toxicology

Vicks, Feet, and a whole load of nonsense.

Vicks Vaporub. It's a staple of our medicine cabinet, and we all reach for it at the first sign of sniffles. You may have seen (usually on a poorly made image posted on Facebook) or heard (from a friend who heard from their friend who heard from their aunt's sister's niece's dogsitter) that actually we've all be using it all wrong. 

It's logical to use Vaporub on your chest, pillow, in a steam inhalation. It makes sense, because the vapours will end up in or around your nostrils, which is where it acts. But no- according to this particular internet fraud, it is only by smearing our tootsies with it that we will get the full benefit. 

I'm going to pick apart the standard Facebook post, piece by piece, so you can see my thought processes and logical reasons why I don't believe a word. Even if you do think this works, stick with me and see whether or not you agree with any of my individual points, or if you can come up with a more robust argument for using it on your feet. 

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between."

 Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.

But I’ve never heard of this. And don’t laugh, it works 100% of the time

100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happened. If a medicine had been truly found to be 100% effective for anything, it would have been ground-breaking, world-changing news- probably not something that's just shared by your cousin on FB. 

 In the interests of research, I actually tried this when I had a troublesome post-infective cough. Needless to say, it did nothing to the frequency of my cough, so we've already disproved that number straight away. Whether or not it works, it most certainly does not work 100% of the time, and if that number isn't true, then why on earth should we believe anything else in this post?

...although the scientists who discovered it aren’t sure why.

 What scientists? What were their names? Where were they working? Where did they receive their funding from? Why aren't their details given? If they aren't sure, do they have any working theories? 

The lack of detail here is really telling. It really suggests that this is a whole load of hokum, especially given that a search (see below) shows no formal records of any "scientists" or research.

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks.

Ahh, feet. Feet really are a favourite for peddlers of quackery. I'm not sure why, but from reflexology to detox foot patches, the alt med world seems to be obsessed with them. Any time feet are suggested as therapy for anything going on elsewhere in the body, loud alarm bells start going off. 

The ironic thing is that feet are probably the worst place to apply any medicine. The skin on your feet is miles thicker that elsewhere. Absorption through the skin tends to be low and erratic at the best of times, but if you apply something onto your feet, the chances of absorbing anything useful from it are very low indeed. 

Additionally, your feet, when lying down, are very far away from your airways. The post requests that you put socks on over it. Therefore there is certainly no way that vapour could get to your airways in any clinically relevant amounts.

Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. 

Coughing fits are just that- fits. They're acute- you cough a lot for a little while, then stop, then it all starts again. A more chronic cough will still follow this pattern or stopping and starting. So yes, persistent, heavy deep coughing will usually stop- albeit temporarily- in probably much less than 5 minutes. If you're coughing for longer than that, it's likely you're going to be having severe problems breathing, and you'll need urgent medical care- you wouldn't really be thinking about smearing goo on your feet. You may find that you put Vicks on your feet and your coughing stops shortly after, but the likelihood is that the coughing would have stopped even if you hadn't. This is called regression to the mean, and its one reason why we can't rely on anecdotes for deciding whether a medicine works. We need to scale up and look at robust clinical trials instead.

Works 100% of the time and is more effective in children than even very strong prescription cough medicines. 

That 100% claim raises its improbable head again. To claim that something is more effective than other medicines would suggest the existence of comparative trials, which-spoiler alert- don't actually exist. This is rather a strawman anyway, as there are very few prescription cough medicines on the whole. Even conventional cough medicines don't really work to any great degree, and are based on very shakey evidence. It would be a very, very rare occasion indeed that a doctor would prescribe a cough medicine on prescription for a child. 

 In addition it is extremely soothing and comforting and they will sleep soundly.

I can see how that tingly, cold sort of feeling you get from menthol could be pleasant, though I don't think I'd go as far as to call it soothing. To be honest, you'd have to have perfectly soft skin on your feet to feel anything at all- when I tried it I didn't even feel a tiny tingle, especially since it was covered over with socks. 

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened.

What guy, and on which radio station? What qualifications does this guy have for making medical recommendations?  Who is even meant to be narrating this post? The only medicines now available for coughs in children in the UK are glycerol and simple linctus paediatric. Both of these essentially work on the basis of being sugary, slightly gloopy water. There's no "strong drugs" here, just some soothing "demulcents" that taste nice and are supposed to leave a soothing lining on the throat, making a cough feel less raw. They're mainly placebos. 

It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly.

 Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, all of this is irrelevant really, as no studies exist. These statements come from the head of an internet fraudster, rather than actually being grounded in reality. 

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it.

 We don't even know who is narrating this thing in the first place, let alone their wife. As I've explained above, this is an anecdote, and we can't derive anything from it. A person, who may or may not be mythical, had a cough, and it went away after they did a thing. It might have gone away anyway, we just can't tell. 

A warm blanket?  far from it. It actually just feels like you have some oily gunk on your feet. At best it might feel a little cold, but for most of us, it'll feel no different at all thanks to our thick skin. 

If you have grandchildren, pass this on. If you end up sick, try it yourself and you will be absolutely amazed at how it works!

Well that's just bizarre. Presumably you don't need to bother if you're simply a parent, only if you're a grandparent? What a load of nonsense. I wasn't left amazed, I was just left feeling a little silly. And I had minty-smelling feet.

So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working. 

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is: Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course ;)

Hxxx
 

How much of [insert drug name] do I need to take to kill myself?

I'm slightly obsessive over checking my blog stats, and I've noticed a trickle of people finding my site by using such terms as the above.

So, if you have found my site by searching for a similar phrase, I just wanted to say a few things to you. I'm not saying this in my capacity as a pharmacist, or skeptic, or anything like that, but just as a human. Don't worry, I won't keep you long. 

Firstly: I know and I understand.

Secondly: It feels like this will last forever, but it won't. Give it twenty minutes or half an hour, and in the meantime, please ring these people. No, really, please do. After all, in the grand scheme of things, a delay of a few minutes wont make a massive difference.
In the UK, the number is 08457909090. In the Republic of Ireland, its 1850609090. In the US its 1-800-273-8255. There will be similar numbers in other countries. 
If you  could just do that for me, that will be brilliant. 

Thirdly: I'm sorry, but you wont find that kind of information on this site. 

Fourthly: I care about people, and that means I care about you. If someone who has never met you at all cares about you, then its highly likely that some other people out there do too. I know that might not be enough, but it should count for something. I and many others don't want you to. 

Oceans of love, 


Hxxx


P.S. There is a lesson here for other bloggers/ website owners/ healthcare professionals too. Please be aware of what you are writing if you are covering anything about toxicology.

Don't worry 'bout the 'bute

So today's news (well, what news has managed to slip through the ridiculously large amount of attention Margaret Thatcher's death has been receiving) brings us the revelation that Asda's Smart Price corned beef contains phenylbutazone. I had sort of thought that the FSA's statement after the initial horsemeat scandal might have gone some way to assuage peoples' fear, but it would appear that the media are pretty hysterically reporting about it, and a small sampling of the general public (i.e. my mum) would suggest that people are still worried about it.

"The levels of bute that have previously been found in horse carcasses mean that a person would have to eat 500 - 600 one hundred per cent horsemeat burgers a day to get close to consuming a human's daily dose."-FSA

Let's have a think about phenylbutazone then. It's a member of a group of drugs called the non-steroidal anti-inflammatory drugs (NSAIDs), the same group as ibuprofen and aspirin. This is reassuring- its not some horrifically toxic chemotherapy agent, or poison, or anything like that. It's a painkiller, related to one of the most commonly used OTC painkillers. That's already looking reassuring. It used to be used in humans as a painkiller, but it was discontinued as it was superseded by other NSAIDs which have a better safety profile.

Whoah there, I hear you say in a panicked fashion. It was withdrawn for safety reasons? What safety reasons? ARE WE ALL GOING TO DIE BECAUSE OF CORNED BEEF? Well, in short: no. Yes, phenylbutazone can be associated with some nasty side effects, as can pretty much every drug going, but these are incredibly unlikely with small (I'll come onto how small later), acute doses from the occasional corned beef hash. Aplastic anemia, for example, is associated with long-term therapeutic use of the drug- usually after about a year. Likewise with leukemia, which has an even less clear association with phenylbutazone. I sincerely doubt that there will be many people who eat Asda Smart Price corned beef in large quantities every day for a year, and if there are, I suspect their heart may be more likely to give out than them suffering from any drug toxicity. 

Let's say though that you had eaten some. This doesn't necessarily mean that you will have ingested all of the drug. Drug companies invest quite a bit of money in their drug delivery systems: tablets, capsules, injections etc. There's a reason why corned beef isn't used commonly as a drug delivery system: there's no data on stability of drugs within it or its dissolution properties. For all we know, phenylbutazone may well be broken down if its stored in such a substance for any appreciable length of time. stability. When you take a tablet, you don't absorb all of the drug within it immediately. Some of it wont even get through your GI tract or into your blood stream. Some of it will tag onto blood proteins, whilst some might be converted into inactive metabolites by the liver. Only the free drug portion that remains will actually exert any effect. And in this case, the drug has had to go through all this process already in the horse before it even gets into you. 


All of this is by-the-by when you get down to looking at amounts.  If you eat 1kg of horsemeat containing the highest possible levels of phenylbutazone, the dose you would get in the worst case scenario is 0.0019 milligrams. Back in the days when it was used therapeutically, the dose given was 100mg every 4 hours.

The corned beef in question has been found to contain 1% horse DNA. Lets say that's all horsemeat. And lets say this horsemeat had the highest possible levels of phenylbutazone in it. 

If you ate an entire 340g tin, you'd  a)be fairly greedy or hungry and b) eating 3.4g horsemeat:

3.4g horsemeat= 0.0000019 milligrams phenylbutazone

Now, by my reckoning, that works out as having to eat 100,000,000 tins of Asda Smart Price Corned Beef to get the equivalent of two therapeutic doses (and its only half of the recommended loading dose). Even by Adam Richman's standards, that is a hell of a lot of corned beef. And remember, you'd have to eat that for approximately a year before you got any of the nasty side effects. 

So really, don't worry about the 'bute. The amount of salt in there is more likely to cause toxicity first.

Hxxx

Red Wine as a painkiller... In babies?!

A couple of years ago, I was working a locum shift in a supermarket pharmacy. It was quite late at night, and a man came up to the counter to ask me if I did circumcisions. I assumed I had heard incorrectly, but no. "I thought you would be able to do circumcisions, since you can do healthcare services and you have a private room" he said, pointing at the extremely small and flimsy consulting "room" and the end of the counter. I couldn't help but notice the small boy cowering behind him as I politely explained that no, circumcision certainly wasn't a pharmacy service.

At the time, I remember being amazed that it would occur to someone to take their child to a supermarket for what is a surgical procedure. Whilst it may be considered minor surgery, I'm sure to the young boy himself it didn't seem all that minor, and I'm pretty sure he wouldn't be wanting a pharmacist to do it in the middle of a supermarket with only some thin plastic walls between him and the vegetable aisle.

Anyway, I shall leave aside the ethics of circumcision for now, and consider a tweet I saw this morning by Andy Lewis. One particular Doctor, on his website, is advising pain relief options for babies who are about to be circumcised. He advises loading the child up on red wine as a preferred option. Now hold on here, this is a GMC registered Dr advising on giving babies alcohol. Whilst he doesn't give any information about how much wine to give, i'm assuming it would have to be enough to get the child at least slightly intoxicated to have any painkilling effect. A quick google search suggests the 8th day after birth is a usual time for the circumcision to take place, e.g:

"To give the baby sweet, red wine prior to the procedure. (Kiddush wine is ideal). This is very effective in calming the baby. Ideally it is given about 15 minutes before the circumcision and I will give it on arrival if you wish. You will need to provide the wine." (http://www.mohel-circumcision.co.uk/1298.html)

At this point, let us consult TOXbase.org, the database of the National Poisons Information Service (NPIS). They advise that any children under the age of 10 who are symptomatic due to an alcohol ingestion (i.e. intoxicated) are taken into hospital for medical assessment.

Why is it dangerous to advise wine as a painkiller in a child of this age? Well, alcohol in children can be very nasty. It can cause hypoglycaemia, particularly in children, and a seemingly well child can sometimes suddenly and quickly go downhill fast- that's why NPIS recommend that they are observed in hospital.

Such advice, coming from a trusted Doctor, is very concerning indeed. It appears from the website that he expects the baby to be "prepared" prior to his arrival, so he is expecting the parents to administer and provide the wine (whilst he says he can give it "if they wish", to me this implies that its more usual for the parents to give it). He gives no directions as to how much wine to give, which could be easily misinterpreted by worried parents. 

I  emailled the GMC to ask what their stance on such advice is. They eventually got back to me to tell me that it wasn't a concern as usually only a tiny amount is given. This doesn't seem like a very satisfying answer, given that either a) the child is given so little that they don't have effective pain relief or b) they're given enough to be toxic. 

The Paracetamol Paradox

I'll often bang on about how "natural" does not necessarily mean safe, and you'll often hear me muttering about how new drugs can be a cause for concern because of lack of safety data. Today, however, I want to talk about some problems with one of our oldest, most reliable friends in the drug world: paracetamol (acetaminophen to our US friends).

Paracetamol appears to have first been used clinically as far back as 1887. It's very widely used in the UK and is very easily accessbile: packs of 16 tablets are classed as GSL medicines, meaning they can be sold pretty much anywhere. Its accepted as a social norm: adults take paracetamol for headaches, and they give their children Calpol (a branded liquid paracetamol) at the first sign of illness. 

And herein lies my first point: its almost so widely available that I think people are starting to forget that it works. I've come across patients and friends who instantly dismiss paracetamol for their pain because "its not strong enough" or "it won't work, this headache's too bad". I'm starting to think that its dismissed offhand without trying it because its so well accepted its almost forgotten in the general public's mind that it is still a medicine, and one that works well. People are too quick to dismiss plain old paracetamol in favour of a shiny new combination product which costs more but works less well, or they're taken in by the promise of a "stronger" painkiller like co-codamol (with little evidence of benefit over paracetamol alone, but a whole lot more problems). Paracetamol has hardly any significant side effects, and it does actually work well for mild to moderate (and even some types of severe) pain, but many people won't even give it a chance. I'm interested to know what you guys think of this and whether or not you would agree that this is the case- do let me know by leaving a comment or tweeting me @SparkleWildfire. Do you think this yourself, or have friends that do? If you're a pharmacist or another healthcare professional, have you noticed a similar attitude? Or is it just me? 

More scary, though,  is my second point: Because people seem to be sort-of-forgetting its a medicine, they are forgetting that it can be dangerous. Horrifically so, in actual fact. Whilst it has few side effects with normal, recommended use, it's horribly toxic in overdose.

Overdose? Lets have a think about that word. It immediately brings to mind suicide attempts, right? So that wouldn't apply to most people, right? Very much wrong. In the last few weeks and months (it being the cold season and all), I've noticed a few of my friends on social media rather jokingly saying things like how they've taken a few extra doses of paracetamol, or they're taking lots of Lemsips because they like the taste, or they're combining a branded cold and flu product with paracetamol tablets, and I've felt the need to intervene and ask them to be careful about the amounts that they are taking. Would they consider themselves to be taking "overdoses"? I fear not. I also don't think they're taking me seriously, to be honest, and I think they think "what's a few extra doses going to do, it's just paracetamol after all". What they don't realise is that this sort of therapeutic excess or staggered overdose scenario can be just as-if not more-serious than a classsic, acute self-harm attempt-type of overdose. And the sort of toxicity that happens is not pleasant, and ultimately, in the worst case scenario could mean a slow, painful death, or a liver transplant. The antidote to paracetamol poisoning (although its not always able to be used, particularly in these sorts of cases) isn't a walk in the park either. It's a lengthy course of an IV drug (in the UK, anyway) which could mean at least a few days hospital stay. 

Unfortunately, its easy to accidentally take too much paracetamol. There's so many branded products that require a fair amount of package-reading before you work out that they contain paracetamol.  I think its also easy for people to feel blase about the way they're using it, because if its available everywhere and its "just paracetamol" its safe to take more than is directed. Maybe people think taking extra paracetamol "proves" that their pain is more severe than other people's pain, who knows. I think many of us would agree that we've heard anecdotal reports of parents putting Calpol in babies' bottles, or leaving the bottle with a child to self-administer overnight, or giving their child Calpol "to make them sleep" (it would have no direct effects to promote sleep).It's just so pervasive that it's almost become like vitamins or a foodstuff in some peoples' mind, or so it would seem. 

Just because a drug is as old as the hills, and its safe in everyday use, and it works, doesn't mean that its innocuous and we can throw caution to the wind when we're using it and have as much as we like, whenever we like.

Why am I on about this? Well, part of my day job involves advising on management of poisoning cases, and as a result I see a lot of these types of cases. And it can be really sad and frustrating and sometimes scary to hear of how commonly this sort of thing happens, and the variety of reasons for it. 

So my point is: if you're taking paracetamol, please take no more than 4 grams per 24 hour period, and please check for other sources of paracetamol in cold remedies or other branded products first.

H xxx