Pharmacy

Unicough: Sadly not as good as unicorns.

Another day and another new cough medicine has mysteriously appeared on pharmacy shelves.  It’s called Unicough® (Infirst), and it claims to work by:

addressing the hypersensitivity of the cough reflex, which makes it suitable for dry, tickly and chesty coughs
— http://www.chemistanddruggist.co.uk/news/new-cough-syrup-pharmacy-only#sthash.toAK6A2l.dpuf (subscription required)
 source: http://www.infirst.co.uk/were-working-on/unicough

source: http://www.infirst.co.uk/were-working-on/unicough

Riiiight. Regular readers will by now know that most cough medicines are absolute nonsense, with little to no evidence of effectiveness. I’m particularly suspicious of products (like this one and Bronchostop, for example), which claim to be able to work on any type of cough. Chesty and dry coughs happen through different mechanisms, so a product that claims to treat all types seems more likely to not work for any. An exception to this would be a simple demulcent like simple linctus, which acts just by coating the throat for a little while. 

Am I right to be suspicious about this product? Well dear friends, lets take a deep, objective breath and dive into the evidence, hoping beyond hope that maybe this time… this time… it might not be a nonsense product. 

Is it actually a medicine? Or is it just pretending? 

Unlike most new over the counter products which all turn out to be medical devices masquerading as real medicines, this product is actually, genuinely a Real Life Medicine. It even has a Real Life License, for the symptomatic relief of common coughs associated with upper respiratory tract congestion. What larks! What a time to be alive!

This means that the manufacturer will have proven three broad things in order to receive the license: safety, efficacy, and quality. We’re not out of the woods yet, by any means, but this is probably the most promising start to an OTC medicines review I’ve done so far.

It contains diphenhydramine 14 mg (an antihistamine, which as a side effect will make you sleepy), ammonium chloride 135 mg (irritates the airways, therefore is supposed to loosen up any mucus and help you cough it up- aka an expectorant), and levomenthol 1.1mg (minty, therefore feels a bit soothing and cooling). Despite Infirst’s hopes that Unicough will “reshape the approach to acute common coughs”, there are no exciting or revolutionary technologies here. All of these drugs are old as the hills, and very similar products (Benylin Chesty Cough Original) have been widely available for pretty much forever.  

Furthermore, it is a totally irrational combination of drugs. You’ve got an antihistamine, which acts to dry up secretions, nestling up alongside an expectorant, which is supposed to promote loosening up secretions. Those two actions work against each other and cancel each other out, rendering the whole thing pretty darn pointless. 

If it's licensed, that means that there is evidence that it works though, right?

Ummm… no. It seems that it’s managed to get its license on the basis of being exactly the same (save for flavouring) as another product called Histalix®. That product got its license in 1999, seemingly on the basis of thin air. It’s safe to say that back then licensing for OTC products was rather less rigorous than these days, and “but it’s been around for a while now” used to be a legitimate reason to grant a license. Now, I can’t find the information that the manufacturers of Histalix® presented at the time, but I’m guessing it’s probably not a whole suite of robust, well designed trials.

An article about the product in Chemist+Druggist magazine gave some vague details about a trial:

A randomised study of 163 patients co-ordinated by King’s College Hospital, London, found that the cocoa-based formulation was more effective at reducing the frequency of coughs and the disrupted sleep caused by coughs than simple linctus, Infirst Healthcare said
— http://www.chemistanddruggist.co.uk/news/new-cough-syrup-pharmacy-only#sthash.toAK6A2l.dpuf

This trial, however, doesn’t appear to be published anywhere. I contacted the manufacturers asking for more information about it and was, perhaps predictably, met with silence. Without knowing how the trial was designed, and what the results were, we will have to just discount it; it’s the medical equivalent of being told that no, this Rolex watch someone wants to sell you for £20 is definitely not a fake, honest guvnor. It’s worth noting too that the comparator they used, simple linctus, is no better than placebo itself. 

Searches of the medical literature found a great deal of nothing, either. I searched for both Unicough® and Histalix® too, as well as the combination of ingredients, to no avail. Yes, it might help you get to sleep at night thanks to the antihistamine side effects, but I wish they would be honest about that in their marketing. You’ll sleep because you’ve been knocked out by drugs, not because its made any difference to your cough. 

Is it safe? 

On the whole, there probably aren't any major safety concerns here. Drowsiness is going to be the main problem with it, and as with all things that can cause drowsiness there is a possibility of dependence. Other effects could be dry mouth and urinary retention. It can interact with a few different medicines. Of course there is always the potential issue of self-treatment of a persistent cough, and masking of symptoms that could suggest a more malignant cause. 

The practicalities

Any product which causes drowsiness is going to be severely limited in its usefulness through the day. If you drive, work, or even just don’t want to be asleep all day, then you’re going to have to avoid this product, or you might even end up having to buy two lots of pointless medicines; one for day and this one for night. Additionally, antihistamine-induced sleep can often leave you feeling still quite drowsy the next morning, and some people can even feel quite hungover. It’s not going to be ideal if you have to be up early for work, or if you drive early in the morning.

The unique selling point of this product is the taste. It's cocoa-based, which I'm sure is pleasant, but it aint going to make a blind bit of difference to your cough. I even wonder whether a pleasant taste might have a detrimental effect on any placebo effect: if it doesn't taste like medicine, then you might get less of a response. 

Is the cost reasonable?

Whoah, £8.85 for 150 mL? Give over! There is absolutely, categorically no way that this product is worth that amount. 

TL:DR! Is it worth a punt? 

Nope. There’s no evidence it works, and the combination of ingredients in it makes no sense. Save your money and invest in some cheap simple linctus or glycerine, honey and lemon to soothe your throat instead. The best cure for a post-infective cough is time. Look after yourself, rest, drink plenty, and eat well. If your cough doesn’t go away after about three weeks, get yourself checked over. I know that coughs can be awful, annoying, embarrassing, and exhausting, but –and I’m sorry to have to tell you this- nothing will get rid of it instantaneously, or even any quicker than using nothing at all, so you might as well save your pennies. 

A Mahoosive Thank You

Last month, in a drunken moment of possible madness, I decided to set up a Patreon page. I did so hoping that even setting the page up might work as a driver to overcome the writer's block that has been cursing me for too long. I set the target amount as a dollar, and limited paid posts to these OTC product reviews, because I think there is a real gap in the market for them, and ultimately they will hopefully help people save money. 

To my utter astonishment, four kindly patrons stepped up and made pledges. I doff my cap to you and can't thank you enough. 

Shaun Sellars
Alex Brown
Jack Wright
Bevin Flynn

If you enjoy these sorts of posts, find them useful, and have more money than sense, then I'll just leave this here

Literature Search terms:

Embase: unicough (freetext, ti.ab) Histalix (freetext, ti.ab) *Diphenhydramine AND *Menthol AND *Ammonium chloride

References: http://www.infirst.co.uk/were-working-on/unicough https://www.medicines.org.uk/emc/medicine/31365 https://www.medicines.org.uk/emc/medicine/11171 http://www.mhra.gov.uk/home/groups/par/documents/websiteresources/con553668.pdf http://www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1445576593772.pdf

Is SoreFix a sore loser?

Cold sores truly are the devil's work. The pesky little blighters make a habit of cropping up at the worst moment, crushing your self confidence within a mere matter of hours. 

Given that cancelling everything and holing yourself up in a darkened room until it has gone away tends not to be all that practical for most of us, It's no surprise that folk are desperate for something that really works, and fast. I've already written about several other new cold sore products on this here blog, neither of which are the miracle cures they're marketed as. 

Enter Sorefix, a product selling itself as a new all-round product to both treat and prevent cold sores. Interestingly, the manufacturers claim that it even works after the cold sore has come out, which if true would make it a really useful product. 

In case you are too late to prevent a cold sore, SoreFix relieves symptoms such as itching, burning and the blisters on or around the lips and it speeds up the healing process. So prevent feeling embarrassed and choose SoreFix!
— http://www.sorefix.com/sorefix-cold-sore/

Medicine vs Medical Device? 

Once again, this product isn't a medicine. It seems that nearly every new OTC product these days is actually a medical device masquerading as a medicine, and this is no exception. It might look like a medicine, it might be sold in pharmacies, and the manufacturers might even make claims that make it sound like a medicine, but nay, it is in fact a medical device. Essentially, this means that the need for good quality, robust evidence of efficacy before marketing is virtually non-existent. Le sigh.

The evidence   

Usually, the first step in finding evidence for how a product works is to find out what is actually in the product. This is proving quite difficult for Sorefix, as all I can find is some vague statements about "two zinc salts". hmph. Ah well, I shall have to make do with what I can. What i am particularly interested in is the claim that Sorefix can reduce healing times for a cold sore once it is already out. 

The manufacturers themselves don't bother with providing any cursory clinical trial data. This is unusual, and sort of  refreshing in a way; at least they aren't trying to palm off some nonsense animal studies as irrefutable evidence. It does, however, leave me with even less of a start than I normally would have for these sorts of posts. 

A quick Google search found nothing whatsoever, so I delved into the medical literature in a Medline and Embase search to see if there is any studies looking at the effects of zinc on cold sores. As I can't find which exact zinc salts are in the product, I just did a search for zinc. I found a grand total of three results, none of which were relevant. 

I did manage to find some information about the topical use of zinc in a trusted database. It seems that there is some, very limited data which suggests that some specific zinc-containing products, none of which are Sorefix, may reduce the duration of symptoms by a grand total of 1.5 days, and that's only if used within 24 hours of onset. There is also some evidence that zinc isn't effective for recurrent infections, which is probably going to be pretty much everyone. 

So it seems that I can find nothing at all to back up any of the manufacturers claims at this point. I've contacted them to see if they have any further information, and it'll be really interesting to see if I ever get anything back. 

Safety

Safety-wise, it's very difficult to comment on without knowing what exactly is actually in it. The manufacturers say you shouldn't use it if you are very sensitive to any of the ingredients, though of course they don't tell you what they are. Helpful much :S

The practicalities

The key with cold sore treatments is that you need to start using them before they appear, and you need to use them regularly. Despite what the manufacturers seem to be saying, it would appear that this product is no different. It doesn't contain an antiviral, but the limited amount of evidence looking at the effects of zinc for cold sores suggest that it needs to used every two hours in order to have an effect. That's a lot of applications per day, and I think it's unlikely that most people will be able to keep up with it for any reasonable amount of time. It's worth noting that, because cold sores can worsen quickly, this probably does include overnight too.

I really like the idea of having something to use for prevention, but its hard to remember to apply something at the best of times.  Its even harder if you haven't got a throbbing mass of evil reminding you of its presence constantly.  Given the lack of evidence for prevention, there is no specific guidance on how often you are supposed to use it in order to prevent a cold sore, but I suspect its going to have to be very regularly. 

The cost

It costs £7.47 for a jar or tub of this stuff. Although that's quite similar to other new products for cold sores, it's waaay more expensive than generic aciclovir or plain old vaseline. 

So, is it worth a shot? 

At this time, no. I can't see anything to suggest it's any better than existing treatments. I'll be interested to see if I get anything back from the manufacturers, but I can't see any reason why this product would work, and there is certainly no evidence to back up their claims.

Unfortunately, when it comes to cold sores, time is the best healer, especially once they are out and proud.  If it hurts, then use painkillers like paracetamol or ibuprofen. If its still at the tingling stage, go for topical aciclovir, but make sure you get a cheap generic version rather than Zoivirax: its exactly the same stuff. It's not going to make much difference once its already taken hold though, and at this point you're better off just using something like vaseline to keep it as supple as possible. 

Hxxx

 

Words are important

This is a guest blog written by the wonderful Cathryn Brown (@cathrynjbrown). Not only is Cathryn is an amazing community pharmacist, she's also involved in teaching pharmacy students at the University of Lancashire. She's smart, brave, honest, and a great friend. It's a pleasure to host her writings here. Hope you enjoy:

We were tidying up the office at home again the other day when I happened across an old Medicines, Ethics and Practice Guide. Flipping through the index, “Addicts” struck me as odd. There was no “see also: Drug misuse, drug misusers, or “people who misuse drugs and other substances.” Instead, a whole, diverse, nebulous group of people and stories, from all sorts of backgrounds, we summed up with one stark word: Addicts.

This got me thinking about how the use of language within pharmacy has changed since I qualified, and how we can make even more positive changes.

I've spent a lot of time over the past few years thinking about how I refer to people and patients. I've carefully avoided labelling people as “asthmatics” or “Epileptics”, preferring “people with asthma” etc instead. I assumed that this people-first language would apply across all groups. But my assumptions were challenged when I happened across an article which suggested that the opposite may be for the best for some autistic people. It made me realise that a blanket approach doesn't work, and that it is important to ask the patient themselves how they would like to be described. (As an aside, I found that article through the Emergency Chat app, which is amazingly helpful for anyone who sometimes feels overwhelmed.)

When I first started teaching on the UCLan MPharm course, we used to ask our students to identify “what a patient might be suffering from” in dispensing classes. Just that one little question presents so many problems. Labelling people as patients, assuming that they are suffering, that their illness defines them. Nowadays, we ask “what might the medicine on this prescription be used to treat?”. My hope is, that by changing the words, we can also change our students' perception about the people they will go on to look after. I'm hoping that they'll start to see people less as suffering patients, and more as fellow people with individual needs.

I also wonder sometimes whether our approach as a profession to patient and public involvement creates a barrier between them and us. Does the way we act cause our students to think of patients as exhibits? “These are the patients we’ve brought you to meet with today, none of the rest of us are patients, oh no…” And do these barriers affect our students, do they see patients as “other” and think that they themselves should never be unwell?

When I refer to my own mental health, I will refer to myself as “bonkers” or “crazy in the head”. That's okay for me to say about myself, but I would hate to think that a health professional would refer to me like that. I know that’s odd, and maybe if we discussed it, then I would let them join in with me, but I would hate to see a consultant’s letter that went to my GP saying “Thank you for referring this bonkers lady to me”. I think it’s easier for me to think about myself as a person with depression, rather than a depressive.

When a friend of mine visited his GP for depression, the doctor described him as “feeling a bit down”. Now, perhaps his Doctor was too scared to use the “D” word. Perhaps he thought he would be resigning the patient to a life of darkness and gloom. But instead, all it did was dismiss the hell he was going through, and on a practical level it also didn't look great on his sick note.

I guess I'd like asking how a person would like to be described to become as ubiquitous a question as “do you take any other medicines?”. Whether someone is gay, trans*, black, a person of colour, a person of faith, Christian, a diabetic, a person living with epilepsy or all of the above, we should be able to ask them who they think they are and respond appropriately. We also need to start being truly patient centred, and let our patients lead the conversations where they want them to go, and if that’s hard to begin with – let’s start a conversation within the profession and see where it goes. Don’t forget there’s lots of help out there, and lots of ways to improve the way we communicate with patients, the public, and other health professionals.


 

Cathryn xx

 

Can you really get all medicines for children free in a pharmacy?

The following message has been widely shared on Facebook over the last few days.

It could have been an accidentally wonderful way of spreading the word about minor ailments services- something that pharmacies, CCGs, and PCTs have been struggling to do for years. Sadly, however, it hasn’t quite had that effect- it’s very inaccurate and is likely to lead to a lot of disappointment for patients and pharmacists alike. As with all things, if something sounds too good to be true, then in all likelihood it is.  Hopefully, this post might clear up some of the confusion caused by the original status.

The purpose of a minor ailments service (MAS)

Far from being a free way to stock your medicines cabinet, MAS’s are in place to reduce unnecessary GP appointments. They’re a convenient way to access medicines and advice for those who would otherwise see their GP in order to get free items on prescription as they can’t afford to buy medicines. As such, it’s not about the patient asking for specific medicines. Services are designed so that the pharmacist can sit down with the patient and give them advice about a minor condition. Yes, they can provide some medicines as part of that consultation, but only where the pharmacist deems them necessary in response to symptoms.  Many of the conditions covered are self-limiting, and will go away of their own accord without you having to use any medicine at all.

Local Schemes for Local People

Unless you’re in Scotland or Wales, MASs are commissioned according to local needs, by CCGs. Not all areas with have them, and of those that do, there may be wide differences in how they are run. For example, to access some schemes, you may have to be referred by your GP. Others, you might be able to just pop into your local pharmacy and ask for the service. Some areas may stipulate that only people from that town or county can use the service, whilst others allow it for out-of-townies. There are currently 70 individually commissioned MAS across England, some of which cover multiple areas. They might all have different names and different scopes. 

 

 The logo of the Think Pharmacy First scheme,  available in some areas of North East England.

The logo of the Think Pharmacy First scheme,  available in some areas of North East England.

"All" medicines?

Nope. It’s not even available for all minor ailments. There will be a selected list of things that the pharmacist can deal with under the scheme, and again these will change depending on local needs. It might be things like headlice, hay fever, sprains and strains, conjunctivitis etc. The average number of indications covered by each service is 16. 

Even if an ailment is covered by the service, not all medicines will be available under the scheme. Only evidence-based, cost-effective medicines will be available. You won’t be able to get branded medicines (like the Calpol and Piriton bandied about in the original post) because this doesn’t represent a rational use of the service. I was lucky enough to be involved in the setting up of Think Pharmacy First, the minor ailments scheme that originally covered Newcastle and which now also covers quite a few other areas in the North East, and I remember the discussions we had about what we were going to include on the formulary. We checked robust sources for primary care management and made sure to remove anything that we considered irrational or which had no evidence to back it up. The post mentions plasters, but I very much doubt that these will be widely available- it’s a minor ailments scheme, not a first aid service.

Is it just Boots, or is it all pharmacies?

Even within an area with an MAS, not all pharmacies will offer the scheme. The original post seems to suggest that this is something only Boots offer, but in actual fact any pharmacy can participate. 34 MASs require the pharmacist themselves to provide the service. in 29, the pharmacist or an appropriately trained member of staff can undertake it. Some areas will require pharmacies, or individual pharmacists, to be accredited before they can start offering the scheme. So, if you do feel that you could benefit from using an MAS, its best to phone your local pharmacy first to check if they do deliver it.

Anyone can use the scheme, right?

MASs are there primarily to help those with a low income, who struggle to pay for medicines. Depending on the local scheme, others may be entitled to use it too, for example those over 60 or all children, but this is likely to vary. To use my local as an example again, the Think Pharmacy First scheme is available only to adults who are entitled to free prescriptions on the grounds of low income and their children along with all people aged 60 or over.

They very much ARE allowed to advertise it.

I’ve no idea where this nonsense about not advertising comes from. We had four foot, bright yellow and green window stickers made up for the launch of the Think Pharmacy First scheme, and I remember spending about an hour trying to remove air bubbles from it once I put it up. I did local press stints to advertise the scheme widely, with photoshoots and everything. The scheme was advertised in local council newsletters, in schools, and goodness only knows where else. For years, even after I left community pharmacy, I would get annual phone calls from people saying “Hey, I saw you in the paper the other day!” CCG websites and pharmacy websites have plenty of information about the schemes. They aren’t a dirty secret that we pharmacists keep to ourselves because we’re mean. If anything, they help us pharmacists demonstrate our worth, and we have long been campaigning for a good quality, robust national scheme to reduce all these inequalities.

There’s one obvious reason why these schemes probably aren’t that well known, and that’s budget. It’s nothing to do with not being able to advertise, it just comes down to cold hard cash. Some of these schemes are woefully underfunded, and as such they sadly get left to limp along.

It might take a while

We pharmacists tend to be very busy, and we usually have about 30 different things to do that all need doing immediately. An MAS consultation is a lot more in depth than a usual Over the Counter sale- it usually takes 10-15 minutes, in the consultation room, discussing the problem and any possible treatment. The paperwork then takes the pharmacist a good deal of extra time. Therefore, if you do use an MAS service, please do so patiently. If you need a medicine quicker and you aren’t willing to wait for a consultation, or you don’t want to answer any questions, it is probably best to buy a medicine over the counter instead.

Misuse

We’re all constantly bombarded with Daily Mail headlines about prescription fraud and the likes. Now, I don’t buy into any of that overblown rhetoric, but I, and probably any other community pharmacist you will speak to, can reel off many an occasion where people have taken the mickey out of a minor ailments service. Some people seem to go completely wild when they realise they can get something free. I’ve had numerous people ask me to hand them the formulary list so that they can mark all the products they’ve decided they want. Others used to demand to “self-prescribe” themselves whatever they fancied that day, which used to drive me mad and which used to lead to a stern talking to from myself. It’s just not in the spirit of the thing- its about accessing the pharmacist’s expertise and skill in treating minor ailments, rather than a shopping list. I fear the wording of the FB post in question may be leading people to think otherwise.

Overall

It’s a really handy, worthwhile scheme, and more people should definitely know about it and access it when need be. But they also need to know how variable it is and its limitations.

If you have any other questions about your local scheme, try having a lookie at your local CCG’s website. If in doubt, ring your local pharmacist and they should be able to tell you what’s available. 

 

 

reference: PSNC briefing 006/15: Analysis of Minor Ailments Services in England, Feb 2015


Is Herpatch Mouth Ulcer Gel worth a shot?

Mouth ulcers can be very unpleasant little blighters. They’re often really painful and can be rather distracting, especially when eating. And, if you ask me, anything that makes eating difficult makes life more miserable. They tend to be self-limiting, but for those most painful moments, there aren’t that many treatment options available over the counter. There’s a new product available in Boots currently called Herpatch mouth ulcer gel, so I thought I’d cast an eye over it to see whether it’s worth spending your hard earned cash on.

What's in a name? Mainly confusion in this case

Its actually been quite hard to find manufacturer’s information on this product due to some brand name issues. It would seem that the Herpatch range is being marketed elsewhere in Europe as two products for cold sores, a preventer and a treatment “serum”. The same manufacturers also market a product called Aphtgel, which is for mouth ulcers.

It seems that in the UK, however, the picture is less clear. From what I’ve managed to cobble together, only two products are being marketed, and they’re both doing so under the Herpatch brand. There is a mouth ulcer gel, which appears to be the same as Aphtgel, as well as the cold sore preventer product. The serum doesn’t appear to be available over here yet. The brand name makes little sense for the mouth ulcer product- there’s no patches, it has nothing to do with herpes, and it ends up sounding gender specific, which is nonsense.

What is it?

Aphtgel Remesense is based on Sylphar’s film forming technology. Upon application, it will form a transparent, thin muco-adhesive film on the mouth ulcer. This film will protect and isolate the injured mouth area affected by the ulcer.
— http://www.sylphar.com/sites/default/files/productfiles/111085Aphtgel_Psheet_UK00.pdf

This actually seems like a very reasonable mode of action. Forming a cover over the ulcer may in theory reduce pain, as well as reducing the likelihood that a secondary bacterial infection can creep in and make itself comfortable. It’s also useful to cover over an ulcer whilst it heals, but its obviously very difficult to stick a plaster in your gob, so a product like this certainly does have an important role, at least in theory. It’s not a new concept, but refreshingly it also doesn’t seem to be marketed as such. A product called Orabase used to do a similar sort of job, though its no longer available.

The main active ingredient is hyaluronic acid, which is naturally abundant in skin and cartilage, along with a few other bits and pieces like xanthan gum and cellulose. Basically, it contains a collection of gloopy, sticky stuff that probably won’t dissolve immediately when in contact with saliva. 

Medicine vs Medical Device?

As with many new Over the Counter products, Herpatch gel isn’t actually a medicine. Instead, it is classed as a medical device- a fact that is fairly difficult to deduce unless you do a fair bit of poking about on the manufacturer’s website. This means that the product doesn’t have to go through the rigorous testing that a medicine would, and it shouldn’t have any direct pharmacological effect- in this case it forms a physical barrier, but isn’t absorbed greatly and doesn’t produce any other effects on the body.

Does it work? 

Wonders will never cease, but it seems that there is actually some half-decent evidence that this product works. There are some actual, real life trials for gingivitis, periodontitis, and a similar product is already licensed for chemotherapy-induced mucositis. There’s not much evidence, admittedly, but the published stuff seems to suggest a decent effect size. It’s worth noting that most trials and evidence include people with recurrent or more severe ulcers, which might skew the results somewhat- most of the folk buying it over the counter will be using it for the occasional ulcer rather than for a more serious, recurrent problem.

Is it safe? 

Evidence seems to suggest that topical hyaluronic acid is well tolerated and there aren’t really any safety concerns that I can see think of with this product. One problem could be indirect harm caused by lengthy self-treatment of an ongoing problem. If an ulcer persists for more than 3 weeks, there’s a possibility that it could be something more suspicious.

The practicalities

Using the product might be a bit onerous. The aforementioned Orabase used to be a claggy, gritty paste which felt pretty unpleasant in your mouth. Being a gel, I’d imagine that Herpatch might feel a bit better, but there’s still a possibility that it might feel weird. You’re supposed to wait for 30 minutes before eating and drinking and avoid rubbing the area with your tongue. That seems… unlikely. We’ve all got that little masochistic streak in us that means you can’t quite leave it alone. I’m therefore not sure how long the barrier will stay in place for.

The cost.

This product isn’t cheap, coming in at £7 a pack. That seems pretty steep to me, especially for something that is self-limiting and will probably resolve in two or three days.

To summarise

Not a medicine as such, but a product that has some prior plausibility and some evidence suggesting it may work. Pretty pricey, but I guess if you’re going out for an important curry or something, you might decide it’s worthwhile. There aren’t that many other options available that aren’t hokum or placebos, so I’d actually-for once- be fairly happy to recommend this product to some patients over the counter.

 

Allergy relievers: red light nonsense

Its just about coming into allergy season again, so today I am turning my attention to a product I’ve seen for sale in a few pharmacies I’ve locumed at of late: The Allergy Reliever Device. These things are sold under some pharmacy chain’s own names, or under brand names like Kinetik.

 An allergy reliever display spotted on a Tesco pharmacy counter by @TheWholeT00th. 

An allergy reliever display spotted on a Tesco pharmacy counter by @TheWholeT00th. 

It’s yet another medical device. These things seem to be hitting the pharmacy shelves more and more often these days, giving them a level of respectability which personally I don’t think they deserve. At least this device makes it clear that it is a device though, unlike things like Prevalin which pretend to be real medicine.

According to Kinetik, it uses “red light therapy to suppress the cells that release histamine, thereby relieving the symptoms of hayfever and allergic rhinitis.”

So, essentially shoving some Christmas tree lights up your nose then. Well I must admit that’s a new one on me. It’s pretty hard to sniff out (geddit?) the theory behind this one too.  The manufacturers of these things don’t give any explanation as to why red light would suppress mast cells, and several Google searches later I’m none the wiser. I have managed to dig out one published paper in rats, where the authors seem to be suggesting that red light changes the redox state of cells, which might cause some changes within the cell. Even these others say that they’re not quite sure what’s happening though, and that further investigation is required.

Armed with a few unsuccessful Google Searches, I delved into the medical literature. I tried every which way I could think of to search for evidence that this thing works, but ended up drawing a total blank. I think this may well be the least successful search for evidence I’ve done so far, and that’s saying something. Even the manufacturers can’t be bothered with listing any sources instead they go wild with the clipart, giving us a Generic Smiley White Coated Person and Happy Photostock Chef alongside some very random recipes and general lifestyle advice.

And it looks like this thing really isn't very pleasant or practical to use. You're supposed to shove the probes up your schnozz as far as you comfortably can, then keep them there for three minutes. Not the most dignified of poses. And you're supposed to do this three or four times a day. That's a lot of inconvenience. Seems like prime Use Once Then Put In A Dark Cupboard territory for me, especially since taking a one a day antihistamine tablet is no hassle at all. 

In short, I wouldn’t waste your money. There’s no basis to these things, and it saddens me that they are not only being sold in pharmacies, but are being sold under pharmacy brand names. The more we associated our profession with such nonsense, the less trustworthy we become to other healthcare professionals and patients alike.

Hxxx

"I do my own research"

Something that I see a lot in on-line debates about alternative medicine is phrases like “I did my own research” or “people should be allowed to do their own research and make their own decisions”

However, I don’t think that the vast majority of people are able to do their own research. Now, that’s probably a pretty unpopular opinion. It’s patronising, paternalistic, and it flies in the face of patient choice. Who am I to question the intelligence and abilities of other people? Why do I think I'm so clever compared to anyone else out there? Allow me to explain myself.

I've been a pharmacist for a very long time now. From uni, through pre-reg, to my own revision at work, I've been taught critical appraisal skills. Yet to this day, it’s something that I actually find really hard work. It’s a skill that requires continual honing, and every time I use it I feel like I am fighting with my brain. 

Even in the last two weeks, I've been revisiting my critical appraisal skills to make sure they are up to date. I've done some in-house work, three on-line courses, and a one to one training session. Yet I still find myself sat here at my desk for several hours, if not days, looking over the same study with a furrowed brow, desperately trying to make the numbers and statistics tell me their story.  If I find it so hard, then how on earth is someone without any medical background or critical appraisal training supposed to do any of it? 

There’s hazard ratios, odds ratios, confidence intervals, numbers needed to treat, event rates, absolute risks and other confuddling terms to deal with. I naturally struggle with numbers at the best of times; like most people, I much prefer narratives. That means that I have to constantly argue with myself to keep looking at the results page, rather than just flicking to the discussion. Because if I did that, I'd be relying on what the authors, with all of their possible biases and agendas, say their numbers say. Then, when I eventually manage to squeeze the swimming mass of figures into some sort of order in my head, I find out that these numbers aren't the full story, and I need to dig even deeper into other analyses of the same figures to find out what’s really going on.* 

  A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias.

A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias.

It’s not a pleasant task by any stretch of the imagination. It really does feel like a mental marathon. I often question whether I am even up to the task- I can end up feeling stupid, and confused. But in order to really figure out whether or not a drug works I need to strip away all the levels of other peoples’ interpretation and start from scratch, with the cold, hard, impersonal numbers. That way I can build my own narrative, uninfluenced by what the study’s authors or sponsors want me to think, by what newspapers want me to believe, by what campaigners want me to know. The only way to know the truth is to start right at the bottom, in a dark dank pit of statistics, then to slowly start building yourself a ladder until you emerge, blinking, into the pleasant knowledge that you've worked out what on earth is going on.

This sort of raw data is not only extremely hard to deal with once it’s in front of you, but its also pretty difficult to come by. Finding it in the first place includes searching multiple medical databases- and these things aren't just a quick free text search like you would do on Google. Constructing a search can in itself take an hour or so, and then you have to trawl through the results to decide which are relevant to what you are specifically looking for. For me, most of the time, a question is structured like this:

What is the evidence that [drug/ group of drugs] works for [disease] in [patient group

 So, in my poorly drawn Venn diagram below, I need to find those holy grail papers that reside in the pink area:

  I am truly terrible at MS paint, but you get the idea.

I am truly terrible at MS paint, but you get the idea.

  What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches.

What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches.

Some of these papers might be pay-walled, so it’ll take me a week or so to get my hands on them. Some of them might initially look promising, but once you start to dig down into the figures you see that there might actually be problems with how they were undertaken or reported, or they might turn out to not quite fit in some way- perhaps the dose they used in the trial is different to the licensed dose in the UK, or the people enrolled into the trial don’t quite fit the population you want to know about, or perhaps the trial just didn't recruit enough people so any results from it are invalidated.

I've been doing this job for years, and I really do still struggle with all of this stuff. That’s not because I'm poor at my job, or because I'm stupid, or because I haven’t put the effort in to understand it. It’s because, when it comes down to it, this stuff is really bloody hard. It’s time-consuming, boring, and unintuitive.

People might well feel like they've done their own research. They might spend several hours digging about on the internet and feel empowered by any decisions that they make. But what they don’t realise is that what they've been researching isn't just the information- it’s the information with many, many layers of interpretation (and therefore bias) added. For a choice to be truly informed, you need to go right back to the start, to those terrifying tables of numbers and statistics. That’s simply not realistic for the majority of people.

Far better, then, to learn how to decide on whose interpretation you’re going to rely on. Will it be those that take the media reports at face value, or who have an agenda or a product to sell you? Or will you go with those that have years of training in how to pull apart complicated data and disseminate it in understandable ways?

Hxxx

*I thought I’d give you a quick real life example here, but I thought it best to asterisk it because I've probably bored you enough already. I'm currently looking at a drug called edoxaban and its use in reducing the risk of stroke in patients with atrial fibrillation. It’s the newest in a series of novel oral anticoagulant drug- they’re supposedly like warfarin, but less faffy. So I find and look at the main trial, and spend days unpicking the stats. It looks like both strengths used in the trial are no worse than warfarin, and the higher dose might even be a little better. Great, right?

Well, that’s not quite the end of the story. Because it turns out- and this isn't reported in the trial at all, but instead is contained in the FDA’s briefing document- that in people with fully working kidneys, edoxaban is actually worse than plain old warfarin. In people whose kidney’s aren't quite at full capacity though, it might work better than warfarin. So the overall trial results are kind of skewed, and if we didn't dig deeper, we might have been giving a whole group of people a more expensive drug with worse outcomes than warfarin. Even the FDA findings are borderline- some of what they describe doesn't reach statistical significance.

Why I'm not currently a member of the RPS

Since there's a whole load of people tweeting their reasons for why they've renewed their membership, it seems like a really good time to discuss my reasons for not renewing.

Historically, membership of the Royal Pharmaceutical Society of Great Britain was mandatory, as they acted as both a professional body and a regulator. Their fees were huge- £400+, and they had a reputation for being very meek and for being a bit of an Old Boys Club. Then the split occurred, and now we pharmacists have to pay the regulator, the General Pharmaceutical Council, but we can choose whether or not we want to fork out for RPS membership. When I was working towards being a pharmacist, I was so excited and proud to be part of a professional body. I'd love to still feel that way today, but there are a few things standing in my way. Some of these reasons are very personal to me, whilst others I think may resonate with many. I can but hope that if they are read by anyone at the RPS, my comments are taken as they are meant- constructively, and with a hopeful heart that one day I will be convinced enough to renew my membership with them after a long hiatus.

Cold, Hard Cash

Membership of the Society costs £192. That's a lot of money. Surprisingly, that's not a popular opinion- whenever I say so on Twitter I am hounded by comments like "It's only the price of a pint of beer per week" or "just give up your morning coffee!". The inference is that my priorities are all wrong, and I must be mad to not join for such a reasonable price.

A few years ago, I really was in financial trouble. It was a combination of things, including a divorce, that got me to that point. Some of those things were my fault, some weren't, but none of that mattered when I had ran out of my overdraft and an enormous bill was overdue. I'm now at a much more stable point in life, but that time is still fresh enough in my memory that £192 is still a lot of money for something non-essential. 

Attitude towards poverty and Other Snark

There have been a few occasions when I have mentioned that I can't justify the cost on Twitter, and as mentioned above the response has been rather eye opening, sometimes from RPS staff. It would appear that there is a complete lack of understanding of financial difficulties from some quarters. You try to explain that yes, it might just be the price of a pint per week, but if you haven't got the price of a pint in the first place it makes no difference, but that concept just does not appear to compute. Some of these conversations got so bad that I had people DMing me to check that I was okay.

I've been made to feel ashamed and belittled. This may not have been intended, but this general conception that pharmacists- presumably because they get paid fairly well- must never have real money worries is really concerning to me. A good wage is brilliant, but it doesnt 100% guarantee such financial security that £192 seems like a throwaway amount. Sometimes life just steps in and mucks everything up. As health care professionals, empathy is an extremely important skill, and there have been a few occasions were that seems to have been lacking. If folk can be so dismissive of financial hardships, what else could they be similarly judgemental about?

Additionally, I did see another, unrelated snarky tweet by a very prominent member of RPS staff to a tweeter who had dared to ask for evidence. This may be a very minor thing, but to me its a big no-no, since I'm so passionate about evidence based medicine. 

I wish I had screenshots of all of these conversations, but they happened a long time ago and I'm too tired to try to hunt them out. I know this might all sound super petty, but for an organisation with professionalism at its very heart, I think such seemingly small things add up.

 Evidence of Value for Money.

The RPS certainly does some very good work. And I can honestly say that I hugely admire their improvement over the years that I've been a pharmacist. They're a lot more visible these days, a lot more proactive. I've admired their stance on things like social media, homeopathy, and e-cigarettes. I love that they've collaborated with Sense About Science. But, despite all of these advances, I'm still not entirely convinced that membership would make enough difference to my daily life to justify a cost of £192. How do I know, if I'm not a member? well, I know this isn't particularly robust, but from my own n=1 experience of previously being a member compared to now, I see no difference.

I've never had a patient look at my credentials and say "Here, you're missing an R and an S from your MPharm, you must be a rubbish pharmacist.

Money=Professionalism

This is a concept which I simply cannot abide, but which is creeping more and more into the forefront. It seems that organisations are starting to equate RPS membership with professionalism, and this is very simply not the case. Throwing money about does not, under any costs, make someone more professional. I know some really terrible, unethical pharmacists who are members. Homeopathic pharmacists who repeatedly endanger peoples' lives, in spite of the RPS stance on homeopathy, appear to be members. Then there's me, who works bloody hard to be a good pharmacist, to promote safe and effective healthcare, and who spends sleepless nights worrying about my patients.

What of those of us who work our asses off, day by day, to help our customers, pay our bills and maybe, if we're lucky go on a little holiday? The implication that people who cannot afford membership are somehow less professional really, really drives me mad, and far from making me rush to hand over my cash, it instead distances me further.

Previous personal letdowns

I've written previously about a complaint against me when I was newly qualified, which was handled by the  RPSGB. Although they no longer deal with complaints, I was left with a lasting sour taste in my mouth following that experience. I spent a lot of time with the inspector, talking about the substandard working conditions I was being forced to work in at the time. I was assured that the RPS would fight to improve those standards, and that they would be taken into account. Of course there was no mention of that conversation in the report i later received.

I know this is anecdotal, and I know its unfair to tar the current RPS with the same brush as I did their predecessors. But it does mean that to me personally, they need to work a little harder than usual to win back my trust.

My Joining Threshold

I'm not entirely sure of what would convince me to join as of yet. This is still, despite all of these years, pretty nebulous and shifts occasionally. Some of my admittedly vague suggestions where there is room for improvement are:

  • Guiding a sea-change in the profession to embrace evidence-based medicine. 

  • Speaking up about the amount of unprofessional quackery for sale over pharmacy counters. 

  • Truly standing up for everyman: acknowledging the importance of every pharmacist out there with aching feet and a headache who hasn't had a proper lunch break in years. 

  • Shaking off the traditional top-down culture of the profession and finding creative new ways to really listen to those of us working at the front line- those of us who can't get the time off work to attend meetings in London and who are too exhausted at the end of our 16 hour shifts to spend hours reading consultations .

  • Making some really meaningful steps towards changing poor workplace conditions for pharmacists.

  • Constructively engaging with non-members in order to raise the profile of the profession cohesively, rather than creating a false, unhelpful two tier system

  • Working towards breaking through mental health stigmatism both for patients and within the profession. 

The other important factor for myself is of course financial stability. I'm getting there. I'm not ashamed to say that at the moment, though, I'd rather prioritise that pint per week over membership. My social life is extremely important to me- its what has gotten me through the hard times, and I can see a clear benefit to my life from it. At the moment, sadly, I can't quite say the same about RPS membership, though hopefully in time I will be persuaded otherwise.

Hxxx

Special Investigation: Is Santa really a pharmacist?

Despite him being one of the most famous people on the planet, we know a suspiciously small amount about Santa Claus's background. I've had the suspicion for some time that he may in fact be a pharmacist throughout the rest of the year. 

A quick check of the GPhC register brings up no S. Claus’s, though of course that only rules out pharmacy practice in theUK. Unfortunately it would seem thatLapland does not have a similarly searchable pharmacist register, so we are unable to confirm his registration status in his home country. However, if Santa were to be working overseas, it would seem that Your Family Pharmacy, 15 N Kringle Place, Santa Claus, Indiana would be his first choice, especially given its prime location near to Lake RudolphCamping Park. (honestly, this place exists)

Santa is, of course, most famous for operating a highly efficient free delivery service. No doubt these skills have been honed throughout the rest of the year, as he organises a prescription collection and free delivery service to his patients.

As the song goes: “He’s making a list, he’s checking it twice”, demonstrating that Santa is following robust self-checking procedures. It is clear that he has the sort of attention to detail that is required by pharmacists. It’s also clear from this song that he is aware of NICE guidelines.

It seems clear that Santa’s system of working, is synonymous of that in a community pharmacy. He works alongside a team of highly skilled and well trained elves, though retaining legal responsibility for all that goes on in his workshop. One assumes that, on visiting the workshop, his Responsible Father Christmas sign is clearly displayed.

Perhaps the most convincing evidence is that of his links with the Coca Cola company. Santa has a long history of advertising the product, adding a splash of red and a liberal helping of fur to his usual pharmacy white coat. Its good to see that Santa is so devoted to advertising the invention of  fellow pharmacist John Pemberton, who originally invented the drink as a cure for his own morphine addiction. Santa is clearly interested in harm reduction and no doubt works closely with local drug and alcohol teams during the rest of the year to dispense opioid replacement therapies for patients.

Santa Claus, however, does have some flaws as a pharmacist. As discussed in the BMJ, he appears to pose a number of public health risks, including as a vector for infectious diseases, and in the promotion of drink-driving. It would seem that he would benefit from a visit to his nearest Healthy Living Pharmacy, where he can access advice on reducing his weight and brandy intake. It is good to note that he successfully quite smoking and seems to have remained abstinent.

Hxxx

Advert Annoyances Vol 1: Senokot

Welcome to the first installment in what is likely to be a very sporadic series. As you've probably guessed by now, I have a tendency to be irrationally annoyed by small things, especially when it comes to medicines. Adverts for OTC meds can be a prolific  source of cringes. Even leaving aside the requests for "you know, that one on the telly, where there is a guy and a dog and its a blue box", there will occasionally be a little phrase or image used in these adverts that makes me stop and seethe a little.

The current one at the moment, is Senokot. I can't find a link to the new advert, but when I do, I shall pop it in here so you can see for yourself.

There's all sorts of naturalistic fallacies going on, but that's not what annoys me the most. It's the phrase " works in harmony with your body" that i'm finding hard to stomach (geddit?)

Put simply, senna works by irritating your bowel. Your bowel notices that it is being hurt by something, therefore starts contracting and producing secretions to hastily get rid of the thing hurting it.  This then might make you poo, but from your bowel's point of view that's a side issue- its just trying to protect itself from harm.

That doesn't really sound to me like "working in harmony". You might as well say that fire works in harmony with human skin to make you walk faster- in actual fact, one is just out to hurt the other, meaning something else happens as an unintended- but sometimes useful- consequence. 

Hxxx

 

It's thyme to Bronchostop this nonsense

I’m sorry, I just could not resist that headline.

Whilst working a locum shift the other week, I noticed a couple of new products had leapt their way to the pharmacy shelves. “Bronchostop”. Sounds interesting, I thought, until I moved a bit closer and noticed that they are, in actual fact, a herbal cough remedy, and my vague excitement was replaced with a bit of my soul dying. Then I saw the price tag, and the anger kicked in.

Brought to us by our old friends at Omega Pharma, Bronchostop syrup contains thyme extract and marshmallow root, whilst the lozenges just contain thyme extract. Omega claim that it “relieves any type of cough”, and that it “takes the hassle out of choosing a solution”. Well, I must say, I’m pleased to hear that, because I find one of the main stressors in my life is choosing which cough remedy to use. I mean, it’s just so complicated to decide if you have a dry or a chesty cough, then realise that it makes no difference anyway as most cough medicines don't work, so you then just by a cheapo honey and lemon thing to make yourself feel placebo-ey better. 

So, given that the great all-consuming cough medicine dilemma of my life has now been sorted out by Omega, I can spend some quality time looking up the evidence to see if it works.

It turns out that there are some preliminary trials which suggest thyme might improve cough symptoms. However, these all use specific cough syrups with different combinations of ingredients compared to Bronchostop, so they’re not very helpful. Because the product is being sold as a traditional herbal remedy, the manufacturers don’t need to bother collecting any evidence that it works before it goes on sale- their claims are based entirely on “traditional use”, which means nothing at all scientifically.

One attempt at a clinical trial compared thyme syrup with a “real” expectorant, bromhexine, and found no difference over a five day period. There are a number of problems with this though- firstly, bromhexine isn’t commonly used in cough medicines. Secondly, there’s little to no good evidence that expectorants work anyway, so we’re comparing something that may or may not work with something that doesn’t.

Worryingly, the website www.bronchostop.co.uk contains absolutely no safety information whatsoever. It doesn’t tell you who can’t use it, who needs to be careful using it, or what any of the side effects might be.

What side effects could it possibly have, you’re wondering. After all, its just a herb. We eat it, so it can’t be that bad, right? Well, sort of. The amounts used in food tend to be a lot lower than when it is used as a herbal medicine.

On the whole, thyme is well tolerated, but occasional gastrointestinal effects can occur. Uncommonly, and more seriously, people can have allergic reactions to it. It can interact with drugs, including those that thin the blood, those used in Parkinson’s disease, those with anticholinergic or cholinergic effects, oestrogens (research suggests it may decrease the effects of HRT, but theoretically also the contraceptive pill), and non-steroidal anti-inflammatory drugs. It may cause problems in people with bleeding disorders, who are undergoing surgery, or who have hormone sensitive cancers. We have no idea of the effects that medicinal amounts of thyme can have in pregnant or lactating women.

It seems to me, however, that its main adverse effect will be on your bank balance. This stuff is £8.99 for a 200ml bottle or £4.99 for 20 pastilles- that’s a whole lot more than simple linctus, which is about £1.50 and which will probably do just as good a job.

Hxxx

Is pharmacy a good career choice right now?

I always wanted to be an archaeologist, growing up. I knew, however, that this was probably a pipedream- partly because I dislike creepy crawlies, but mostly because I was pretty sure in my childhood brain that everything interesting would have been dug up already by the time I was old enough to work.

Turns out I was wrong about that, but I’m still really proud of the profession I ended up in. I remember wandering up to the local shops with my Mum when I was little. We were talking vaguely about the future, when we had a little nose around the local chemist’s shop, cooing at the colourful bubblebaths and hairgrips that they had in stock.

“I know”, Mum said. “Why don’t you become a pharmacist?”

“What’s one of those?”, I asked. As far as I was concerned, the chemist’s shop was a place to buy cheap make-up and bath salts.

“Well, they stand in the back and mix up the medicines”. That’s it, I was hooked. I had images of brewing potions, mixing up gloopy ointments, and all sorts of stuff that, it turns out, in real life you only actually get to do for a couple of hours as an undergraduate. But my decision was made, and all the rest of my life I knew I was going to be a pharmacist.

As I got older, and I started telling people what I wanted to do, I used to hear nothing but positive things. I worked as a counter assistant in my local super market, and locums always used to tell me “You’ll never be out of work. Everyone is always desperate for pharmacists.”

At the time I graduated (2006), it still hadn’t been that long since the Great Pharmacist Shortage. This happened because the old style three year degree now became a four year Masters degree- so there was one year where no newly qualified pharmacists came on the scene. Everywhere you looked, people were crying out for a full time pharmacist to work for them. Whatever happened, you always knew that you could locum as a back up, and earn a good wage doing so.

As university went on, and I started applying for pre-reg places, I got worried. Not because I didn’t think I would get a place- in actual fact I was being courted by several companies, all of whom were clamouring to fill their pre-reg spots. I think I did maybe 10 interviews, and I got job offers from every one of them (and believe me, some of those interviews I was really quite atrocious in). No, I was worried, because I wanted to do my pre-reg in hospital, and I knew that pre-reg places really were limited in my local area- only 7 for the whole city.

I was lucky, and I got in. My year was really lucky, as it turns out there were enough jobs going for each of us pre-regs- though I actually went elsewhere. Whilst community pharmacy jobs were plentiful, hospital pharmacy was a lot more difficult to get a job in.

Nowadays, it has changed so much. I don’t think I can ever really hear myself saying the sort of things I was told to an enthusiastic school child now. “You’ll never be out of a job” would just simply be a massive lie.

When I was choosing universities, there were only a handful that actually offered pharmacy as a degree. In recent years there has been a proliferation of universities offering it now though, and as a result, the number of graduates is increasing year on year. I’m sure this isn’t the whole reason, but we have now reached a point where pre-registration places are becoming really hard to come by. There is a group of potential pharmacists, year on year, who will simply never be able to get a place anywhere.

So what does that mean? Well, you can’t register as a pharmacist, so you can’t work in your chosen profession. You’ve still got a Masters degree- but you’re actually pretty limited as to what you can do with it. Sure, its equivalent or better than a pharmacology degree, but you’ll always have a question hanging over your career, whatever you choose to do: “If you’ve got a pharmacy degree, why aren’t you a pharmacist?”. There’ll always be a slight, unfair, cloud of suspicion there. It means, even for those lucky enough to get pre-reg places, that jobs are more and ore difficult to come by, wages are being lowered despite responsibilities and workloads being higher, and locum shifts are both hard to get and pay an awful lot less.

Several places that I do locum shifts for have an email alert system for new shifts. On several occasions, I have received an email, checked my diary for my availability, then rang back immediately only to be told that all the shifts have gone already. The good thing that comes out of this is that, once you get your foot in the door, there is an incentive to work hard and become known as one of the best, most hardworking locums, because then you will get offered shifts first. The bad thing is that its now really hard to get that first step on the ladder.

How do we fix it? I have no idea, as it’s a multifactorial problem. A cap on the number of students studying pharmacy does seem logical, but that’s already been stamped upon by the Minister for Universities, science and cities Greg Clark MP, who has said:

Having considered the evidence I have decided that it is not necessary to introduce a specific student number control for pharmacy. The government's objectives for pharmacy can best be achieved outside of a number control system. It is the government's policy to remove student number controls wherever possible to enable students to have greater choice and to encourage universities to offer better quality courses to attract students. I believe pharmacy students can and should benefit from this reform and not be restricted. Therefore there is no need to consider further options for a pharmacy number control.”

It seems to me that the one thing that Mr Clark isn’t considering is those students. Yes, they might have greater choice, but I wonder, if asked, where their priorities lie- would they rather have more choice, or would they rather have some security in their future. I wonder if it has occurred to him to ask them directly.

So it is that I, and a number of other pharmacists, are sadly starting to discourage students from looking at pharmacy as a profession. Its through no fault of their own, and its brilliant that so many young people want to be pharmacists- but its hard out there, and its only going to get harder. Our bright young potential pharmacists might be better off opting for a less focused, vocational degree.

Hxxx

 

When real science gets left out in the Coldzyme

There’s no getting away from it, folks. Its sniffle season. For the next 6 months or so, the sounds of sneezes, coughs, and millions of noses being blown will echo throughout the nation.

We all know by now that the common cold is a virus. We all know that there is no cure. We also all know that, although you feel like crawling into a small dark warm cave and dying at the time, its usually much better after a few days, and it goes away of its own accord. Cold and flu remedies do nothing to actually get rid of your cold- they are there to make you feel better during it, although many of them are actually irrational combinations of products in shiny boxes with a redonkulously high price.

It is often said that if someone did come up with a cure for the common cold, they would be millionaires. I was, therefore, surprised to read this week in Chemist + Druggist magazine that indeed, the first ever product to not only treat the symptoms but to act on the virus itself was winging its way to pharmacy shelves as we speak. Really? Because blimey charlie, if that's the case, then this product should be Big News. 

The product is ColdZyme, a mouth spray that costs £8.99 for 20mLs. Seems a pretty fair price to pay for a product which claims to cure the most prominent infectious disease in the western hemisphere. It seems odd, though, that instead of this marvellous scientific breakthrough being plastered all over the media and medical literature, the article announcing it is tucked away quietly in a barely read corner of a trade journal.

What is this breakthrough, miracle product that will powerfully break down viruses? Well, an enzyme called trypsin. An enzyme that already merrily and plentifully kicks about in your digestive system, breaking down proteins. An enzyme which, for the purposes of this product, is inexplicable being derived from cod (which has meant that I have had to resist the urge to refer to it as somewhat fishy.) An enzyme which should be stored at temperatures of between -20 and -80 degrees Celsius, to prevent autolysis. Now, I've seen some fancy medicine packaging in my time, but never a simple mouth spray bottle that can manage such cold chain storage feats. So, if trypsin really is present in this product, then it seems fairly likely that its going to be inactive, unless the manufacturers have found a way of warping room temperature. Or you happen to be in Winnipeg in the middle of winter.

Medicine vs. Medical Device

The manufacturers make some really very extraordinary claims on their website, including one textbook example of special pleading. Their product, they state, isn’t a medicine. It’s a medical device, because it has no systemic effect. They then of course go on to helpfully tell us about the systemic effect it has:

“The medicines currently on the market only treat the various symptoms of a cold. ColdZyme treats the cause of the symptoms – the virus itself – and thus works both preventively against the common cold and shortens the duration of illness if you have already been infected.”

Right. So in the same breath, they are claiming that the product only forms a barrier, no more. But then they are also claiming that this barrier affects the ability of the virus to produce illness if you are already infected- viruses which are already through that barrier and inside your body. Come on, Enzymatica, you can’t have it both ways.

The Evidence

All these claims are backed up by evidence, right? Well, there is a tiny trial performed on only 46 people, which isn’t published anywhere. I can’t say whether or not it is a well designed trial, because I can’t see it in full, so to be honest, we pretty much have to just discount it. What we can do, however, if have a look to see if there is any other decent published information looking at the effect of trypsin on the cold virus. So I turned to the medical databases Medline and Embase, to trawl through the published medical literature. 

I did find one experiment which looked at the trypsin sensitivity of several human rhinovirus serotypes(1). And this appears to have found that viruses are only really susceptible to trypsin when there have been exposed to low pH, followed by neutralization- something which wont have happened to your common or garden cold viruses. I couldn’t find much else suggestive of a clinically significant antivirus action of trypsin.

The practicalities

This isn’t a simple, one-off- couple of sprays and away flies your cold sort of product. You have to use it every two hours, as well as after you brush your teeth and before you go to bed, and you have to continue this “until your symptoms are relieved”. That’s one hell of a regime. I have difficulty remembering to use medicines twice daily, never mind every two hours. I’ve never used this product, but I’d imagine that if it really does leave a “barrier” coating in your mouth, its a pretty unpleasant sensation. I can’t imagine many people sticking closely to these dosage instructions, and if the mechanism of action is as the manufacturer’s claim, skipping doses would cause the product to fail (if, indeed, it works in the first place)

We are also directed to “Start using ColdZyme® as soon as possible when you detect symptoms of a cold.”. Now, those of use who suffer with cold sores who have ever used aciclovir cream will know that this is often easier said than done- you probably haven’t got the stuff in the house, or at work, and by the time you’ve managed to get your hands on some, its already too late- your cold sore is out loud and proud, and using the drug will be pointless. Its likely that the very same thing will apply here. And remember that the incubation period for a cold is about 2 days- so the virus will already be cosily settled into your body before you even know about it. Its therefore completely ludicrous that this product claims to be able to reduce the length of a cold simply by forming a barrier.  

I know it can be used as a cold preventative, but how many people who feel completely fine are going to remember to use the product every two hours, every day, for the entirely of the cold season?

To Summarise

So, do I think there is scientific evidence to back up the extraordinary claims being made by ColdZyme? I might do when hell freezes over. Or at least when some decent trials are published, which might take just as long.  Do I think that this product should be sold through pharmacies? Absolutely not- this isn’t, if you ask me, real medicine. This is pure pseudoscience, trying its best to fool you into buying real medicine. Do I think lots of people will buy this, use it once or twice, then leave it to languish in their bathroom cabinet? Absolutely.

Here’s the problem though: this stuff will appear on the shelves of pharmacies all over. The pharmacists wont have a clue what this stuff is, and because they are really busy and probably quite tired at the end of each day, they wont be able to do the sort of evidence review I have managed to squeeze into a quiet moment. So they’ll get asked about it, and they’ll sell it. Some people will buy it and will feel better after a few days, and will think that the spray has made them better, forgetting that colds are self-limiting anyway. A customer might come back in the pharmacy one day, and say something like “hey, that new-fangled spray got rid of my cold!”, and the pharmacy staff will end up making recommendations on the basis of customer feedback and anecdotes, rather than on the basis of rational, scientific evidence. In my eyes, this really is a shame, and by selling this sort of nonsense, we really are cheapening our profession, and we're causing our customers to waste their money. 

If patients ask me about it, when I’m working behind the counter, I’ll tell them something along the lines of: “there’s no evidence or logical way that it works. It seems to be a bit of an expensive gimmick, with no decent basis to it. You’ll feel horrible with your cold, but it will start to go away of its own accord, I promise. In the meantime, you’d be much better off looking after yourself, having plenty of fluids and rest, and taking paracetamol according to the packet.”

Hxxx


A Miracle Migraine Machine?

Cefaly. No, it's not a village in Wales, nor is it a type of cheese (actually, it might be for all I know, but nevermind.) It is instead a new all singing, all dancing miracle cure for migraines, according to its manufacturers anyway. So, in our usual fashion, let's take a look at the evidence and see what on earth it is, and whether it is worth spending money on.

It's a medical headband device that you wear on your noggin, around your forehead. This means that you can easily pretend to be the Empress from the Never Ending Story. The downside is that you'll have to pay somewhere in the region of £250 to do so, plus electrodes and batteries. So, for that amount of money, you want to know that what you're getting is going to provide you with a bit more than simply cosplaying as a child-like film character.

 What I love about pictures like this is that it's always perfectly made-up women in them. As if anyone can be arsed to think about makeup when they're vomiting everywhere and their head feels like its being crushed. 

What I love about pictures like this is that it's always perfectly made-up women in them. As if anyone can be arsed to think about makeup when they're vomiting everywhere and their head feels like its being crushed. 


It is essentially a TENS machine, which applies an electric current to the middle of the forehead via self adhesive electrodes. Anyone who has ever used one of those godawful Slendertone thingies on their stomach is probably right now recoiling in horror at the idea of having to endure such torture right between their eyes- I know I am. But first I suppose we need to see if it works- after all, migraines are horrible things which can massively impact on the quality of life of sufferers. Those who are desperate may be quite happy to have their foreheads electrocuted.

Its been approved by the FDA, which is nice. What isn't quite so nice is the fact that this approval is based on one trial- the one and only trial in existence, despite what the manufacturers would have you believe.

This trial included 67 patients who suffered at least 2 migraine attacks per month. Although small, this trial is well designed, with an identical sham stimulator being used as a comparison to the test product. After three months of daily 20 minute usage, the mean number of migraine days in users of Cefaly was significantly reduced (6.94vs 4.88, p=0.023), but were not significantly changed in the sham group. But here's the thing: the difference between groups was not significant (p=0.054).

There was significantly higher percentage of responders (defined as ≥ 50% reduction in no of migraine days per month) in the Cefaly group compared to the sham group (38.24% vs 12.12%, p=0.023).

There was no significant difference in severity of migraine.

Although some of the results in this trial are encouraging, it is limited by its very small size. It is worth noting that the authors and manufacturers claim that this trial proves that the product is effective at preventing migraine, despite the lack of a significant between-group difference in the primary outcome of migraine days.
Other papers have been published in the literature regarding this product, and the manufacturers try their best on their website to make them look like they are real trials. However, these range from letters, conference abstracts, experiments in healthy adults, and case studies- not robust clinical trials.

An uncontrolled survey of 2313 Cefaly rental users found that roughly just over half of patients were satisfied with the treatment and would be willing to buy the device. The rest of the patients stopped therapy- that's a pretty high number of people. There are a number of methodological and confounding problems with this study, so the conclusions drawn from it should be considered unreliable.

Being a rental user is one thing- at least they were able to try it out before taking the plunge and handing over a rather large wad of cash. In the UK, though, it seems that the rental option isn't readily available. £250 is an awful lot of money to spend on a product, especially when, for roughly half of its purchasers, its going to be used a couple of times then lie in a cupboard, forlorn and forgotten about. 

Let's have a think about compliance. To get the best results, you are supposed to use it for 20 minutes per day. Now, initially that might not sound like too big a deal, but if you work, have a social life, go to the gym, or spend every waking minute building a house in Minecraft, finding 20 minutes a day for something that could be, in most cases, painful, is probably pretty unappealing, and impractical. I can't see too many people who will be able to religiously use this product exactly as intended in the long term. I'm guessing that in most cases its going to go the way of that bit of exercise equipment that you bought 5 years ago and that you've used twice and now only trip over on occasion.

So to summarise: there is a little bit of encouraging data, though it's not as compelling as the manufacturers would like us to think. It's extremely expensive, impractical, and probably pretty unpleasant to use. Its an interesting device, but one that I am placing firmly in the "Yet to be convinced by larger trials" pile.

Hxxx
 

The importance of a fluffy pen

Many years ago, in my pre-reg year, I was pulled into an office by my tutor and told that I needed to sober up. She didn't mean that in an alcohol sense, but instead that I needed to start being more serious, dour, and less quirky. She told me that my personality, as it was, wasn't right to be a professional.

At the time, I believed her. She told me that I would never make a good pharmacist if I carried on the way I was. I was terrified, as all I wanted to do with my life was to be a pharmacist. If I couldn't be a good one, then I would really need to change my personality.

All of this started because I had a Christmas pen. It played tinny music for an alarmingly long time when pressed, and it became a bit of a joke in the dispensary to sneak up behind me when I was working and set it off, making everyone dissolve into giggles. A dispensing assistant, who was wearing a Christmas tie, was also told off, and strongly advised to not wear it again.

But nowadays, I disagree heartily that you have to be serious to be professional. I think a little bit of well-placed silliness and a lot of humour can add to our professionalism.

We need to be approachable to patients. And what makes a person more approachable than a little bit of personality? Nothing, except perhaps a novelty pen. On a couple of occasions, women who have come to see me about the emergency hormonal contraception pill, and who have been very nervous, have ended up giggling at a ridiculously fluffy pink flamingo pen I used to have. It broke the ice, and they could see that I was a person just like them, and I wasn't going to sit there all business-suited and high and mighty at the other side of the table and judge them. They felt a lot more comfortable because of that pen, and I think I was able to help them a lot more as a result.

At the moment, I have a Special Pen in my desk drawer. It is comedically large, pink, and slightly phallic, with some floppy rubber spikes on the end. I like to take it out of my desk drawer and offer it up, straight-faced, when people ask to borrow a pen. 

 my special comedy pen, with a banana for scale

my special comedy pen, with a banana for scale

We health care professionals deal with a lot of dark stuff on a daily basis: sickness, death, disability, anger, frustration etc. We need to balance that darkness out with something lighter. Whether its doing something daft in the dispensary to make your staff laugh for a few seconds when times are stressful, or donning a fox mask and writing silly things on the internet, it all counts. 

As long as we put the patient first, we treat others with respect, and we work within our limits, true professionalism doesn't have to mean that we all walk about with serious faces.


Hxxx  

A comparison between medical and homeopathic information sources

Recently, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

Part of my research and preparation has been consulting homeopathic texts- materia medica and repertories that are still in use by modern homeopaths.

One thing that I have been repeatedly struck by is the stark differences in the quality of these information sources compared to those used in modern medicine. Let’s take a look at some of those differences.

Up To Date?

Part of my day job’s role is resource management. This means that I need to make sure that all of the resources that we use and have access to are present and up to date. Whenever I use a book as part of my work, I document which edition I have used. If I use a website, I make sure to include when it was last updated. When we get a new book in the office, I find the old copy and cover it in stickers saying “Out of date- do not use”.

I don’t do these things because I am weird, or because I enjoy it. I do it to ensure that I give the most accurate, up to date information so that the patient gets the best care. What we know about medicines is constantly evolving- new medicines, new safety information, and new evidence is emerging daily. What might have been correct to the best of our knowledge last year may now have been subsumed by more recent experiments, and so the information sources I use change accordingly. So, for example, I can reach for a copy of the British National Formulary from 2005, and find information that recommends sibutramine as a weight loss aid in certain patients. However, if I look at the current version, I won’t see it in there, as it has since been withdrawn for safety reasons. If I were to have used the 2005 copy to advise a patient, I might have given them the wrong advice, in the context of what we know today.

How up to date is the information used by homeopaths? According to The Homeopathic Pharmacy (Kayne, S. 2nd Edition, published in 2006 by Elsevier Churchill Livingstone, page 192- I did warn you about the documentation): ‘The most well known are Boericke’s Materia Medica with repertory and Kent’s Repertory of the Homeopathic Materia Medica’. Sadly, the author of this book doesn’t see fit to bother telling us when these were published. Neither does the online version of it, although there is a bit of a hint in that the “Preface to the ninth edition” on there is signed off by William Boericke in 1927.

Nineteen Twenty Seven. Medicine and healthcare is a pretty fast-paced industry, with new innovations and information coming out at an overwhelming rate. So much has happened in medicine since 1927 that there is no way that anyone should accept health care advice based on something written from that time. I know I certainly wouldn’t be too happy if my GP gave me health advice from a dusty tome, or if I went to the dentist’s to find them using equipment from the 1920’s.

Maybe Kent’s Repertory will be more up to date? A Quick look at the website gives us no clues. This time, the preface contains no date at all. The closest thing that we have to a publishing date is the fact that the website is copyright 1998, and appears to have been formatted by a default-font loving child in the early nineties.

Political Correctness

Over the years, medical terminology has changed and evolved along with society and scientific discoveries, and rightly so. In some cases, words that used to be considered as perfectly legitimate scientific terminology (such as ‘Mongol’, or ‘Mongoloid Idiocy’, used to describe a person with Down syndrome) are now considered downright offensive. Even whole swathes of what is now considered normal society (such as gay people) were once declared as illnesses- and of course we know better by now, or at least we should do, and if you don’t- grow the hell up, will you. We generally don’t refer to people as “hysterical”, or “insane” anymore, as we know a lot more about such conditions, so are able to categorise people more helpfully and professionally.

As a result, we healthcare professionals are very aware of how crucial the use of clear, concise, professional communication is, including the information in our resources. No self-respecting modern medical text would ever dream of using out-dated, offensive terms, and if it did, there would be an outcry.

Let’s have a look at the sort of thing that Boericke’s Repertory wants to help us to treat. There are things like “Brain-Fag”, “Cretinism”, “Masturbatic dementia”, “Fears of syphilis”, “hysteria”, “insanity”, “weak memory from sexual abuse”, “Haughty”, “Stupid”, and many others. These were just taken from the “Mind” section, but there are many other examples in the other sections too. These terms are just too outdated and are wholly inappropriate to be used in today’s society.

Having looked through various other Materia Medica entries too, I’ve found statements that are sexist, bigoted, and occasionally racist. Nice eh? You don’t find that sort of thing in an up-to-date copy of Martindale: The Complete Drug Reference.

Clarity

Good, modern medical resources are all about clarity. They need to be- after all if someone gives the wrong medical advice because they have interpreted something incorrectly, patients could be at risk.

Jargon is sometimes necessary, but nowadays medical jargon tends to use standardized, accepted terminology which keeps the risks of misinterpretation to a minimum.

Homeopathic repertories and material medica, on the other hand, are full of vague, odd terms which are massively open to interpretation. What, pray tell, is a “voluptuous, tingling female genitalia” when it is at home? (and I wonder whether Ann Summers offers free delivery on such a thing?). What does “expectoration, taste, herbaceous” mean clinically? How is one supposed to diagnose “Taedium vitae”? When would you class a person as “Obscene, amative”, and when would they be considered as merely “gay, frolicsome, hilarious”?

In Conclusion

Our health is arguably the most important asset that we have. Why would we entrust it to sources which are terribly out of date, inaccurate, and in some cases, offensive?

Homeopaths like to paint themselves as a caring, human alternative to the more business-like, clinical world of real health-care professionals. But when this alternative categorises people as being “stupid”, or “cretinous”, and is happy to use criminally out of date resources which can risk peoples’ health, I wonder just how caring and ethical it really can be.  

I've said this before, and I'll say it again: why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

 

The Ultimate Christmas album for the Existentially Wounded

"It's why, it's why we hang lights so high
and gaze at the glow of silver birches in the snow
Because of the dark, we see the beauty in the spark
We must be alright  if we could make up Christmas night"
-Tracey Thorn, Joy. 


Now, I'll admit that at this time of year, I can get rather annoying.

I love Christmas, I really do. I'm often to be found wearing antlers and tinsel. I put my decorations up at the first opportunity humanely possible, and start on the mince pies in September. This year, I excitedly bought myself a Lego advent calendar, despite the incredulity of the guy behind the counter in the shop. I also have snowman hoodie which yes, I shall wear out in public.

As a child-free, cynical, atheist adult, it might seem like this is a hard time of year to enjoy. And, to be honest, you're probably right. It would be a whole lot easier to throw in the towel and grumble about how commercial it all is, and how I just wish it was over and done with and everything can go back to normal. But I refuse to give into this, and put quite a bit of effort into maintaining my child-like delight at the festive season.

Obviously, its nothing to do with god. And don't get me wrong, I love the presents too (dear parents, if you are reading this, please do take note that I shall never be too old for Lego). But my desperation to enjoy this time of year runs somehow deeper than all that. I don't need to link it to religion, nor do I need to experience it through a child or partner. Christmas reminds me of my own, hard-won personality.

For me, it is about traditions. And these traditions, as they shift and change slightly each year, somehow reinforce my own self to me. Back in what now seems like a lifetime ago, my ex-husband and I took joy in forming new traditions together at this time of year. It was a way of reinforcing ourselves as a couple unit, of forging our own little family ways. Small things, like buying a new special decoration for the tree each year, came to mean a lot to us.

When my marriage broke down on Boxing Day 2010, I had to start again. Everything I had known up until that point fell apart, and my hopes and dreams, which I had been carrying like a shield all my life, shattered in a matter of hours. I had to begin again from scratch, and it was often the smallest of things that seemed to make all the difference to me.

The next year, my new, empty Christmas tree seemed somehow symbolic of how I had to start to collect some traditions of my very own. These traditions would belong to me, and me alone. I started picking up little decorations here and there, and now I have a rather lovely collection of bits and pieces to adorn my home with. And I've done the same with traditions: baking certain things at certain times, (including my beloved Christmas pie), drinking startlingly strong fruit wine in a particular pub on Christmas Eve with my friends, seeing Rare Exports at the cinema, taking part in a gingerbread contest, and many others. Some of us even go so far as to throw ourselves into the freezing North Sea on Boxing Day which not only washes away any vestiges of hangover cobwebs, but also distracts me from the awfully sad memories I would otherwise be thinking about.

Winter is a dark and often terrifying time for many of us. Dark mornings and dark nights make it easy for the sadness and emptiness to creep in. Getting home to a cold, dark, empty, one-bedroomed flat can start to feel like a failure. But then I pop on the tree lights, and I have something to focus on, some little pinpricks of hope that, in the end, the world is full of good people, and I will be able to spend some quality time with those who I love most- my friends and my family. And I will have an excuse to fill my flat with sparkly things, and wear glitter eyeliner.

Christmas is, to me, an acknowledgement that times will be dark and hard ahead, but that I will get through those times, with the help of those around me. It reminds me of how far I've come, and how proud I am of myself. It reminds me of all the good I have found in the world, of all the little bits of help I have gotten from the most unexpected sources, of all the new people I have met and the pride I have in my oldest friendships. If humankind has the presence of mind to plonk a huge celebration in the middle of the darkest season (even if they have done so on the pretence of a god I don't believe in), then that's fine by me, and I shall do my damnedest to make sure I embrace it with gusto.

I love the standard Christmas songs. I'll dance about to a bit of Slade with the best of them. But the saccharine jingle bells of most of the tunes you'll find on Now Thats What I Call The Ultimate Best Ever Christmas Tunes In World... Vol 3 don't seem to quite catch the nuances of the festive season for me. I've only come across a few songs which do, and I have collected them here for your auditory pleasure. I'm keen to know of more, so if you have any you would like to recommend, please do let me know, either in the comments, by email, or by tweeting me (@SparkleWildfire). What I would like to do is create a playlist of genuinely good, beautiful songs that evoke both the joy and the darkness of Christmas.

Joy by Tracey Thorn.
Tracey Thorn's (of Everything But The Girl fame) Christmas album Tinsel and Lights, which she released last year, was a total revelation to me. Its a gorgeous, calming album which hits just the right pitch of melancholy and joy for this time of year. I think this song says it all really.

Snowglobe by Dean Owens.
I saw Dean play at the Tyneside Cinema just before that fateful christmas of 2010. This is a lovely, sad little song about having depression or mental health issues over Christmas time. It serves as a reminder that mental health issues don't instantaneously resolve over the festive period, and that this time of enforced happiness can be extremely hard for many.

December Will Be Magic Again by Kate Bush
You may already know by now that I absolutely adore Kate Bush. Even the title of this song is poignant. This song has the same theme to me as Joy: its about using tradition to cover the darkness of the winter.

Winter by John Smith
This is simply the best, most beautiful song about the baby Jesus that I have ever heard. I first saw John play as support for John Martyn, and I have since seen him live several times and been reduced to tears by him. I absolutely adore his voice. I don't mind that this is a song about the nativity: to me it is a song about a story, and I just love how plaintively he sings that "I was there" line.

A Christmas Fable by The Selecter
I love a bit of ska. I've spent a full day agonising over which song to go for from this single. Then it occurs to me: its a double A-side, so I can legitimately have both. The songs are supposed to symbolise the light and dark sides of christmas, so they're pretty perfect for my playlist. Skank 'Til Christmas is all about letting your hair down when everything else in life has gone to shit (I love the references to the current financial situation), whilst a Christmas Fable is about a rather distressing family breakdown on Christmas day.

River by Madeleine Peyroux & K.D. Lang
A cover of this track also appears on the aforementioned Tinsel and Lights album. Thanks to the ever marvellous Ian Robinson (@eyeswideshut75) for suggesting it.

White Wine in the Sun by Tim Minchin
Thanks to Steve Haigh for reminding me of this. There's so much truth and humour in this gorgeous little tune, and it really sums up a good old family Christmas.

The Atheist Christmas Carol by Vienna Teng
This is just gorgeous.Thanks to Jackie (@Jackpot73- one of those new people so I am so thankful for having met this year) for

Silent Night/ 7 O'clock News by Simon and Garfunkel
Pretty self explanatory.

Love is All We've Got by Paul Fisher
I have loved Paul's music since the first time I saw him at a folk night when I was still underage drinking. I can remember being completely astounded by the noises that were coming out of this guy on the tiny stage upstairs in the Egypt Cottage pub. Turns out he has made a beautiful, gorgeous, poignant Christmas song this year which I will be listening to over and over.

Candle Song 3 by Mojave 3.

Tar Barrel in Dale by Rachel Unthank and the Winterset
Another one suggested by the lovely Jackie. A New Year's song about a Northumberland tradition. This year has been so cruel to so many of my friends and people I know, so I listen to this hoping that the new one brings those who I love some luck.

Hxxx

P.S. Here's my Sparkle Wildfire Top Festive Tip for the year: mulled wine liquid soap might seem like a good idea in the shop, but its really not. You end up smelling like a wino.

The Tale of the Pencil Woman

She used to visit us in waves. We wouldnt see her for a few weeks, then it would be up to three times a day, every day, for a week. First, it was pencils, so she became known as The Pencil Woman.

She would ask us each time if we sold pencils. We would reply that we didn't. She would smile a lovely, lopsided grin, and say oh yes she remembered now, silly her.

One day a rep came round, and in his catalogue we noticed some pencils. We ordered them in. 

She came in and asked for pencils. We told her that yes, we did have some in stock now. We sold her one, and off she went. 

She came back the next day, and asked if we sold pencils. We must have looked a bit confused, as we knew we had told her where they were yesterday.

 

"Oh yes, I remember now. I bought a pencil, but you see, its my son. He's an artist and he draws all the time, and he had ran out of pencils so I gave him mine. Now I need a pencil."

 

This started happening a lot. Always the same story. We laughed about it because we didn't know what else to do.

The next time we saw her was about three weeks later. She asked if we sold reading glasses. We showed her where they were, on the counter. She selected some, paid her 99p, and off she went. She came back the next day and asked if we sold glasses.

"Oh yes, I know I just bought some, but you see its my son. He needs glasses for when he is drawing, and he has taken my pair because he lost his. So now I need another pair. "

She would sometimes return just an hour later, and say exactly the same. She would come in when we were really busy with prescriptions, and sometimes we would be impatient with her.

One morning, we sold her a pink, flowery pair of glasses, joking that her son wouldn't want to steal those ones. She was back in for more in the afternoon. 

There were various other sundries that she cycled through.

Then one day she asked for aspirin. I asked her all the questions, and she Said she wasn't taking any other medicines etc. She said she just like to keep them in the house in case she got a headache. So I sold her them.

The next day she came in and asked for aspirin.

"Well its my son you see. He had a headache too (probably because he does so much drawing) so he took the pack of aspirin to  work with him so now I need one for me."

The same thing happened over and over again. I tried to question her more and more, but without accusing her of lying I couldn't get anywhere. I tried to have long chats with her, to find out her name, and who her doctor was. She told me she wasn't registered with a doctor and she didn't like going to see them.

I was worried. She was obviously forgetting that she had bought aspirin, and buying more. The son was a clever cover story, for the times when she could see the pity in our faces. One day, she came in for aspirin again and I saw a large bruise on her hand. She said she didn't know where it had come from, it just appeared one day. I asked her to promise me that she would see a doctor. She held my hand and said she would and how sweet I was.

If she was forgetting that she had bought the aspirin, was she forgetting when she had taken the aspirin. Was the bruising because she was bleeding because of taking too much aspirin?

I asked our delivery driver to ask around when he was out and about, to see if anyone knew her. We asked in the local shop and pub if anyone knew her name or address so I could look her up on our records and see who her doctor was. No luck. Everyone knew her, but no one knew her name.

One day, a woman came in with some medi-boxes that had been dispensed from another pharmacy. She said she had found them in her mum's house, but her mum had plenty of boxes, so could we dispose of them. I did so, and just happened to glance at what was in there. It was some Alzheimer's drugs. I didn't think anything else of it.

The same woman rang the pharmacy a few days later, to ask something about her health. She said she was feeling really run down, as she was finding it hard to work full time and look after her mother who had dementia. Something clicked, and I asked her to describe her mother to me. It might have sounded like an odd question to her, but she described the pencil woman. What happened next might have been a breach in confidentiality, but I told her about the aspirin, and the bruising, and how I had been worried about selling it. I figured yes, I had broken confidentiality, but the pencil woman was in danger if I didn't.

Her daughter told me the story. It started with tins of soup. She had cupboards and cupboards full. Then it was loaves of bread, which went mouldy, and the daughter had to clean out her whole kitchen. There were tears, and I had absolutely no idea what the right words to say were.

We still used to see her. When she came in to ask for aspirin, I told her that her daughter had been in to get her some and would see her later. I had agreed this line with her daughter. It was a little white lie that saved her from more embarrassment, and kept her a little safer.

I still think about her a lot, especially now my own Grandma is approaching the upper end of the moderate stage of Alzheimers. I think of all the times we were impatient, or didn't have time to stop and chat. I wonder what her story was, and what she had done when she was younger. I wonder about all the tales she might have had to tell, and how many of them are lost.

I wonder where she is now, if she is still alive. I wonder how her son and daughter are coping. 

I think of the embarrassment and terror in her eyes when she was telling us about how its her son, you see.

Today is Dementia Awareness Day. I think of The Pencil Woman.