Saturday, October 23, 2010

I Hate Recommending OTC Meds

"I have a cold. What can I take for it?"

I get this question at least once a day, but I never feel comfortable answering it. It's not that I don't know how to treat common cold symptoms. I just don't know how to explain to people that the answer isn't necessarily in one medication bottle.

Whenever people ask for a recommendation about what to take for a cold, the first question I always ask is what symptoms they have. I can't make a proper recommendation without knowing what symptoms I'm trying to treat.


Great... I'll always follow up by asking whether the cough is productive or dry, but the answer doesn't really matter I suppose. By this point, we all know that dextromethorphan does absolutely nothing to relieve coughing. Therefore, all OTC cough suppressants are ruled out. For productive coughs, most pharmacists will recommend Mucinex. However, if we're going by evidence, there's not much evidence that guaifenesin loosens up mucous, so I always hesitate before making that recommendation.

According to the American College of Chest Physicians, acute cough should be treated with a first generation antihistamine, like clorpheniramine, and pseudoephedrine. They also say naproxen can be used to help reduce cough. Nowhere in the entire executive summary of the cough guidelines does it mention guaifenesin, dextromethorphan, or any opioid cough suppressant for that matter. There's very little evidence that they actually reduce cough.

How do you explain that to a customer though? When there are dozens of products in the OTC aisle that say "cough and cold" on the box, how do you explain to people that most of them are unlikely to reduce cough? You have to see the looks customers give me when I go out in the aisle and grab a box of store brand "Allergy Medication" (containing chlorpheniramine) as a recommendation to reduce cough. They think I'm crazy.

Moving away from cold medication... People often ask about vitamins. "What brand multivitamin should I take?" is a very common question. My response: You probably don't need to take a multivitamin.

People have this obsession with vitamins. They think they're the answer to all their ailments. However, in most cases vitamins are a waste of money. Unless a doctor diagnoses you with a specific vitamin deficiency, there's really no need to take a multivitamin. In fact, a recent large study showed that taking antioxidant vitamins not only didn't increase life expectancy and reduce the incidence of diseases like cancer, but people who took them actually had a 16% increase in mortality.

The modern diet, as poor as it might be in terms of overall health, usually provides enough of all the important vitamins to stave off any deficiency condition. About the only vitamin that a normal person might need to supplement is Vitamin D, and that's because we lather sunscreen all over ourselves, and sunlight is needed for the body to produce Vitamin D. Otherwise, if you aren't malnourished, you probably get plenty of vitamins in your diet.

You can show people a million studies on this stuff, but they won't listen. It's ingrained in their minds that vitamins are good for you and Robitussin is a great cough medicine, and there's nothing you can do to change their minds. After all, it must be true; they saw it on TV!

Or if they didn't see it on TV, their doctors said it was true, so it must be. You ever try to convince someone that what their doctor said is entirely incorrect? It's very difficult, especially when just about every doctor says the same thing.

For example, every doctor tells you to avoid saturated fat and cholesterol like the plague... and every doctor is wrong. No matter how hard I try though, I'll never get those health nuts to go back to drinking whole milk and eating whole eggs instead of just egg whites.

The problem is that conventional wisdom is murky at best instead of scientifically tested truth. Since I know that the evidence is quite shaky, I can't in good conscious recommend what others would without batting an eye. Therefore, I've come to dislike the part of my job that involves counseling on OTC meds.

I'm my employer's worst nightmare in this regard. I actually prevent more OTC sales than I facilitate. That can't be good for business even though what I say is backed by the most current scientific evidence. That's why I'm so happy to be promoting flu shots. Flu shots are the rare occurrence in pharmacy where what's best for the patient is supported by science and good for our business.


pharmacy chick said...

I dislike making recommendations for cough/cold for a couple of reasons..similar to yours. Most of the stuff is crap anyway, and since the patient wants magic in a bottle, regardless of my suggestions, they lock on to the Nyquil and move on. I do like to recommend breathe right strips. they do work cuz I have used them myself...they dont raise your blood pressure or keep you awake. Yea they make you look dorfy, but you are at home..its ok to look dorfy. It seems people like those nasal pots, but if they dig that, fine, but I dont think I could run a river thru my sinuses..the whole idea is gross.
I agree about vitamin therapy, most dont need vitamins..but where I live, we need extra D, so I tell people to get their D (and Calcium).
Hows those flu shots going?? are you also going to venture into other adult vaccinations??

Shamra said...

Have you considered, Mike, that all you are really doing is denying your customers the most powerful medication in the world? There is no medication stronger than Oprah-recommended-this-tonic aka I've-seen-it-on-20/20 or even known infamously as Martha-Stewart-is-in-jail-but-said-it-is-a-good-thing. Nothing is stronger than a placebo, not to mention a placebo that the patient "knows" will help because their friend's neighbor's dog said so. Just think, they get a good placebo, they feel better, your store makes money and keeps middle management off your back so you feel

I mean hell...screw the science anyway, stone age fairy tales written down by desert-dwelling sheep herders must be true because some 40% or so of the world's population believes they are so, right?

oleapothecary said...

Mike, this is an area that finds ignorance among most of the folks who recommend these products to their patients no matter where the patients are found (i.e., in or out of the hospital). Sounds as if ole' Mr. A.H. Robins' Dimetapp (back in the days when elixirs were king, it was Dimetapp Elixir because it contained alcohol) was indeed a great product. For those who don't remember, as a prescription drug product it had twice the amount of brompheniramine that it had as an OTC item. But, who suggests it today in any form?

I think they recommend thes things "without batting an eye" because they know it will get the finicky consumer off their backs and they can get back to their usual rushing around filling 100 prescriptions an hour.

One sure way to "answer" the patient's question is to listen how the question is framed.

patient: What's good for a cold--Sudafed PE?

pharmacist: {Points to Sudafed PE on shelf) Right there.

patient: Thank you!

You see, it was never a question about what, but rather, about where!

Pharmacy Mike said...

Two interesting points that I believe have a lot of truth in them.

1) Shamra brought up the notion of the placebo effect. I tell people all the time that placebos actually work! If you give people sugar pills and tell them it's supposed to lower blood pressure, some of those people will have decreased blood pressure. It's a well-known but poorly understood fact.

Therefore, if someone really believes something will work, especially if it's something so trivial as an OTC cough medication, we might as well let those people keep believing it will work.

2) Ole Apothecary brought up a good point also. I've also noticed that many times people just want to be pointed in the direction of something rather than getting advice about it. Or, they'll grab a box of Robitussin DM and ask, "Can I take this for cough?", to which I'll always respond, "yes."


PC- Flu shots are going OK. I'm almost to 100, which was my very modest goal from the beginning.

Question: In your (or anyone else who wants to chime in) experience, when do people stop asking for the flu shot?

Frantic Pharmacist said...

I feel the same way about the "what's good for a cold" question... trying to figure out how to sound more than lukewarm about any of the multitude of stuff on the shelves.

Harry said...

I was very surprised by the link you published on fats/cholesterol/"healthy" fats. I am a pharmacist and this is really the first time I read something that says that animal fats are better than vegetable fats. Is this article really legit?

What about the struggle for low blood cholesterol and the blockbuster drugs that are given out like candy from doctors offices in all countries (I live in Greece). The article mentions that high blood cholesterol is not the culprit for cardiovascular incidents, but just an indicator that something is wrong and thus should not be treated as a disease. This is also the first time I have heard this being mentioned.

I am just asking if you have read this kind of research in other places, because I am really dumbfounded!

Anonymous said...

Like you, this is where my employer's goals and my goals differ - my goals win!

I will not recommend something that has no purpose just for a "sale". I'll also look my boss in the eye and tell him that. if need be. knowing my State Board will back me up.

As for flu shots, I do about 1000 per year. After October, they peak again the week before travel at Thanksgiving & Christmas, then taper off towards Feb. I'm usually done by the end of February since our cold weather tapers off by then (yeah - flu is not tied to cold weather, but those who don't want to ruin a snow vacation want the coverage they were too busy for earlier).

Anonymous said...

It wasn't the manager looking me in the eye, but the techs (pulled from stocking the H&B! They thought I should be trying to sell something.) Hot tea and beddy-bye, if the patient can afford it, (and don't go out after work to tie one on).

Nate said...

I get the feeling that the public thinks I'm a complete jackass and moron every time I tell a person to take benedryl or naproxen for a cough so I've given up and tell them to take Buckley's. It's what they want anyways. I really stopped trying to lead people to effector OTCs a while ago and now I let them tell me what they want and I confirm it won't maim them.

Anonymous said...

I dont care what you say. I love my probiotic, my Vit D gtts, and pissing out my astronomical amounts of B complex. It makes my life better.

And as far as cough. Xoponex and decadron. Cant be beat.

OTC, what is that?