Drugs and Self-Care

Joe Graedon got interested in pharmacology while working as a conscientious objector at the New Jersey Neuropsychiatric Institute in Princeton.

He later took a masters degree in pharmacology at the University of Michigan, then taught pharmacology at the medical school in Oaxaca, Mexico. He now lives in Durham, North Carolina, and writes a syndicated column, “The People’s Pharmacy,” which provides self-care drug information. He is a consultant and guest lecturer at the Duke School of Nursing, and teaches a course called “Pharmacology for People” in the Continuing Education Program at Duke. He does a biweekly radio show for National Public Radio, and serves as a consultant to the Federal Trade Commission.

He is the author of The People’s Pharmacy, and the drugs editor of Medical Self-Care Magazine.

TF: You were saying that you first got interested in helping laypeople learn about drugs because your friends used to ask you questions.

JG: Yes. When people learned I was a pharmacologist, friends, neighbors, and complete strangers would have all these questions about the drugs they were taking: “the little blue pill I’m taking for my high blood pressure,” “the little white pill for depression,” and so on. And when I asked them the name of the drug, they practically never knew. I was struck by how commonly people take drugs—some of them very potent ones—completely on blind faith. They didn’t know the first thing about them. They didn’t know the side effects, they didn’t know the possible interactions with other drugs. In many cases they didn’t even know exactly what the drug was supposed to do.

They certainly wanted to know, but their doctors just weren’t making the information available. And I began to realize that there were a lot of people out there who wanted to know about drugs. who weren’t getting the information they needed from the people who should be supplying it. So I thought, who better than a pharmacologist with a special interest in communication to try to provide some of this information.

What are the most important things for people to know about drugs?

The first and foremost thing is not to focus exclusively on drugs. If you have an ailment, the most important thing is to understand what’s going on and how it relates to the rest of your life. First, try to understand the problem, its causes, its signs and symptoms. Then you can go on to possible ways of treatment, with drugs being just one possible kind of treatment.

What are the things a person should be sure to ask when his doctor wants to prescribe a drug?

You should ask whether the drug is intended to give purely symptomatic relief, or whether it will actually help the body cure the underlying ailment. People tend to focus exclusively on side effects, and while that’s vital, it’s also crucial to know what the anticipated benefits are. Any time you’re considering taking a drug, you’ve got to weigh potential benefits against potential drawbacks.

And that would be true for over-the-counter drugs as well.

Yes. Another thing you should always do when your doctor wants to prescribe a drug for you: Know the name of the drug. That should be an absolute rule. It sounds simplistic, but it’s frequently not provided to the consumer. Make sure that your doctor pronounces the name of the drug so that you can understand it, and pronounce it back. Many drugs have difficult names.

And have your doctor write the name of the drug down for you.

Yes. And not only write it down, but write it down legibly. It’s not going to help too much if it’s an unreadable scrawl. Any health worker who prescribes a drug should not let the client go out of the of office without having in his or her possession the name of the drug, typed or neatly printed. Ideally, they should also be provided with a sheet of written information about that drug.

If the drug is prescribed by brand name, your doctor should also write down the generic name of the drug. And if it’s a combination product, he or she should write down the name of each ingredient.

What else should people know besides the name of the drug?

Find out precisely how to take it. “Before meals.” is not specific enough. You need to know exactly how long before meals. Find out the reasons behind these instructions so that they make sense to you.

How about side effects?

That’s the next thing. Be sure to find out about all the common side effects, whether they’re serious or not. Also be sure to find out about any dangerous side effects—no matter how infrequent.

I’m not going to be worried about a very minor side effect which occurs in one out of two thousand people. But if 20 percent of the people taking the drug feel drowsy? I want to know.

I’m also going to want complete information on very rare side effects, if they’re serious ones, even if they only occur in one out of ten thousand people. I’d want to know what the early warning signs are for the serious side effects.

I guess the other thing would be possible drug interactions.

Yes, and this is more of a problem than ever because so many people are taking more than one drug— sometimes prescribed by different doctors. I’d want to receive a list of all the drugs and foods that might interact with the drug I was taking.

I think it’s vital for the prescriber to give not only verbal information but written material to take home. There’s a wonderful book available for exactly this purpose. It’s called Drug Information for Patients, by H. Winter Griffith. It’s published in a looseleaf binder with removable pages so that a health worker can remove the appropriate pages, copy them on the office copying machine, and give the client a copy. It gives information on taking the drug, possible side effects, how the drug may interact with your activities of daily living, how to store the drug, refills, and dealing with overdoses.

Are there any completely safe drugs?

No. There are potential problems with every drug. Both doctors and their clients are at risk of being lulled into a familiarity-breeds-contempt kind of attitude. If your doctor has prescribed a drug a number of times and no one has ever complained of any side effects, he may begin to assume it’s completely safe, and may no longer feel it necessary to warn people about side effects. But every person responds differently and you may have a side effect even though none of your doctor’s previous patients did.

Incidentally, this is an excellent reason for letting your doctor know about minor side effects of a drug you’re taking—if you don’t tell him, he might not think to warn the next person for whom he prescribes that drug.

What are the important differences between prescription and nonprescription drugs?

It’s a somewhat artificial distinction. There are a number of drugs, presently available only by prescription, that will soon be available over the counter, such as Benadryl (diphenhydramine hydrochloride), an antihistamine. The more potent or potentially dangerous the drug, the more likely it is to be available by prescription only.

I think that a number of drugs that now require a prescription could be made available over the counter—if the buyer was provided with good, clear information on how to use them.

I think the idea of increased access to a limited number of drugs is very exciting. The number of effective pharmaceuticals available is much smaller than most people think. We have thousands of drugs. But there are only about three or four dozen really widely used and effective therapeutic agents. The average physician prescribes only about two dozen on a regular basis.

I have no doubt that with an effective medical education program in our schools, we could have high school graduates with a level of drug expertise sufficient to safely use many, many drugs that are now available only by prescription.

You were saying that you felt we relied much too heavily on drugs. Why is that?

I think there are four main reasons. Number one is the huge amount of money spent on advertisements for over-the-counter drugs. Kids grow up thinking that pills and potions are the answer to health problems—a pill for your headache, a cream for your hemorrhoids. Just count the number of drug ads on television in one week. You’ll be astonished.

Number two is an even more intense effort by drug manufacturers to advertise their products to doctors. There are thousands and thousands of detail people who do nothing but go around to doctor’s offices pushing their companies’ drugs. Almost every major medical journal, including the most reputable ones, contains gobs and gobs of very impressive and expensively-done drug commercials. That can’t help but have a big impact on doctors’ prescribing habits.

Number three is the way health workers are educated. Prevention and nondrug treatment are either ignored or given lip service. The message we give health workers is that there’s a pill for every ill.

Number four is the pressure from the very nature of the clinical visit to give a prescription. The doctor has perhaps ten or fifteen minutes to see each patient. That’s not enough time to even begin to ask how the current problem relates to the rest of their lives. You can’t even begin to think about prevention. That’s barely time to take a brief history, check your blood pressure, and write a prescription.

And a lot of people will feel cheated if they get advice instead of a prescription.

Absolutely. A lot of the pressure comes from the client. We live in an “instant” society today—with instant hamburgers and instant checking. So when we’re ill, we expect instant relief.

There’s an economic pressure, too. The doctor who’s charging you fifty dollars for a fifteen-minute visit is going to have a lot of difficulty prescribing aspirin— even if that’s the best and safest remedy. The person could have done that much for himself.

How can we get away from these patterns?

I think that people have to learn some basic clinical medicine. 1 think that health workers need to help them do this—by stepping out of their authority roles and sharing their uncertainties and their doubts.

I think that medical education needs to stress nondrug treatments. If someone comes in with high blood pressure, most doctors’ first thought will be to prescribe a thiazide diuretic, but a much more appropriate first step might be to recommend that the person lose weight, begin exercising, quit smoking, cut down on salt intake, learn new ways of dealing with stress, or apply some combination of these self-care approaches. The drug should be used only as a last resort.

You were saying that our health workers are being trained in a professionally- and pathology-centered medicine rather than in a client-centered medicine. What would a client-centered medicine be like?

Some health workers are already practicing client centered medicine. For instance, someone seeing a person with an ailment might ask, ”What’s worked for you when you’ve had this problem before?” Maybe the person has used hot baths for menstrual cramps or an over-the-counter remedy for indigestion. If a person has strong feelings against pharmaceuticals, an herbal remedy or a homeopathic remedy may be more effective—for him.

I would think that one good local resource for information on drugs would be your local pharmacist. How can a person best use their pharmacist?

The pharmacist is probably the most overlooked and underused health professional. It’s a shame, because not too many years ago, the pharmacist was a respected and important source of drug information within the community.

One of the big problems is the way pharmacists are used in the big chain drugstores. The center of these stores is devoted to selling fishing tackle and cosmetics and motor oil, while the pharmacy is stuck in some little corner way in the back. The pharmacists are kept out of sight, filling ”scripts,” as prescriptions are called, as fast as their hands can move. They frequently receive incentive pay for the number of scripts filled in a day, and they’re not encouraged to spend any time giving people drug information.

This is a very sad misuse of talent, because the pharmacist is a well-trained pro who is perfectly capable of answering most questions on prescription and over-the-counter drugs.

This assembly-line approach allows the chain stores to charge less for prescriptions—which makes survival difficult for the old-fashioned pharmacist. With a small pharmacist who runs the store himself, you can develop a useful, personal relationship. Look for an individual who is good at communicating and is willing to take the time to deal with your concerns. Ask your friends about the pharmacists they use. And once you find a good one, let him know you appreciate his services.

So you’d advise trying to understand a particular symptom instead of just trying to get rid of it.

Sure. Symptoms are an early warning signal. Eliminating symptoms without paying attention to the underlying process that’s producing the symptom is like putting a penny in the fuse box when a fuse blows. The next warning is likely to be something a lot more heavy-duty.

That doesn’t mean I think we should all be masochists. If you’ve got a headache and you know it’s from stress and muscle tension, there’s nothing wrong with taking aspirin. If you have severe menstrual cramps, codeine may be very effective. If you have diarrhea, you may decide to take codeine or Lomotil even though you know that the diarrhea is helping to cure you of something else—because the inconvenience just isn’t worth it. And there are some cases in which a drug actually attacks the root of a problem instead of just removing a symptom. If I had a bad sore throat, I’d have it cultured. If the culture grew out strep, I’d be the first in line to get some penicillin.

It should always be a carefully weighed decision whether or not to use a given drug. And I think that it should be the informed consumer who ultimately makes those decisions.

What other kinds of products are available in drugstores that might be good self-care tools?

One very promising tool is the dipstick sets that allow you to test your own urine. They provide a number of easy, inexpensive, completely safe screening tests for excess sugar, blood, or protein in the urine.

Another device now being tested is a tampon which will allow women to collect menstrual blood and cell samples to be sent in to a laboratory and examined for evidence of cervical cancer. If the present testing goes well, it will be marketed under the trade name Ascend.

I highly recommend blood pressure cuffs for home use. Some of the new automated models make a stethoscope unnecessary. Having a cuff at home is particularly helpful if you have high blood pressure and are working on controlling it on a self-help basis— through such approaches as weight loss or exercise or stress reduction or quitting smoking or meditating, or a combination of these methods. The cuff provides a kind of biofeedback, rewarding you by letting you see the immediate results of your efforts. And people taking blood pressure medication can help adjust their own dosage of the drug if they can monitor their own blood pressure at home.

Another new kit allows you to test your own stool specimen for traces of blood. This test is highly recommended once a year for persons over forty. You just touch the fecal specimen to a piece of moistened test paper, and if blood is present, the paper changes color.

What drugs should be kept on hand at home?

If I could take only one drug with me to a desert island, I’d take codeine. It can be used to relieve quite a few common, distressing medical problems.

Codeine is good for pain—a toothache, a headache, or bad menstrual cramps that aspirin won’t handle. And codeine plus aspirin has an additive effect, so that both together are especially powerful. Codeine can also be used to control diarrhea.

Codeine is a prescription drug in most states, so you’ll have to get your doctor to prescribe it for you. You don’t need much, and if you ask for a whole lot, your doctor might start thinking you’re a drug addict. Ten 30-mg. tablets should be plenty. Take a whole tablet for serious pain, half a tablet (15 mg.) for a cough or diarrhea. At our house we go through maybe one or two tablets in a year.

While it is true that codeine can be abused, it is almost never habit-forming in the doses we’re talking about. Drug companies have made millions by playing on the fears of people and doctors by claiming that their expensive preparations are safer than the older and much cheaper codeine.

If your doctor resists prescribing this cheap and effective medicine, make sure that he does prescribe some Lomotil for potential traveler’s diarrhea and something like Capital with codeine or Tylenol with codeine for pain.

The one caution would be not to use codeine—or any other painkiller—for a pain of unknown origin. If you had an inflamed appendix, for example, a painkiller might make it hard to diagnose what was really going on.

What else belongs in a home medicine chest?

I always keep some Tinactin (tolnaftate) handy. It’s one of the best antifungal agents for athlete’s foot or jock itch and it’s available over the counter.

People troubled by motion sickness might want to include Dramamine (dimenhydrinate). It’s an antihistamine and may cause sleepiness. Another antihistamine, Phenergan (promethazine), available by prescription, is a stronger antidote for motion sickness, and has such a strong sedative effect that it can do double-duty as a sleeping pill. Don’t try to drive or operate machinery while taking this one.

For occasional indigestion, I use a little baking soda in half a glass of warm water, but that’s not for people with high blood pressure because of its high sodium content. For chronic indigestion I’d recommend any product with magnesium and aluminum hydroxide. Ask your druggist for the cheapest stuff that contains these two

Aspirin is a mainstay of any home medicine kit. I buy the cheapest aspirin I can find. You can also buy aspirin as a powder. Or you can crush regular tablets between two spoons. The crushed or powdered form may be a little less irritating to the stomach.

If anybody in your family has an acne problem, I’d recommend the cheapest product containing benzoyl peroxide.

If I had an allergy to bee stings, I’d definitely keep a couple of syringes with adrenaline around. You’ll need a prescription and your doctor will have to show you how to perform an injection. Some people don’t think they could ever do such a thing, but you’d be surprised how easy it comes when somebody’s life is at stake. More people die from allergic reactions to insect stings each year than do from snake bites.

There’s an excellent Emergency Insect Sting Treatment kit available from Hollister Stier Laboratories (P.O. Box 3145, Terminal Annex, Spokane, WA 99220). You’ll need a doctor’s prescription to purchase one. And if I lived in snake country, I’d have a snake bite kit around. These are also available by prescription from most drugstores.

If I had children in the house, I’d also have a poison antidote kit. The best one I’ve seen contains a syrup containing activated charcoal and syrup of ipecac. (But don’t use ipecac for all poisonings. It can be extremely dangerous in cases of corrosive or irritating chemicals or petroleum products.) The charcoal absorbs the poison, and the ipecac is an emetic—it makes the child throw up. The kit is available without prescription from Bowman Pharmaceuticals (Canton, Ohio 44702). I’d also want to have a poison antidote wheel. You dial in the poison that the person swallowed and it tells you what to do. There’s a good one available from SlideGuide (Box 241. Pacific Palisades, CA 90272).

For an occasional case of constipation, I’d have something containing either psyllium or methyl cellulose. Both of these work by increasing the bulk of your stool. They’re found in such products as Metamucil and Serutan.

For traveler’s diarrhea, I’d have some Pepto-Bismol. There’s good evidence that one of its ingredients, bismuth subsalicylate, really works for this annoying problem.

A lot of people report that thiamine, Vitamin B-1, taken orally, will keep away fleas and mosquitoes. There have been no controlled studies on this yet, but the existing evidence is impressive. If I had problems with these critters, I’d keep some thiamine around the house.

For preventing sunburn, anything containing para-amino benzoic acid is good. Pre-Sun is probably the best buy.

A paste made up of meat tenderizer and water is a good treatment for insect stings. And, of course, ice is the best emergency treatment for minor burns, bumps, sprains, and bruises.

To return to the doctor-patient relationship again . . . whose responsibility is it to make drug decisions?

I don’t mean that laypeople should never take drugs, but that the decision to take a drug should be their decision. Sometimes it may work the other way. Sometimes a doctor may not want to prescribe a drug that a person wants.

After writing a recent column in which I criticized the widespread use of estrogen for menopausal women, I received a letter from a woman who had been using estrogen.

“Mr. Graedon,” she wrote, “You have no idea what it’s like to have hot flashes. It gets so bad that sometimes I just can’t stand it. They’re so unpleasant and they upset my life so badly that I’m willing to take a risk and use estrogen for a limited period of time. And I don’t think you have any right to tell me not to.”

And she’s absolutely right. She’s looked into the available evidence about possible risks and weighed the risks against the benefits and has made the choice that’s right for her. She made the right choice because she went to the trouble of really informing herself.

Many doctors act as if choosing a drug is always the doctor’s decision.

And they’re taught to think that way. It’s not easy for doctors, because to support their clients to be self reliant health consumers, they have to unlearn some really deep-seated elitist attitudes. But some doctors are really working at it, they’re really trying to share their knowledge and their uncertainties.

I got a call the other day from a man who was in great distress. He had a skin condition that had been bothering him for three years. “It’s unbearable,” he said. “it’s gotten to where it’s preventing me from working. It’s really painful. I’ve gone the whole route of symptomatic treatment, and now my doctor’s suggesting that I consider going on methotrexate.”

Well, my immediate reaction was, “My God, you’re kidding! Methotrexate? For a skin condition?” Because methotrexate is a very potent antimetabolite with massive side effects. It’s normally used only in cancer therapy.

And he said, ”Well, my doctor explained it in great detail, and I’ve been reading up on the side effects. I think I understand what the benefits are and what the risks are.

”My doctor told me to take ten days and talk to anybody I could find—other doctors, anybody—to try to get any other suggestions or any other advice. That’s why I’m calling you, to find out what you think about the use of methotrexate for my condition.”

I’ll tell you, I was impressed by the way that doctor was taking the necessary time and giving the necessary information and support to help that fellow make his own decision about using a drug. I really had a sense that they were working as partners. And the doctor made it very clear that if the caller decided not to try the drug, he would not be insulted, and he would continue helping him in the best way he could.

We need more doctors like that.

Yes. And it doesn’t matter whether the drug under consideration is a very potent one like methotrexate or a widely used and relatively safe one. The doctor should supply the information and describe the alternatives, and the layperson should make the final decision.

Tom Ferguson MD Written by Tom Ferguson MD

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