management is particularly important in the context of the Medicare prescription drug benefit that took effect last January 2006.

OBJECTIVE

To determine the prevalence of physician-patient dialogue about medication cost and medication adherence among elderly adults nationwide.

DESIGN

Cross-sectional survey.

PARTICIPANTS

National stratified random sample of community-dwelling Medicare beneficiaries aged 65 and older.

MAIN OUTCOME MEASURES

Rates of physician-patient dialogue about nonadherence and cost-related medication switching.

RESULTS

Forty-one percent of seniors reported taking five or more prescription medications, and more than half has 2 or more prescribing physicians. Thirty-two percent overall and 24% of those with 3 or more chronic conditions reported not having talked with their doctor about all their different medicines in the last 12 months. Of seniors reporting skipping doses or stopping a medication because of side effects or perceived nonefficacy, 27% had not talked with a physician about it. Of those reporting cost-related nonadherence, 39% had not talked with a physician about it. Thirty-eight percent of those with cost-related nonadherence reported switching to a lower priced drug, and in a multivariable model, having had a discussion about drug cost was significantly associated with this switch (odds ratio [OR] 5.04, 95% confidence interval [CI] 4.28-5.93, P < .001).

CONCLUSIONS

We show that there is a communication gap between seniors and their physicians around prescription medications. This communication problem is an important quality and safety issue, and takes on added salience as physicians and patients confront new challenges associated with coverage under new Medicare prescription drug plans. Meeting these challenges will require that more attention be devoted to medication management during all clinical encounters.

Prevalence of the use of cancer related self-tests by members of the public: a community survey

BACKGROUND

Self-tests are those where an individual can obtain a result without recourse to a health professional, by getting a result immediately or by sending a sample to a laboratory that returns the result directly. Self-tests can be diagnostic, for disease monitoring, or both. There are currently tests for more than 20 different conditions available to the UK public, and self-testing is marketed as a way of alerting people to serious health problems so they can seek medical help. Almost nothing is known about the extent to which people self-test for cancer or why they do this. Self-tests for cancer could alter perceptions of risk and health behaviour, cause psychological morbidity and have a significant impact on the demand for healthcare. This study aims to gain an understanding of the frequency of self-testing for cancer and characteristics of users.

METHODS

Cross-sectional survey. Adults registered in participating general practices in the West Midlands Region, will be asked to complete a questionnaire that will collect socio-demographic information and basic data regarding previous and potential future use of self-test kits. The only exclusions will be people who the GP feels it would be inappropriate to send a questionnaire, for example because they are unable to give informed consent. Freepost envelopes will be included and non-responders will receive one reminder. Standardised prevalence rates will be estimated.

DISCUSSION

Cancer related self-tests, currently available from pharmacies or over the Internet, include faecal occult blood tests (related to bowel cancer), prostate specific antigen tests (related to prostate cancer), breast cancer kits (self examination guide) and haematuria tests (related to urinary tract cancers). The effect of an increase in self-testing for cancer is unknown but may be considerable: it may affect the delivery of population based screening programmes; empower patients or cause unnecessary anxiety; reduce costs on existing healthcare services or increase demand to investigate patients with positive test results. It is important that more is known about the characteristics of those who are using self-tests if we are to determine the potential impact on health services and the public.

The use of non-prescription medicines by general practitioner attendees

PURPOSE

Against a background of increasing availability and use of non-prescription medicines, this study set out to explore: use of such medicines by patients seeing their general practitioner (GP); frequency of GP enquiry about such use; and frequency of recommendations to use a non-prescription medicine.

METHOD

Patients attending four general practices in Aberdeen, Scotland, completed separate questionnaires (before and after seeing their GP).

RESULTS

Some 461 individuals waiting to see their GP were invited to participate: 427 (93%) completed the pre-consultation questionnaire and 305 (71% of questionnaires issued) completed the post-consultation questionnaire. Almost half (45%) of all participants reported using non-prescription medicines in the 7 days prior to visiting their doctor; with 20% of the medicines purchased from non-pharmacy retail outlets. Thirteen per cent of participants were asked about their use of non-prescribed medicines by their GP. Eight per cent of participants were recommended to use a non-prescription medicine by their GP.

CONCLUSION

Although there was a high level of recent use of non-prescribed medicines by the general practice attenders, relatively few reported being asked about such use, or were recommended to use such medicines by their GP.

Treatment modalities and medication recommended by health care professionals for treating recurrent herpes labialis

BACKGROUND

The authors conducted a survey to determine how health care professionals respond to patients' inquiries about cold sores, also known as recurrent herpes labialis, and their choices of treatment modalities and medications.

METHODS

The authors mailed a one-page, pretested survey to a random sample of dentists, pharmacists and family physicians in Alberta, Canada. After receiving ethics approval from the University of Alberta, Edmonton, the authors mailed 998 surveys. The response rate was 51 percent.

RESULTS

Topical antiviral medication was the most common treatment recommended (63 percent). Over-the-counter medication was the first choice for pharmacists (83 percent) as compared with dentists (15 percent) and physicians (16 percent). Emotional stress (60 percent) was reported by patients to be the most common trigger, and pain or discomfort (81 percent) was their primary concern. Acyclovir ointment was the most common antiviral drug recommended or prescribed by health care professionals (60 percent), and cost was the major reason they gave for not recommending or prescribing antiviral drugs (73 percent).

CONCLUSIONS

The authors found variation in treatment modalities and recommendations by each health profession, despite the fact that patients reported similar triggers and concerns. This may be due to individual patient need and the health care professional's lack of knowledge.

PRACTICE IMPLICATIONS

Survey results may serve as a reference for health care professionals to use to determine how their choices of medications and treatment modalities compare with those of other practitioners. Professionals should know the benefits and limitations of all therapies, discuss them with the patients and select a treatment.

Self-treatment and its discussion in medical consultations: how is medical pluralism managed in practice?

Recent policy changes in the UK such as deregulation of prescribed medicines and the introduction of telephone helpline services are intended to promote self-treatment. Drawing on interviews with, and consultations between, 35 patients and 20 general practitioners, we use Kleinman's (Patients and Healers in the context of culture: an exploration of the Borderland between Anthropology, Medicine and Psychiatry, University of California Press Ltd., London) model of the three sectors of health care in order to examine the range of self-treatments people use and the discussion of these treatments in medical consultations. We argue that despite the availability of a range of treatment options and policy changes advocating greater use of self-treatment, patients are inhibited from disclosing prior self-treatment, and disclosure is affected by patients' perceptions of the legitimacy of self-treatment. The findings are in keeping with Cant and Sharma's (A New Medical Pluralism, Alternative Medicines, Doctors, Patients and the State, UCL Press, London) contention that although there has been a pluralisation of "legitimate" providers of health care and a restructuring of expertise, biomedicine itself remains dominant.

Access to medicines: cost as an influence on the views and behaviour of patients

The present paper explores how charges for medicines incurred by patients influence their decisions for managing acute or chronic conditions, and whether prescription cost and affordability issues are discussed in the general practitioner (GP)-patient encounter. People suffering from dyspepsia, hay fever or hypertension, or those taking hormone replacement therapy, were recruited through three community pharmacies in the North-west of England. Six focus groups were conducted with a total of 31 participants, the majority of whom were non-exempt from prescription charges. The management behaviour of those participants who had to pay for their prescriptions, particularly those from less-affluent or deprived backgrounds, was influenced by cost. However, cost was not the overriding influence, with other factors, such as symptom or disease severity, effectiveness, or necessity of treatment, playing a more important part in participants' management decisions. Cost as an issue was reflected in the various strategies used by participants to reduce medication cost, such as not having some prescribed items dispensed, taking a smaller dose or buying a cheaper over-the-counter product. Despite the use of numerous strategies, participants did not talk to their GPs about issues of cost and affordability. Participants felt that paying for prescriptions was their problem. There was a belief that discussing cost issues could jeopardise the doctor-patient relationship. Although not the dominant factor, medication cost nevertheless influenced participants when deciding how to manage their condition. Awareness of the existence of prepayment certificates, which can be bought by patients who require regular medication, was low, and this should be addressed through improved information/dissemination. Despite the high level of prescription items exempt, the current level of the prescription charge is still a barrier to obtaining prescription medicines under the National Health Service to those on lower incomes.

Benefits and risks of self medication

Self medication is becoming an increasingly important area within healthcare. It moves patients towards greater independence in making decisions about management of minor illnesses, thereby promoting empowerment. Self medication also has advantages for healthcare systems as it facilitates better use of clinical skills, increases access to medication and may contribute to reducing prescribed drug costs associated with publicly funded health programmes. However, self medication is associated with risks such as misdiagnosis, use of excessive drug dosage, prolonged duration of use, drug interactions and polypharmacy. The latter may be particularly problematic in the elderly. Monitoring systems, a partnership between patients, physicians and pharmacists and the provision of education and information to all concerned on safe self medication, are proposed strategies for maximising benefit and minimising risk.

Community pharmacists' experience of over-the-counter medicine misuse in Scotland

Over the last decade Britain has observed a trend towards the re-regulation of 'prescription only medicines' in favour of pharmacy status drugs. This move towards self-treatment to reduce pressures on general practitioner drug budgets and workloads has focused attention on the need for community pharmacists to extend their patient education and screening roles. In response to these changes, this study was conducted to explore: the type of over-the-counter (OTC) medicine being misused in Scotland; pharmacists' professional attitudes and management of OTC misuse; and the training and support needs of pharmacists. A postal questionnaire was designed. This was informed by an earlier stage of qualitative research and the available literature. It was then piloted and administered to all 110 pharmacies in the study area. A 79% response rate was achieved. The research found that OTC misuse, particularly of certain analgesics, sleeping prescriptions, products containing codeine or pseudoephedrine, caffeine, cough mixtures, and laxatives was common. The estimated mean number of patients suspected of misusing medicines in a typical week was 5.63. Pharmacies in urban areas were more likely than those in rural areas to report suspected misuse. The research identified a number of intervention strategies relating to: patient/pharmacist interaction; information provision; removal of products from the point of sale; sharing of information with other local pharmacists; and referral to other members of the primary care team. Pharmacists expressed a need for support in managing OTC misuse and in organising 'early warning systems' to share information locally.

Toxicity of over-the-counter cough and cold medications

Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. Physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.

Physician-patient communication about over-the-counter medications

The purpose of this study was to describe physician-patient communication about over-the-counter medications using a data set comprised of audio-tapes and transcripts of 414 primary care medical visits. The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center. Twenty-seven resident physicians and 414 of their adult patients participated. Fifty-seven percent of patients reported using one or more OTC medications during the past month. Analgesics, cold or allergy products, and antacids were the most commonly used OTC medications. White patients were significantly more likely to have reported using an analgesic in the past month than non-white patients. Female, white, and younger patients were more likely to have reported using a cold or allergy product in the past month than male, non-white, and older patients. Approximately 58% of patients discussed OTC medications with their physicians. Older patients and female patients as well as patients who reported using an antacid in the past month were significantly more likely to have discussed OTC medications with their physicians. Physicians asked questions about OTC medications during only 37% of encounters. Patients asked questions about OTC medications during 11% of encounters. Patient ethnicity did not influence physician or patient question-asking and information-giving about OTC medications. Male physicians were more likely to state information and ask questions about OTC medications than female physicians. Patients were more likely to ask male physicians questions about OTC medications. Physicians were more likely to state OTC information to and ask OTC questions of female and older patients. Physicians were more likely to ask less educated patients questions about OTC medications. Less educated patients were more likely to ask physicians questions about OTC medications. Despite the fact that more than half of all patients reported using OTC medications, physicians asked questions about OTC use during only approximately one-third of encounters. Of patients who reported using an OTC medication in the past month, 58% did not tell their physicians, yet only 14% of patients believed that it was not important for the physician to know about their OTC use. Physician-patient communication about OTC medications should be encouraged so that the patient becomes a collaborative partner in medication management.

Who uses over-the-counter psychotropics? Characteristics, functioning, and (mental) health profile

As part of a population study on the prevalence of psychopathology, users of "Over-The-Counter" Psychotropics (OTC-Ps) were studied. First, their mental health profile was examined by a number of subjective and objective assessments. Second, the medical consumption of the users was studied with special attention to the psychotropic drugs prescribed. The prevalence of psychological problems and symptoms of psychological distress was higher among OTC-P users than among non-users. Somatic problems and symptoms were comparable in the two groups; social support was better in the OTC-P users. Half of the users were known to have mental health problems by their Primary Care Physician (PCP). The DSM IV Axis I disorders were mostly mood and anxiety disorders. A benzodiazepine had been prescribed to one-third of the OTC-P users. No other psychotropic drugs had been prescribed, and the medical consumption was comparable in the two groups. PCPs should be aware of concomitant OTC-Ps use.

[Externally induced prescriptions, degree of agreement and ... possibility of change in primary care?]

OBJECTIVE

To find whether externally induced prescriptions (EIP) condition attendance through their prevalence, quality, the degree of agreement of the PC doctor and his/her capacity to alter them.

DESIGN

Cross-sectional study of use of indication-prescription type medicines.

SETTING

Health district.

PARTICIPANTS

2656 prescriptions for 678 patients interviewed.

MEASUREMENTS

Each interview recorded: type of visit, age, sex, work situation, existence or otherwise of social problems and/or psychiatric pathology; doctor-patient relationship, pharmaceutical preparations (PP) prescribed and those which the patient remembers he/she is taking, indication, origin, duration, speciality of the prescribing person, agreement of the PC doctor issuing the prescription and the possibility of his/her changing it. For each prescription the following was analysed: therapeutic group, intrinsic value, time it lasts, cost and whether it is a recently marketed PP.

MAIN RESULTS

90% of visits to the doctor end in prescription. 58% of patients remember taking one or more EIP. 72% of the prescriptions analysed were externally caused. They came mostly from the public health system (66%), private medicine (20%) and self-medication (11%). There was no PC agreement with almost half these EIPs, but only 13% could be changed. The EIPs without agreement and without possibility of change were greater in: women, the elderly, people on a pension, psychiatric pathologies and in cases of bad doctor-patient relationship. The EIPs originated in health insurance companies, pharmacies, self-medication, former GPs and private doctors. They were associated with ill-defined signs and symptoms, circulatory diseases and locomotive disease. We found no significant differences in expenditure or use of PP recently put onto the market between self-medication and EIP, though there were in quality.

CONCLUSIONS

The current model of prescribing medication causes consultations to be greatly "medicinised" at the expense of EIP. Doctors only alter a small part of the EIPs they don't agree with. Longitudinal studies are needed to monitor patients to find the evolution of EIPs (withdrawal, replacement, dragging on or new external prescription).

Physicians' attitudes toward reclassifying drugs as over-the-counter

OBJECTIVES

Releasing prescription drugs over-the-counter (OTC) has been a trend in many Western countries. The purpose of this study was to find out about Finnish physicians' attitudes towards OTC switches and to find out whether transfer of drugs that are used in a doctor's own area of specialty increases negative attitudes toward release. For the latter purpose, gynecologists' perceptions about the availability of vaginal antifungal OTC drugs was studied.

METHODS

Postal questionnaire to a representative random sample of gynecologists (n = 169) and general practitioners (GPs) (n = 288) in six counties in Finland in 1996. After a reminder, the response rate was 77% (n = 341). Multivariate logistic regression models were used to explore the relationship of factors to attitudes toward OTC drugs.

RESULTS

The overall attitude toward the availability of OTC drugs was moderately positive but was more reserved toward those drugs only recently given OTC status. However, physicians were judged in many cases to be the most suitable source of information on OTC drugs. GPs working in health centers, more often than other physicians, found drugs suitable for self medication. Our hypothesis about gynecologists being against the release of vaginal antifungal drugs was not supported.

CONCLUSIONS

Physicians' views about OTC drugs are influenced by the current OTC status of the drug and by public discussion. The place of work has an important influence on these opinions, most likely reflecting the effect of case mix and patient load.