The Pharmacy Field Trip:

The Pharmacy Field Trip:
Resurrected in Medical School
Dennis Mayeaux, MD
Nancy Baker, MD
Ryan Howard, MS4
Suzanne Leonard Harrison, MD
The Florida State University College of Medicine
Disclosures
• No disclosures
• No financial conflicts
• No other conflicts of interest
Educational Gap
• Medical education often lacking in basic
information, pharmacokinetics and
availability of OTC medications, herbs and
supplemental products.
• “Just say no” atmosphere!
Increasing Use
• Americans are using more OTC and
nonprescription medicines than ever
before
• OTC medicines now account for the
majority of all medications used in U.S.
Changing Medicine
• More than 100,000 OTC products on the
market today with about 1,000 active
ingredients
• More than 700 contain ingredients and
that were previously available ONLY by
prescription
Not Regulated
• OTC available substances are not
monitored or regulated by the FDA
Engaging the Students
• Difficult at best and impossible at worst – to hold
the attention of students with a PowerPoint
presentation
• One approach is to throw up a lengthy list of OTC
products and perform a matching game with
symptoms
• Not a memorable experience or effective teaching
technique!
Inadequate Training?
• Students become data heavy and application light
– frequently demonstrated when a senior resident barks
at the hospital ward nursing staff, “Laxative of choice”
when hoping the nurses will actually know what to do
• Students can answer every board question
regarding bowel agents, but putting the pieces
together for such a common problem is a puzzle…
Therapeutic Classes of OTCs
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Analgesics and antipyretics
Cold, cough, and allergy products
Nighttime sleep-aids
Gastrointestinal products
Dermatological products
Other topical products (including dermal and vaginal antifungals,
anorectal medications, head lice products, hair loss products, otics)
Ophthalmic products
Oral health care products
Menstrual products
Nicotine replacement products
Weight loss aids
Vaginal contraceptives and emergency contraceptives
Increasing Use
• 35% of adult Americans use OTC
medications on a regular basis
• Children age 12 and younger administered
OTC meds twice as often as prescriptions
Practical Knowledge
• Students appreciate the opportunity to
understand more about medications that
are used so frequently by
– Their patients
– Their families
– Their friends
– Themselves
Not Included in Curriculum
• Most educators agree on the need for
training to include OTC products
• ‘Time Real-Estate’ in medical curriculum precious and politicized - every block of
minutes is lobbied for and fought over
Making Learning FUN
• Lets go back in time. What do recall about your
elementary school days?
• I wager, you remember that field trip to the zoo or
museum and have not forgotten those
experiences
• Why do we abandon such a powerful, indelible
teaching tool as soon as we become adults and
educators?
Format
• Once during the 6-week FM clerkship, we
escort the students to a local pharmacy
•
• While there, we go through the aisles and
discuss the products one-by-one
• Questions prompted by patient cases
incorporated
Tons of Overlap
• 400 different products contain perhaps
less than a dozen ingredients
“Fantasy Football Players”
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Dextromethorphan
Guaifenesin
Acetaminophen
Ibuprofen
Phenylephrine
Behind the Counter
• Pseudoephedrine
• Used to ‘cook’ crystal methamphetamine
– Instructions available online and on cable
televistion (Thanks Breaking Bad)
• Most states have restrictions on purchase
http://www.nacds.org/pse.aspx
The STD of the OTCs
• MENTHOL
– In Vick’s VapoRub
– In cough drops
– In topical ICY HOT arthritis
Historical Perspectives
• Kaopectate was Kaolin, now Bismuth (2004)
• EX LAX was phenolphthalien, now senna
– FDA pulled from market in 1997 due to tumors in
mice; after 90 years human use without harm
documented
– “…reasonably anticipated to be a human
carcinogen based on sufficient evidence of
carcinogenictiy in experimental animals.”
Historical Perspectives
• Bendectin voluntarily withdrawn from the
market in 1983 secondary to costs of
litigation
– Unisom: pyridoxin and doxylamine
– Resurrected 2013 as Diclegis (same combo)
– Expensive, now > $300 for 60 pills
– Pregnancy risk level A (highest)
Shelf Space is Real Estate
• Companies pay for the privilege of placing
merchandise (drugs) at EYE LEVEL
Pricing Differences
• House brands packaged similarly and
priced competitively
• Identical medications priced differently;
depends on marketed use
– Clotrimazole for yeast vaginitis vs. jock itch
Confusion
• Frequent the same substance is called by
two different names
• Kaopectate and Pepto Bismol are identical,
but most laypersons AND STUDENTS don’t
know this
• Diphenhydramine - lots of names
Subtle Naming Twists
• Sudafed = phenylpropanolamine
• Sudafed PE = phenylephrine
• Preparation H Cream = phenylephrine
• Preparation H anti-itch = hydrocortisone
• Preparation H medicated wipes = witch hazel
• Unisom PM = diphenhydramine
• Unisom Sleep Tabs = doxylamine
• Dramamine Original = dimenhydrinate
• Dramamine Less Drowsy = meclizine
Dangerous?
• OTC epinephrine inhalers
– Asthmanefrin, Primatene Mist (off market, but
application to reinstate has been submitted)
• Diet pills
– Alli, chitosan, chromium, green tea extract, hoodia
• Alpha-1 agonist nasal decongestant
– Afrin (Oxymetazoline)
Safety
• Most patients can self-administer OTC drugs
safely
• 2001 survey* indicates that most individuals take
necessary precautions
– 95% read directions before taking a nonprescription
product for the first time
– 89% read labels to choose appropriate OTC
medicines
– 91% read about possible side effects and interactions
BUT…
• 33% of Americans admit that they have taken
more than the recommended dose of an OTC
medicine
• Do physicians ask patients about OTC use?
– 75 % of physicians report that they ask their
patients directly about OTC drug use
– 25% wait for patients to volunteer this information
Herbals and Supplements
• Milk Thistle for Liver concerns
• Senna for constipation
• “Drawing Salve”
Pediatric Formulations
• AAP recommends AGAINST giving OTC
medications to children under the age of 2
• Extreme caution in Children 2-6
Lidocaine Formulations
• Solarcaine
• Bactine
• Dermoplast
Cost
• Average cost prescription meds
– Name-brand $96
– Generic $28
• OTC drugs cost an average of $7
• Use of OTC meds estimated to save US
Healthcare system 102 billion dollars
annually
Ongoing Education
• Impossible to cover an entire pharmacy in one
FIELD TRIP
• Value of activity is to peak interest so they will
begin to think critically every time they are in a
pharmacy
• Encourages students to become familiar with OTC
products as many can be very helpful when used
properly (or at best will do no harm)
Finishing Up…
• Regardless of specialty choice, neighbors,
relatives and friends will begin a casual
conversation with, “You’re a doctor, right?
What do you think about…”
• Just knowing what is on the shelf in your
pharmacy will make them the family hero
Contact Information
Dennis Mayeaux (Creator, Clerkship Director)
[email protected]
Nancy Baker (Adaptor, Clerkship Director)
[email protected]
Ryan Howard (Participant, Student)
[email protected]
Suzanne Harrison (Adaptor, Education Director)
[email protected]
Please evaluate this session at:
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