Pharmacy

Pharmacies, pharmacies, everywhere.

"Phew, I tell you what, I can't move for pharmacies these days. They're everywhere I turn, and I can't walk down a street these days without tripping over multiple green crosses. Everywhere you go its pharmacy here, pharmacy there, pharmacies everywhere"- No-one, ever.

And yet, apparently there are too many of the blighters, according to some pharmacy leaders. About 3,000 too many, give or take. Funnily enough, I beg to differ. And here's why.

I have worked in two newly-opened pharmacies in my career. In each, I was inundated with customers wandering in and telling me how lucky they were to have a pharmacy in their area. In one, the residents of the local area had campaigned for years to get their own pharmacy. Within months, the pharmacy was busy and the delivery service was thriving- and this was in a very small pit village.

We weren't, however, busy enough to justify a second pharmacist. This meant that I-despite good, efficient staff- would have to work many a late night-for no extra pay or lieu time- just to keep my head above water. The pharmacy closed at 5.30pm. I was regularly there until 10.30pm on a Thursday night, dispensing and checking prescriptions to make sure we were clear for Friday morning so that we could get all the prescriptions done and delivered in time for the weekend. This was just to keep on top of the day to day dispensing and didn't take into account any of the routine business things I had to do, like writing SOPs, Business continuity plans, finances, etc etc etc as a pharmacy manager. The pharmacy opened at 9am. I would turn up at 7:30am (again, unpaid) to get the till float done, prescriptions counted etc before we opened.

Its not that my time management or organisation was bad. It was just the sheer volume of work that needed to be done. I got away lightly- one of my fellow pharmacists in a different branch was known to be still at work at 2am at least once a week, just to keep afloat.

This was a few years ago now, but I locum fairly regularly and I still see busy pharmacies, with staff working flat out to get their work done as efficiently as possible. Not that much seems to have changed. What I don't see is empty, quiet overstaffed pharmacies filled with bored staff who have nothing  to do.

One day, the managing director for the company came round, and had a go at me because I hadn't been doing enough Medicines Use Reviews (MURs). Now, I was initially enthusiastic and excited about MURs. I couldn't wait to sit down with patients and get my teeth into providing a good quality service.

But I just couldn't do it. I didn't have time to do as much training, preparation, and CPD as I wanted to, and as a result I was nervous of doing MURs. What didn't help was the fact that, throughout each one, a large part of my brain was taken up with worries about how many prescriptions were piling up in the dispensary, when I wanted to give the patient my full attention. Each 15-20 min slot I spent in the consultation room with a patient meant I was behind with prescriptions- and because most of mine were deliveries, this had a huge knock on effect on the delivery drivers, and ultimately, the patients, who would then ring up in a panic wondering why their medicines hadn't been delivered by the usual time, putting us even further behind schedule. Thus began a vicious circle, worsened by my own constant feeling that I was so thinly stretched I just wasn't able to do enough justice to every aspect of my work. I'm by no means a perfectionist, but I like to do things well, and the fact that I just didn't have the resources to do so constantly played on my mind.

I ended up frustrated at my own inadequacies and inability to get on top of the situation, stressed to breaking point, and incredibly disheartened. I'd even go so far as to admit that resentment started creeping in too. I know I'm not alone here, and suspect that the majority of community pharmacists have felt this way. 

MURs are just one example of a service of course. In the year and a bit I worked at that pharmacy, we started doing MURs, morning after pill, over 50 men's health checks, diabetes screening, a minor ailments scheme, smoking cessation schemes, and a weight management scheme, amongst others. I was desperately swimming against a tidal wave of more and more jobs to do in the same amount of time.

Each time I read a pharmacy magazine like Chemist + Druggist, there seems to be yet another call from yet another pharmacy body or the other for pharmacists to be involved in delivery of yet another service. And my heart sinks, because I wonder just how on earth this is supposed to fit in with all of the other jobs that need doing.

Now, I'll admit that I haven't read the Now or Never report from the Royal Pharmaceutical Society commission (on account of being a cash-strapped non-member pleb). Nor have I kept up to date with the response to it on social media, blogs etc (on account of a fairly severe bout of anxiety-induced apathy over the last few days). With that in mind, though it still seems to me that the following metaphorical conversation is going on:

Pharmacy leaders: "And, and, and, you would be really good at delivering all these new services, so you should start doing that."

Pharmacist (from underneath a large pile of prescriptions that need checking, in between phone calls, and being called to the counter to speak to patients): "Yeah, I probably would be good at that. And I would love to do it, if only I had time."

Pharmacy leaders: "Good, well that's settled then. We'll pay you less for dispensing, but because you'll be doing all these services that will definitely be okay because you'll make up the money elsewhere."

Pharmacist (desperately attempting to gulp from a cold cup of tea to avoid dehydration): "Erm, right. Sorry, I need to go and talk to a patient now hold on... right, sorry, I'm back, what were you saying again? oh hang on, that's the phone ringing, I'll just have to get that..."

Pharmacy leaders: "We're so pleased you're co-operating. Oh, and by the way, we've decided there's too many pharmacies, so we're going to close all the ones near you, so you'll be getting more prescriptions to do, and more customers."

Pharmacist: "hang on, whaa- yes Mrs Brown, your prescription will only be a couple more minutes"

Pharmacy leaders: "Great! so to summarise, that's more prescriptions, more customers, more services, less pay. See you later!" (flounces off)

Pharmacist: "What in the hell just happened?... No no, Mr Smith, its okay, I don't need to see your haemorrhoids again, thank you"

Strategic decisions and the bigger picture are all very well, but at the end of the day they are just words if the people at the front line aren't able to deliver the vision because they are already overloaded. To me, it feels like new ideas, new visions and new services are bandied about by the top level folk, but what they neglect to do is look at the minutiae and check how the "little people", the folk on the ground are doing and what they think about any changes.

The realities of life on the shop floor are, in my mind, not conducive to delivering the sorts of services that the profession is calling for, unless there is a huge overhaul in how pharmacies are staffed, funded, and managed. And given that, in these austere and pressured times, everything possible is being done to reduce costs, pare down staffing, and maximise profits, I just cannot see the sort of situation in which we can do all of these things to the best of our abilities well panning out in real life. Yes, great changes in the direction of the profession need to come from the top, but they also need to come from the pharmacists behind the counter in the little pharmacy in the tiny pit village too.

The only way that I would have been able to deliver MURs in my pharmacy to the standard and quality that I so desperately wanted to acheive would have been to have had a second pharmacist present. And the only way a second pharmacist would have been present was if they had been paid. And the only way the company would have paid for a second pharmacist would have been if they were absolutely, just short of gunpoint, forced to.

I'd like to suggest that before the profession starts excitedly waving its hands and shouting "ME ME ME!!" to every available service going, we take a step back and decide whether or not we can actually deliver it, given everything else we also have to do. That enthusiasm is great, but if we can't follow it up with actions, we will end up an all-talk and no substance sort of profession.

So, in summary: are there too many pharmacies? No, although there might be the odd street or village which has more than its fair share. To be honest its a moot point. What's a more important question is: "what can we do to support pharmacists and improve the quality of services in the pharmacies we've got?"

H xxx 

 

Stick a label on this...

Since before I began my career in pharmacy, there has been a drive to get pharmacists "out of the dispensary", in a bid to better utilise their medicines expertise with patients. This sounds great- we have unique clinical knowledge and skills that we have always wanted to use more to make sure medicines are used effectively, safely and efficiently.

For a patient to use a medicine effectively, they need to actually have it in their possession. There is no getting away from the fact that dispensing prescriptions remains a large part of the community pharmacy business model (leaving aside concerns about the contract and reimbursement etc for now). However, dispensing remains the frumpy friend of the drop dead gorgeous, charismatic clinical side of pharmacy. It seems that these days it is seen as repetitive drudgery: the smartie counting and label sticking that we hear so much about. It is, in short, a waste of pharmacists' time, and is something the profession as a whole seems to unquestioningly want to leave behind.

I believe, however, that it is pharmacy's unique selling point. Its only through dispensing that a prescriber's directions are translated into reality. We can prescribe and advise on the most efficient use of medicines imaginable, but if the patient doesn't physically have the right medicines and know how to use them, all of that is pointless.

Yes, there are ways to reduce the pharmacist's input in the dispensing process. There are robots, accredited checking technicians etc. But a prescription still needs to be clinically checked- and that requires the unique skills, knowledge, and abilities that only pharmacists have.

But lets say we step away from dispensing and move in a purely clinical direction. We sit in a room and do reviews of patient's medicines, answer queries, prescribe medicines, monitor and screen patients. Does this sound familiar to you? It sounds to me like the sort of thing a GP does. So, why do pharmacists exist? What do they add to the healthcare picture? Doubtless such pharmacists would be useful, but the profession would become more nebulous, the edges of our role more diluted and less defined.

In my eyes it is our practicality, our ability to supply essential medicines in a safe and effective way to patients that defines us as a separate profession. That, to me, doesn't have to just mean sticking labels on boxes, and doesn't mean that the profession has to be at a standstill. I just think that we need to stop putting ourselves down and accept and be proud of our role in supply. For years we have been declaring ourselves as able to provide new and more clinical services- and we can. But we need to make sure that we define and build on our niche to give us the solid foundations we need to start branching out.

We pharmacists are an interface. Our role is as go-between, and a bloody important role it is. We are go-between a patient and their GP or their consultant, or whoever. Or, we are a go-between the patient and complex medicines information- we can, crucially, convert difficult to understand evidence into patient friendly terms. We can explain what they read in the paper or on the internet, what the directions of a reducing dose are, help them to navigate through the overwhelming choice of medicines over the counter. We are a go-between the drug manufacturing plants and the patient's bathroom cabinet. And the thing that underpins this role is our accessibility. And the reason we are so accessible is because- wait for it- we dispense prescriptions.

If you ask me (not that anyone will), we need to stop thinking of dispensing as the poor relation and see it for just how useful it is.

Hxxx


 

Common Community Pharmacy Annoyances

It's funny how variable working in a community pharmacy can be. Nowadays, I locum here and there, and I tend to really enjoy it. I usually do evening shifts, so you have an hour or two of bedlam, followed by several hours of blissful calm and quiet, where you get to sort out all the outstanding things, do lots of other bits and pieces like checking owings, controlled drug stock levels, and cleaning. I usually also end up having bizarrely deep and meaningful conversations about life, love and philosophy with whoever I am working with. Usually when I leave a pharmacy it is as clean and tidy as possible, I've sorted out what I can, and have left notes for anything that I haven't been able to deal with fully.

I say all this because I lately did one of *those* locum shifts. The ones where it is constantly busy, no prescription is straightforward, the fax machine isn't working, and you seem to have to deal with every problem under the sun. On this particular locum shift, I think my colleagues and I encountered every single type of category of impolite customer possible in a 4 hour shift.

So, because the only way that we can cope with such things is to laugh about them, and because I fancy a self-indulgent rant, here is my compilation of the things in pharmacy that annoy me and that happened in that locum shift.

The Mythical Taxi

Some people do get a taxi to their local supermarket. I have done it myself. But it would appear that taxi companies must have an amazingly lucrative trade in ferrying people to and from pharmacies if the frequency of use of the phrase "Can you do it quickly please, I've got a taxi waiting" is anything to go by. These are not, as far as I am aware, magic words that will somehow warp the time-space continuum so that I am able to dispense and check a twenty item prescription in a mere matter of seconds. Whether or not you actually have a taxi waiting will simply mean that your prescription gets put in the queue in the same place it would have done anyway, and you will wait the same amount of time as you would have done anyway. Needless to say, I suspect that many of these taxis don't actually exist, but merely a tactic used by some people to attempt to "hurry their prescriptions along".

The Dry Chesty Cough

"What sort of a cough is it?" "Well, its a dry, chesty cough."
No, no it isn't. It's either dry or its chesty, its not both. And either way, there is little point buying anything for it given that there is no evidence that any cough medicines work.

The Evil Eyes

Glaring at me continuously for the entire time that I am dispensing your prescription will not in any way speed up my work, and in fact may have the opposite effect as I am more likely to lumber around in a sloth-like manner just to annoy.

"I Need To Be Somewhere"

At 6:05pm, a woman handed in her prescription of 4 items. At 6:07pm, having spent all of two minutes repeatedly sighing and tapping her feet, she asked to speak to the pharmacist. Off I went, leaving a prescription half-dispensed. She demanded to know how long her prescription was going to be (the one I left to go and speak to her), because she needed to be somewhere. I gave her an estimation, told her I was doing it now, then went off to complete it. She then asked to speak to me a further three times to find out how long it was going to be, each time meaning it would take a little longer. "But I need to be somewhere at 6:15!!" she told me each time. I handed her the prescription at 6:12pm, thanking her for her patience. She then proceeded to rant for several minutes about how long the prescription had taken and how it meant she was going to be late and she had to be somewhere at 6:15. She eventually stopped complaining at exactly 6.15, and I returned to the dispensary, whereupon I noticed out of the corner of my eye that she had taken the time to hang around to complain about how long it had taken her to get her prescription to some of her friends who she just happened to bump into in the shop. Goodness only knows what time she actually left.

Invading Privacy

If you have ever picked up a prescription from a pharmacy, you will have probably been asked to confirm your address. This is so that we can make sure that you actually get the correct prescription. This is not because we are evil assassins or because we want to sit in a bush outside your house and spy on you- we really don't- and you're address is written on the prescription so if we wanted to we could anyway. On this locum shift, however, we were accused of invading someone's privacy for asking for this information. "I don't need to give you that information!" he declared. The counter assistant advised him that this is a routine question to ensure that we give out the correct prescription. But this wasn't good enough, and he wanted to speak to someone in charge. Off I went into the breach. I told him that he could come into the consultation room to give us his address so no one could overhear, but this was "an inconvenience", apparently.

By this time, he was shouting and other people in the queue were staring at him.

Again, I advised that we routinely confirm the address to ensure that the correct prescription is given out.

He decided to prove that the prescription was his instead by giving out his name, date of birth, and by telling me every item that was on the script. Loudly. One of which was sildenafil (Viagra).

Magicking Up Medicine

Me: "I'm sorry, we don't have that item in stock. There is a manufacturing problem on it, so we can't get it from our suppliers"
Patient: "But I need it" 
Me (in head): "Oh I see. Well if you can hold on a few minutes, I'll just nip round the back into our large pharmaceutical manufacturing factory, dig out the raw materials, and whip you up a batch right now then" 
Me (in real-life): "I understand, but I'm really sorry, we can't get any in at the moment."
Patient: "But I need it."
Me: "Where is the nearest wall please, so that I can bash my head against it repeatedly?"

The Expert Customer

I'm advising a patient about how to manage their child's teething problems. Another customer waiting in the queue decides to chip in with "Those Nelsons Teetha sachets are really good." (Nelsons Teetha sachets are homeopathic, therefore contain nothing of use and have no pharmacological effect). From then on, I (and my many years of training and experience) might as well not exist, as nothing I say can steer the patient away from believing that Nelsons Teetha are simply THE best thing since sliced bread, and in her eyes I'm obviously a terrible pharmacist for not recommending them immediately.

Impatient Patient Questioning

You ask the patient all the usual questions. They're all answered with a loud sigh, vacant eyes, and a disinterested "yes" or "no" at all the bits that they think are right. I could be asking anything, and I'd get the same response. So sometimes, I like to mix it up a bit and throw in a question they're not expecting. If its something like Nytol or a codeine containing medicine, I'll ask "Do you take it regularly?" to which the response is usually a bored yes. In which case, I advise them that I can't sell them any, then swiftly duck for cover when they inevitably throw things at me.

A variant You ask the patient if they are taking any other medications, to which they sigh and say "no". It's only when they're about to hand over their money that they a) ask what would happen if they were taking medicines, then confess, or b) whip out an inhaler and proceed to take a couple of puffs right in front of you after they have just told you that they don't have asthma or COPD.

Specifics

The patient can inexplicably only take one or two brands of generics for a product. You are, of course, expected to telepathically know this and dispense the right one, and woe betide anyone who doesn't. Now, I am entirely understanding of cases where a patient has specific requirements for one type of product- maybe an allergy to an excipient, say. But when there is not reason for it, and the patient is shouting at you for not giving them "the right medicine" despite them at no point telling you what "the right" one is, then I tend to feel a bit put out.

Mobile Misery

Now I am known for being attached to my mobile phone. However, one of the most annoying things when working in retail is having to deal with customers who refuse to hang up theirs whilst you are trying to have a conversation with them. Over a pharmacy counter, we often need to give detailed counselling, and of course we need to ask a lot of questions. I can't really do that if you are also listening to so-and-so discussing who was drunkest down the pub the other night. At this particular locum shift, I had to attempt to explain that there was an item owing on a prescription to a chap who was having just such a conversation. The icing on the cake was when he said to his phone-based friend "Hang on, I can't hear you, this stupid woman keeps talking about something and wont give me my prescription". Needless to say, despite me explaining the owing and handing him an owing slip, he returned a few minutes later demanding to know where the missing item was. This "stupid woman" then had to patiently and politely re-explain everything I had already told him.

How do I deal with situations like this? Politely, professionally, and with a smile on my face. I might have a bit of a rant and a laugh about it later in the back of the pharmacy, but outwardly in these situations I remain as calm as possible and attempt to be as helpful as I can. I've had many years of practice. The worst thing about this shift was that I was working with a new counter assistant and a newly qualified pharmacist, and I could see their morale slipping minute by minute. Their shoulders slumped, their smiles became more forced, and I found myself desperately trying to reassure them that this is just how some days go. Of course, we pharmacy types do make mistakes on occasion, and inconveniences do happen. I can understand that, when it comes to health, people can be scared and anxious, and that can come across as aggression. It is my firm belief, however, that a little bit of kindness and manners get you everywhere, and I am always much more likely to respond positively to calm and polite customers than those who default to outright rudeness, although I will do what I can to ensure that I help them all.

Hxxx

 

Pills, Thrills & Methadone Spills 2: Book review

Community pharmacy can be a pretty lonely career at times. It can be a horrendously stressful and pressured environment to work in. It can also be hysterically funny, and those times often make the rest of it worthwhile. In a workplace that is ultimately centred around illness, the pinpricks of hilarity become all the more important.

Its good, then, that someone decided to make a book of all those funny moments that happen in the average pharmacy day. Its even better when they decide to do so twice. Enter the second instalment of Pills, Thrills and Methadone Spills by fellow anonymous pharmacist Mr Dispenser.


Those of us pharmacy types who use (for which read obsessively depend on) Twitter or who read any pharmacy magazines will no doubt be aware of Mr Dispenser, who is a regular day-brightener with his wit and humour. 

Partly constructed of tweets, part blog-anthology, this is a warm and good natured collection of anecdotes. All but the most curmudgeonly of pharmacists will find themselves laughing out loud, and there will certainly be many moments of recognition in there too. You find yourself thinking 'oh I've got one of those stories too'.

Its a nicely inclusive format, which I think in its own little way helps to address the isolation of the job.  If you look closely enough, you'll even find a couple of pearls of wisdom from yours truly, which is nice. Its like sitting in a pub with a big group of other pharmacists and having a good old chortle about the daft things you encounter everyday. You're left feeling much cheerier about your lot, and with a nice sociable glow. to a non-pharmacy eye, some parts may be slightly close to the bone, but I think that from within the profession its clear that it is meant affectionately.

There is, however, a bit of a disappointing #everydaysexism moment later on in the book in 'Gender Bender'. Given that I write this whilst an unfinished blog post about how harmful portrayals of women can be sits in my blogger account, this is me courteously reminding Mr Dispenser that all women do not merely discuss hair and nails and read Hello magazine, nor do they all coo over babies whilst men leer at sports cars and read Top Gear magazine (Which, by the way, I used to have a wardrobe full of. despite having no driving license). So less of the stereotyping, please, and we will all get along fine at this year's Pharmacy Show

Now lets address the font. Very attentive readers of this blog will know that there is one font that I consider to be an abomination against mankind. Comic sans  is not big, its not clever, and its certainly not jaunty. It doesn't make me think "ooh, a light-hearted and humourous piece of writing!", but rather makes me stabby. There's is nothing wrong with good old arial, and the writing in this book is funny and clever enough on its own without having to resort to comic bloody sans.

Hxxx

DISCLAIMER: This book isn't actually due out yet for 8 weeks or so and may be subject to font changes and editing. If this occurs, I'm going to leave this post as it is, as a testament and reminder of how I can occasionally have some influence. Also possibly because I will be too lazy to amend it.   

You can also find this post- and a whole variety of mine and many other lovely people's book reviews over at Backlight, my collaborative book review blog for busy people.

To self-monitor blood glucose, or not?

Today's news greets us with a story about "rationing" of diabetes glucose test strips. Diabetes UK, in a survey of about 2,200 people, found that 39% of people with diabetes have had their prescriptions refused or restricted. Meanwhile, politicians are wading in stating that restrictions are unacceptable. 

Now, this sounds bad. But when you start applying some skeptical principles to this area, it all becomes slightly less clear. Here are some brief points to consider about self monitoring of blood glucose (SMBG) to put today's news into context:
 

Test strips are expensive. 

Spending on test strips in the UK is pretty high, and has been rising year on year since 2008. In 2010/2011, a whopping £158.4 million was spent on testing in England alone. These things are expensive, and a lot of them are being prescribed. Historically, they have been over-prescribed, and this has been a priority area for the NHS to attempt to prescribe more rationally. (NB: rationally does not necessarily mean rationing, it just means using resources more effectively.)

The UK Guidelines are clear that SMBG has an established place in the management of diabetes controlled by insulin, whether this is type one or type two. Its also accepted in the guidelines that it is useful for patients with type 2 diabetes who are at risk of hypoglycaemia. Reports such as this one from the NHS Diabetes Working Group are also clear that rationing should not be undertaken in patients who are deriving benefit from SMBG. 
 

SMBG doesn't actually do anything to control diabetes.

 It isn't an intervention, it's a testing tool. The only way it can have a positive impact on diabetes treatment is if the results are used to guide treatment or behavioural choices. So its useful for insulin dosing, for example, as it is variable and needs to be responsive to what you have eaten that day. However, if you take a twice daily dose of metformin 500mg, say, SMBG isn't going to really help anything. I think this point isn't quite as clear as it should be to some patients, carers, and even healthcare professionals.  

It only gives you a result for one pinpoint in time. It doesn't tell you anything at all about more long term control. This limits how useful it is in assessing lifestyle changes, such as exercise and longer term changes in diet.


Studies have found that some patients are not using SMBG to guide treatment changes or choices

...so they are essentially testing for no gain at all. If this is the case, then it is clear that the SMBG can be discontinued with no impact on the patient's overall care- in fact its an all-round win situation, as the NHS saves some cash and the patient no longer has to bother doing a painful test.

Its not a no risk option. Apart from the obvious discomfort of testing, there is some (although limited) evidence that some patients can feel more depressed, anxious, and even obsessive if they are using SMBG.
 

The evidence that SMBG works is very limited, 

and is confounded by lots of different factors. You can find more detailed information on the evidence base in this Medicines Q&A. The technology of SMBG was welcomed with open arms by patients and healthcare professionals alike, and it was widely accepted before there was robust evidence that it worked to improve outcomes. In these sorts of situations, where people are used to using a technology or drug etc, it becomes quite difficult to start being rational about it, without people feeling that they are having something taken away from them. If you really want to have a good look at the evidence, you can have a look at this Health Technology Asessment by Clar et al. It's only 156 pages long (!) but it is a really good quality summary of the evidence. 
 

The evidence that SMBG is cost effective is even more limited.

We simply don't know if it represents good value for money for the NHS. Meanwhile, there are interventions which we do know are cost-effective. So doesn't it make sense to limit spending on the unknown, and to put funds into the interventions that we know work instead?

Its a real shame if these sorts of issues have been ignored in favour of rationing. Rationing test strips for patients who are insulin treated isn't rational prescribing, its just daft. But there is a serious issue of overuse and over dependence on SMBG, which blanket rationing makes more difficult to address. The UK guidance makes a lot of sense given the state of the evidence we have access to at the moment, and I would be very sorry to see it being misused in some patients, whilst others are fruitlessly undertaking a needless task at a potential cost to their quality of life and the NHS. 

Hxxx

Water in a can now available on prescription. No, really.

No, its not a homeopathic sort of magic water this time, but instead Magicool.

Yep, remember when there were cheesy adverts on the TV all the time advertising this breakthrough, world's first spray? The website for Magicool even goes so far as to call it "heaven-sent". What in it? Well, water it would seem. I can't find any of the other ingredients listed on the website, save for a rambling explanation of how they still manage to get away with putting fragrance into it whilst claiming that it is an "unscented" product. Presumably it will have some sort of propellant in it too.


The theory is simple, and to be honest pretty good. When its warm, water on your skin evaporates, drawing out the heat. You feel cooler. So that's good. But its fairly impractical to keep having a cold shower every two seconds if you're at work or out and about, so Magicool is a nice portable option. Fine so far. 

However, Magicool have decided to go one step further, and start making medical claims with their Magicool Plus range. They're classed as medical devices (sound familiar?) so don't need to go through the rigorous clinical trials that licensed medical lotions or potions have to. But they're now apparently available on prescription, so there must be some evidence that they work, right?

The Magicool website is frankly appalling. But what I'm looking for is a plausible mechanism of action for why their products work, and some good evidence that they do work. Let's have a lookie, shall we?

Kinetic pulses? anaesthetizing? Vital deep cell hydration? adjusting pH? Despite its claims to be unscented, I am smelling pseudoscience at work. And what is with the text speak?! I've had emails from Nigerian princes asking for my bank details so that they can send me millions of pounds that are better written than this supposedly medical resource.

The evidence section appears to be a badly scraped together list of links from places like Trip Advisor and Yahoo Answers, where people have vaguely mentioned in passing that the product worked. But, dear readers, as we know by now, testimonials and reviews certainly do not constitute robust medical evidence, especially when lots of them are merely spam adverts posted on forums etc, as they are here. Again, there's no indication of what the ingredients actually are, so I have no idea whether or not there is even any plausibility in the claims above and beyond the fact that it might make you feel a little bit cooler.

So, if the manufacturer's aren't being forthcoming with any evidence, let's turn to the medical literature. This is made difficult, of course, by fact that I have no idea what is in it, other than water. Searching for the brand name brings up nothing at all, so it would appear that there is a grand total of no evidence whatsoever that this stuff actually works more than ordinary Magicool, or a shower, or standing next to a fan. The manufacturers are claiming that the product has "maximum therapeutic efficacy" on the basis of thin air. 


According to Chemist and Druggist, the availability on prescription is coinciding with a large advertising campaign. This means two things:We'll have to sit through more daft adverts filled with smug thin people on holiday cooling themselves down despite not even looking remotely hot (where's the red face and frizzy hair, eh?!) and that some patients will inevitably rock up to their doctors and demand it on prescription. 

The cost price to the NHS is £5.77. That doesn't seem like its going to break the bank, but I don't care how small an amount it is, frankly. There is a finite pot of money in the NHS, and we need to use every single penny of it wisely. If £5.77 is being spent on water in a can, that £5.77 can no longer be used to pay for something life saving.

Hxxx 

Prescription exemptions and the bloody Mail on Sunday.

Today, I feel ranty. So ranty, in fact, that I can't even think of a clever title for this post.

Why? because the Mail on Sunday has riled me up with this story about how pharmacies are failing to check exemption statuses of patients. I have been weak, dear readers, and I have allowed the Mail to affect my emotions.

As a pharmacist, my job is to make sure that patients get the right medicines, can use them safely, and have all the information that they need. My ultimate goal is to make sure that my patients stay as healthy as they can for as long as they can, and to improve their quality of life.

My role is not as a fraud investigator, but as a healthcare professional. Its up to the patient to ensure that their exemption is correct and up to date, and its up to me to ask to see proof of exemption, and to train my staff to do likewise. So that's what I- and many, many other pharmacies- do, day in, day out.

What if a patient says they don't have any proof of exemption? I go right ahead and give them their prescription anyway. What am I supposed to do? Say no, sorry, you can't have this inhaler until you go home and get your exemption certificate and bring it back to me. And then what happens when the patient has an asthma attack on the way back to the pharmacy, and without their medication dies? Funnily enough, I suspect newspapers like the Mail on Sunday would just as gleefully report on my failure as a pharmacist to supply life- saving medicine to a patient, and how I was just being evil and money-grabbing instead of thinking about patient care. So we are literally damned if we do, and damned if we don't.

Of course, we can cross the box on the back of the prescription, which means that a small, random selection of prescriptions may be investigated. But this process is pretty murky, and the details of it are unclear to the majority of patients, pharmacists, and pharmacy staff. We get little to no feedback of any cases which are identified as fraud through this method, so it ends up seeming pretty pointless. You spend years and years of dutifully crossing the box, and you never see it making any difference. Perhaps if this process were clearer, and we could more clearly see some results from it, this would spur pharmacists on to continue with the box ticking exercise.

Ever tried to confront someone about the fact that they may be committing fraud? Ever tried to do so over a counter, when you're working on your own and have a queue of about twenty people behind the person you are accusing? A pharmacy is certainly not the correct place for such things to happen in- the personal security of the staff, the workload, and the potential for a patient to have to go without their medicines all mean that its practically something that we cannot do well, without a massive overhaul of staffing and how pharmacies are designed.

I suspect the reporters at the Mail on Sunday haven't ever had to stand on one side of a pharmacy counter whilst a patient asks which of their medicines is the most important because they can't afford to buy all of them. I have, and its heart breaking. Prescription medicines in the UK are £7.85 right now. We're currently in a time when Atos are merrily declaring- sometimes on very shaky grounds- that people who are crippled by a variety of medical and psychiatric problems are fit for work, and are stopping their benefits. There are people out there who cannot afford to pay £7.85 per prescription item, through no fault of their own, and these are the people who are likely to be taking a variety of different medicines. Do I therefore withhold their prescription, or tell them which is the most important drug for them to take and send them off on their way with a sub-therapeutic drug regime that is going to make them even less able to work and find means of paying for their medicines? I can't imagine the hurt and shame that a patient must have to go through to admit that they can't afford their medicines, but I know I don't want to have to put an already unwell patient through that.

I've had a friend worry how he was going to pay for his prescriptions because of problems with his benefits, problems that he had no control over and were to do with mistakes at Atos. Do you know what I told him? Go to your usual pharmacy, tick the box, and don't say anything. I know that's wrong, but given the options: he becomes very unwell vs a small risk he gets a fine of £100 at a later date when he would hopefully be able to pay it, I'm sorry dear readers, but I'm always going to opt for the former. That may be, as the Mail so charmingly puts it "scandalously careless" of me, but it doesn't feel like it. It feels like I am caring for my friend's health, and that's my job, and my personality. What would feel "scandalously careless" would be to force someone with no income through no fault of their own to choose between food or essential drugs. 

Forgive me if I would rather give patients their drugs and keep them as healthy as I can. Do forgive me if I put the quality of my patients' lives ahead of the fear of prescription fraud, which I can do very little about anyway.

This whole system of exemptions and payment is outdated and needs an overhaul. In the meantime, branding pharmacists as lazy debt collectors and desperate patients as robbing prescription cheats doesn't help. As a healthcare professional, my need to provide vital medicines to my patients transcends petty demonisation by a scaremongering newspaper. 

Here's an extract of the Mail on Sunday's report:

 

"Dr Clare Gerada, chairman of the Royal College of GPs, called for a ‘fundamental review of prescriptions’. But a spokesman for the Royal College of Pharmacists said it was ‘not their job to police the Government’s prescription exemption system’, adding: ‘Guidance is very clear that pharmacists must put the clinical needs of a patient first, and not deny someone access to lifesaving medicines because they haven’t got proof of exemption."

Interesting, really, given that the "Royal College of Pharmacists" doesn't actually exist. This is lazy, crappy reporting, if they don't even bother to get the Royal Pharmaceutical Society's name right. You can read how the RPS have responded to this article here. Its a perfectly reasonable response, and in my opinion reflects what actually happens in daily practice.

Hxxx

Customer walks into a pharmacy...

...and chooses what medicine they want to buy, before taking it to the pharmacy counter. Yes, that's right folks, instead of telling a daft joke, I'm going to witter on yet again about the self-selection of P-meds. This time I want to think about it from a patient's perspective. Some of these considerations may seem small and petty, but i just want to put my thoughts down on virtual paper and you can see what you think.

When I walk into a shop, I can be pretty easily intimidated. I'm shy, and I don't like to bother people. I also hate that uncomfortable feeling when you walk into a shop and you feel like you're being watched by someone and then you feel terrible about not buying something. I can get anxious about the smallest of things, in particular not quite knowing what you're supposed to do in a shop- if I can't find the til, or there's an empty box and i don't know who to ask, or if I can't find something, for example.Of course this is worse when I am feeling a bit poorly and I can be particularly skittish- im likely to go home without buying anything, even if i need it, because i can't be bothered to have to work out what I'm supposed to do. This brings me onto my first point about self selection

1. It could be different everywhere.

 Not all pharmacies will take up the self-selection option, so I'll need to ask at the counter as i am used to. But in some pharmacies, the packs may be out on the shelves, whilst in others, they might be in security packs or might be empty packs that I need to take to the counter, like an early nineties video rental shop. It sounds daft, but this sort of thing could be quite off-putting.
 

2. How the hell am I supposed to know what to buy?

 I tend to acknowledge people who know more than I do about a subject and listen to their opinion. If I go to the hairdressers, for example I tend to ask them what style they think would best suit my hair type and face. After all, they've done some training in cutting hair whilst I am utterly clueless about it. If I walk into a pharmacy, therefore I don't expect to have to do all the hard work of product selection myself. My product selection process for most things usually goes like this:

Its either that, or I stand around reading every single box of every single product. This would take me bloody ages, and would be pretty inconvenient.

3. What If Its The Wrong Thing?

 After I have found the shiniest product, I take it to the counter, where I am then told that I've picked up the wrong thing and I'm not allowed to buy it. This, frankly, pisses me off and adds even more inconvenience o the whole affair. I've chosen the product, and now some jobsworth glorified shop assistant is saying that I've chosen the wrong thing? how dare they! (I've lost count of the number of times I've been called a glorified shop assistant by patients-and on occasion non-pharmacist managers over the years, by the way). You know like when you're in a hurry, and you've picked something up in a shop and you take it to the counter, and they tell you that its on buy one get one free, but there is a huge queue behind and you're going to be late for your train so you just say "oh its fine, I'll just take that one". I suspect that would end up happening quite a bit as well.

4. Advice Isn't Quite So Forthcoming.

 When I ask for a specific product in a pharmacy, the counselling and advice I am given tends to be minimal (if at all), whereas if I ask what they would recommend for a particualr symptom (not that I usually have to bother doing that myself, but you know), I tend to be given fuller, more rounded advice as part of the product selection process- I've written about this before. If I want to know something about a product, I have to ask about it, and I might feel a bit stupid doing that when I'm supposed to have picked the product myself. In addition, I might not actually know that I need to ask for advice unless it is offered. With self-selection, I fear that offering routine advice would become the exception rather than the norm, and instead of being proactive in giving advice, we would instead get into a pattern of waiting to be asked.

5. Medicines Are Commodities And Its My Right To Buy Them.

 I've written before about the paracetamol problem- its so widely available that people think its safe and innocuous, and they can take extra or dismiss it because they've sort of forgotten that its a medicine. I think this may become a wider problem. If medicines are available on the shop floor for me to handle and choose myself, I assume that they're either not very good medicines, or they are so safe that I can use them how *I* like. If I want to take three times the amount of antihistamines that it says on the pack, then I can do, just like how if I want to eat peanut butter out of  a jar with a tablespoon then I should be allowed to, because its my choice to buy it and who is anyone else to judge me and tell me otherwise? this is going to be particularly problematic with codeine-containing medicines and similar.

Anyway, those are a few thoughts for now. I may add to them as time goes on. What do you think?

Hxxx 

When Z-day comes, Think Pharmacy

A little while ago, it occurred to me that I hadn't watched many zombie films in my life. I therefore made it a bit of a project to watch a whole load of them. I got myself a mentor (my friend Frankie) and together we perfected the art of walking back from the cinema in a zombie fashion whilst giggling hysterically.

 

I've watched good zombie films, bizarre zombie films, Christmas zombie films, thoughtful zombie films, and absolutely terrible zombie films starring Billy Connelly. So I sort of know the ropes when it comes to the genre. On the advice of Nancy, I started listening to the We're Alive podcast, and now extol the virtues of it to any who will listen. Although I dont recommend listening to The Archers right after it, as you find yourself waiting for zombies to jump out and ruin the Ambridge flower festival.

 

So I've just gotten back from World War Z. It was better than expected, and it managed to squeeze more entertainment than I thought may be possible out of a lab in Wales and Peter Capaldi wearing a jumper. Although I may be biased as I do have a bit of  a thing for Peter Capaldi (and Brad Pitt), so I was happy enough as soon as he arrived on screen. All that was missing was Hugh Laurie. And a better ending. And more gore. And less CGI. And less not realising that with a pen and paper and the camera he could easily get the people in the know to tell him which vial to choose. And wouldn't there be an intercom in a WHO lab with infectious diseases in it anyway?!

 

Anyway, I digress. Aside from all the problems with the film that no one else would probably notice, I did note one shining light in all of the z-day carnage. Brad Pitt, like any good citizen should, Thinks Pharmacy. In need of an emergency supply of a salbutamol inhaler, off he goes to the local, friendly community pharmacy.


I don't think this is much of a spoiler, given apparently pretty much the whole film is in the trailer, but after barging into the supermarket pharmacy (probably unlikely: in real life he would have just coughed loudly and shouted "shop!") he is greeted by a friendly professional, white coated  pharmacist who offers him an NMS consultation. Okay, maybe not. He's wearing  hoody and carrying a gun, but, ever the professional, still manages to give some health advice when handing over three inhalers. "Children grow out of asthma" he says, helpfully, which may be true, but I think is unlikely to be the case by the time the  3 inhalers are used up.


He even link sales, passing over some bottles of what I presume to be paracetamol liquid too. How very helpful.


Its nice to see a pharmacist in a film or TV show doing something other than serial killing, murdering, nearly killing orphans with poison when drunk, or merrily doling out vicodin to Dr House without a prescription. Its nice to see a pharmacist resolutely doing what he can to help. It reminds me of all those stories you see in Chemist and Druggist, where there has been horrendous flooding but the pharmacy staff still manage to open up and do their deliveries in a makeshift canoe. The ones who, despite broken shutters or six foot deep snow or pandemic Ebola still turn up to make sure all the collections are done and the order is put away.


The pharmacist in question doesn't do any WWHAM questioning though. I'm not convinced Which? Would have been very happy with him.


Hxxx

Self Selecting P-meds: searching for the evidence

The other week, the lovely folks at The Pharmacy Show Community (they are really lovely, my flattery of them is nothing whatsoever to do with the fact that they are linking to and publishing bits of my blog) held a tweet chat all about the self-selection of P meds, led by the mysterious and always entertaining @MrDispenser.

There are a few concerns that I- and it seems many other pharmacists share about the self-selection of P-meds. I've covered some of my concerns here, but the tweet chat threw up many others too. Other pharmacists have also shared their concerns, and you can find some of them in the links below:

Right now I want to look at the evidence that self-selection works. The theory is that allowing patients to choose their own medicines leads to greater adherence. As the patient feels they have more ownership over their healthcare decisions, they might use the drugs more effectively for a better outcome. But is there any cold, hard evidence that this is the case when it comes to over the counter medicines? 

As a skeptic, the words "Where's the evidence?" are often found escaping from my mouth. Sometimes the need for evidence is countered by the risk averse pharmacist side of me, where the theoretical likelihood of a risk outweighs the need for evidence. As with all things in healthcare, a balance needs to be taken into account: what are the risks vs what are the benefits?  In this case of self selection, I can see there being a real risk of fatalities. Any evidence of benefit to patients needs to be robust in order to outweigh the risks, in my opinion.

So I've made a start by looking at Embase and Medline. I've also had a look at NHS Evidence and have even googled. And I've been able to find very, very little on the subject. I found one Dutch paper about self-selection in the pharmacy, but that has no abstract.

I found this World Self-Medication Industry website which states:

"A study done in the United Kingdom showed that consumers welcome the opportunity to self-select medicines in that country's pharmacy class. Three out of four of the British consumers in the study felt that re-configured pharmacies with easier access to non-prescription medicines was a good idea, half because it would save their own time or that of their doctor, and the remainder because it offered greater choice."

But this doesn't appear to be referenced, so I can't find the study to see how reliable it is.

Have I missed anything? If you're aware of any evidence for the efficacy of self-selection of P-meds, please do let me know by dropping me an e-mail at healthydoseofskepticism@gmail.com. I would be particularly interested in any evidence that could be provided by the GPhC, and might drop them a line to see what they have to say on the matter. 

In contrast, I stumbled across a study from New Zealand, which concludes that, when purchasing a pharmacy medicine for the first time, in 62.2% of cases the sale was influence by pharmacy staff. This study has its limitations of course, but if true (and from my personal experience of many years of community pharmacy work it would appear about right), it would seem a shame to eliminate this from the medicines buying experience. 

There is also some evidence that patients who approach the pharmacy counter with a specific product in mind are given poorer advice than those who ask for a recommendation based on their symptoms- again something I have experienced both as a pharmacist and a customer. 

Of course patients can still ask for the expertise of pharmacy staff, but how many of them will know to ask, and how many will simply pick the nearest thing and hope for the best?

I'm going to hopefully write another post about my concerns about how the patient experience will be affected. If you have any thoughts on this, again do get in touch. If you're a customer in a pharmacy, I would love to know whether you think self-selection of Over-The-Counter medicines would be good for you. 

Antidepressants in pregnancy

This morning BBC News are running with this rather terrifying looking story about the dangers of antidepressants in pregnancy. This is an area that I deal with pretty commonly, so I thought you may be interested in my assessment of the situation. 

First thing to note: things can go wrong in even a normal, healthy pregnancy. There is always a risk of malformations or miscarriage, and unfortunately these things can happen for reasons that we dont understand. The risks are usually low, but are increased by things like increased age, obesity, illnesses etc.

One of those illnesses can be uncontrolled depression. "But how can feeling a bit sad harm an unborn baby?" I hear you ask. Well firstly, depression can be a very serious illness which should be taken seriously. It may even be terminal. Pregnancy is a time of massive changes, and as a consequence is a high risk time where someone's mental health can destabilise. If you have depression, you may not be looking after yourself properly: you might not be eating well, you might be avoiding exercise etc. In the worst, most tragic cases, suicide attempts might happen. We don't have enough data to put figures on how much of an increase in risk this all adds up to, but we do know that it can increase risks in a pregnancy if not sufficiently controlled.

Of course, this doesn't even take into account the more nebulous risks to both the child and mother- how will having a depressed mum impact psychologically on the child, how will the bond be affected, and what are the long term effects of this?  

So what of the SSRIs, the most commonly used type of antidepressants in pregnancy? Looking at the risk of cardiac malformations,, the BBC article claims that:

"Currently, prescription guidelines for doctors only warn specifically against taking the SSRI, paroxetine, in early pregnancy."

 It used to be the case that we were aware of the possibility of a cardiac malformation risk with paroxetine. Up until, oh, about 2010, when a large review was published whichsuggested that the increase in risk, if it exists, may be a class effect. The UK Teratology Information Service's Guidance was changed accordingly to be more practical, to remove a heirachy of one particular SSRI, and to make the drug of choice that which is the best for the individual patient (please note that UKTIS are a service for healthcare professionals only, and pateints should not ring them directly). The fact that NICE guidelines haven't yet been updated probably says more about NICE's workload and update schedule than any evil big pharma cover up. 

As an aside, you will notice that there are a lot of words in this post which suggest uncertainty. That is because there is a lot of uncertainty in teratology: because we cant do large robust trials on pregnant women because of ethical concerns, we have to scrape together what we can and make the best of it. There are few certainties in this area.

Strange then, that the BBC are quoting a Prof Pilling from NICE:

"He says the risk of any baby being born with a heart defect is around two in 100; but the evidence suggests if the mother took an SSRI in early pregnancy that risk increases to around four in 100."

I'd love to know where these figures came from. The current status of data on the risks of SSRIs is pregnancy is as follows:

  • There is lots of data, which has had various statistical analysis methods applied to it. 

  • Some of this data suggests no increase in risk

  • Some of it suggests a small increase in risk.

So, with some data saying there isn't an increase and with some saying there is, it is virtually impossible to say for certain if there is an increase. The only thing we can say for certain at this point is that we can't say anything for certain. But given that we have lots of data, and SSRIs are commonly taken in pregnancy, I think we can say that if there is a large increase in risk, we would have known about it by now. So any increase in risk, if it is there, will be low.

Of course the BBC are reporting the relative risk, which sounds more impressive: a doubled risk sounds much more sensational than a small absolute risk. But I'm not even sure where this figure has come from, given the conflicting state of the evidence at the moment. Needless to say, research is oretty much constantly ongoing. 

All of this is a very long winded way of saying: we dont know at the moment. But the fact that we don't know, in the face of how commonly used these drugs are in pregnancy, could be seen as reassuring.

As with all things in healthcare, this is a balance. A balance between the risks of uncontrolled depression and destabilising a mother's mental health during pregnancy, compared with the -as yet unknown but likely to be small- risks of SSRI antidepressants. Of course some women with minor depression might be taking antidepressants unnecessarily, but in cases where it is required, we need to look at the bigger picture. Just focusing on a drug's teratogenic potential is not enough: we need to consider the teratogenic potential of the illness itself, and the impact on everyone's lives that might happen if treatment is withheld. 


The bottom line is, if women are thinking of becoming pregnant or are already pregnant whilst taking an SSRI, and they are worried, they shouldn't stop it of their own accord, but should make an appointment with their GP to have a discussion about their concerns. 

Hxxx

UPDATE: I've been thinking about this 4 in 100 figure for cardiac malformations, and last night tried to find the reference source from it.

I've tweeted @bbcpanorama asking to know where this figure has come from, as have a few others. I've also tweeted @shelleyjofre, the journalist who has mad ethe programme, and have been met with a stony silence. This is really unfortunate, given that to be able to deal effectively with any enquiries from patients relating to this programme, I -and all the other health care professionals dealing with worried mums to be- need to be able to see and appraise the evidence for ourselves.

I have managed to find this document from the MHRA, which does mention a 4 in 100 figure. However, I sincerely hope that this isn't the source in question, given that:

  • The document refers to paroxetine alone, not the whole class of SSRIs

  • There is no date on the document, meaning we have no way of knowing how up to date these figures are.

  • the 4 in 100 figure cited refers to the risk of ALL malformations, not just cardiac ones.

  • the risk cited for cardiac malformations is 2 in 100. Half that which the BBC and Professor Pilling are quoting.

  • The background risk of all malformations cited is 3 in 100, and the background rate of cardiac malformations is 1 in 100. So yes, the relative risk is doubled, but the overal risk remains very low. 

As I say, I really do hope that this isn't the source, and that @bbpanorama or @shelleyjofre are able to provide me with the reference soon.  

Needless to say, I never heard back.

 

Making Clinical Trials Sexy

If you're buying a new TV, how do you go about it? My guess is that you probably have a look around the shops or internet, find a model you like, then get online to find some reviews of it and decide whether or not to buy based on what you've read. You may well scroll down to the reviews if you're buying something on Amazon, before you click the "Buy" button. If you book a holiday, you're probably straight on Trip Advisor to see what other people- humans just like yourself- have got to say about the hotel.

It is perfectly reasonable behaviour. We understand and respond to the personal experiences of other people- its part of our nature, stitched into our being. Each review is a little story, and humans love stories, especially when they are about other humans.

Its therefore a hugely unfortunate problem that, when it comes to healthcare, stories just aren't good enough. When peoples' lives are hanging in the balance, reviews and testimonials just aren't up to scratch. Here's why:

I have guttate psoriasis. Imagine I go on holiday (alas this is merely a pipedream this year, thanks to what feels like millions of large unexpected bills that seem to keep turning up in my life) and lo and behold, when I return, my psoriasis has cleared up. I conclude that it is definitely the sunshine that has cured it, and proceed to proclaim that I have found the ultimate 100% effective cure for psoriasis.

Is it reasonable that I have come to that conclusion, based only on my own experience? No, not at all. Why have I focused on the sunshine aspect alone? Maybe a week spent relaxing is what has actually cured it. Maybe its because I've changed my diet on holiday and have been eating lots of lovely fresh fruit and vegetables and fish?  Maybe it is because there is a magic ingredient in Sangria which miraculously beats rogue skin cells into submission. What if chlorine in swimming pool water is my skin superhero? Maybe-just maybe- its because guttate psoriasis can be self-limiting, and it has just faded away of its own accord. With just my experience to go on, there is no way I will ever be able to know what it is that has made my condition improve.

What I would need to do to be able to decide is to scale things up. Get as many people as possible with guttate psoriasis, and divide them into at least two groups- one exposed to sunlight, one not. I'd have to try to control the peoples' behaviour as best as I could for the other factors like diet, chlorine exposure, sangria intake, stress etc. Whilst I could never completely control for everything, if the group exposed to sunshine experience a significantly better improvement in their psoriasis, then I could say with more certainty that it is the sunshine that did it rather than anything else.

This is the beauty and elegance of a clinical trial. They are simply the best, slickest, most reliable way we have of teasing out whether a treatment actually does make a difference. They're like an anthology of stories, carefully selected and analysed by researchers in a bid to start finding an answer to a treatment question. Whilst they're not 100% perfect, they're certainly the best sort of information we have at the moment on which to base any decisions about which treatment to choose for which disease, and for which patient.

This is, however, very easy to forget when you actually have to read one. I do not have a mathematically inclined brain, and when faced with tables full of numbers, p values, confidence intervals, hazard ratios, relative and absolute risks etc, my grey matter is usually to be found quivering and wimpering in the corner of my skull. I have to really try hard to focus on the stats and results when reading a clinical trial- its a constant fight to wrench my thoughts back onto the page, when they keep merrily skipping away to think about kittens or bunnies or *that* picture of a minipig wearing red wellies. And I say this as a geeky pharmacist who has undertaken a decent amount of training in how to read a clinical trial. What hope then, does an individual patient or regular joe have of understanding trial data?

A quick glance at pretty much any website selling an 'alternative medicine' and you'll notice there is usually a "Testimonials" page on there. Many other types of healthcare sites also use testimonials to prove their treatment works. They're easy to read, often full of personality, and can really seem to speak to you as a reader. They may seem convincing, but as you've (hopefully) seen from my example above, they simply can't be used to decide if a product works or not. A glossy celebrity story endorsing a product in a magazine is infinitely more sexy than ten pages full of stats and graphs in a medical journal.

Testimonials and reviews are, at first glance, more attractive and more seductive than the more dowdy clinical trial. So what can we do to help the clinical trial apply a bit of lippy, spray some perfume on itself, and don its heels to get out on the town and make people weak at the knees? My short answer is I don't know. Campaigns like International Clinical Trials Day help of course, but at the moment it feels like we're swimming against the tide somewhat. My ultimate dream would be a primetime TV series, fronted by a hunky Brian Cox type. If he can make physics sexy enough to be at the forefront of our entertainment, surely there is some way that we can do the same for one of the best inventions in healthcare? I'd like to get to a place were it's second nature for everyone, whether they be a patients, pharmacist, healthcare professional or general geek, instinctively bypasses testimonials to look for clinical trial evidence instead.

Do you have any ideas? Have you had any really good experiences of explaining clinical trials to patients? Are there any techniques we can use to simplify the stats and make trials more accessible to all? My friend Nancy had a great idea of including a Plain English summary as part of an abstract for every trial. Is there anything else we could do? Let me know, however outlandish your idea, either by commenting, tweeting me (@SparkleWildfire), or dropping me an e-mail at my new shiny sparkly e-mail address healthydoseofskepticism@gmail.com

Hxxx

In which the title of pharmacist makes a real difference.

Here is a little story of something that made me proud to be a pharmacist. It works as a sort of counterpoint to all the talk of pharmacy as a quack profession, the sort of bad experiences I have recently had as a customer in a pharmacy, and the Which? Report. 

It happened now behind a pharmacy counter, or in my office, but instead at one of my last phototherapy sessions. Because they were three times a week for 10 weeks, you sort of start to get to know the other folk who go there, and of course I got chatting with a few. I had mentioned offhand to one of them during a bout of small talk that I was a pharmacist.

The next time I saw her, she was eager to talk to me "I've been thinking, and I have a question for you, although I hope you don't mind me asking." She had had very severe psoriasis for many years, and it was having a real, tangible impact on her life. It had been suggested to her that she could try methotrexate, but she had been resistant to this treatment strategy "Because I'm just so terrified of all the side effects"

Her question to me was simple: Would I, as a pharmacist myself, take methotrexate if I was in her position? What a great question. And how amazing that someone I don't know at all thinks enough about my opinion, simply because of my job description, to ask me it.  And so, shivering slightly in our hospital gowns in the clinical white of the dermatology changing rooms, we had a really good chat about the benefits and risks of all drug treatments, about how methotrexate works ("someone told me its like chemotherapy!"), about her fears of the medicine ("I've had a look on the internet and the side effects are terrifying") and her fears of the psoriasis ("I sometimes think other people think psoriasis is something that isn't serious enough to warrant a drug like methotrexate, when it's also used to treat cancer and things. But it really is ruining my life."), about the sort of monitoring she could expect. and some of the things to look out for if she did decide to take it. 

My bottom line answer was that yes, I would take it if my psoriasis was as severe as hers, and having the impacts on her life that she was experiencing. I explained that I too would be scared of the side effects, but not everyone gets them, and because you're quite closely monitored whilst you're on it, the most serious side effects should be pretty easily picked up and with some careful dosing, along with folic acid, could hopefully be minimized. 

"Eeee, well thank you. You've really put my mind at rest." she said, and off she padded to receive her few minutes on the NHS sunbed whilst I attempted to put my clothes on the right way round for the second time that day- no mean feat when you're me and you haven't yet had your first cup of tea or coffee yet. I don't know whether or not she was definitely going to start taking the methotrexate, but I get the feeling that I had given her a few things to consider that she hadn't thought about, and that I had provided some reassurance that the horror stories on the internet are not the full story. 

This just goes to show the sort of esteem we pharmacists have the privilege of in the eyes of some. Its a privilege we should honour by doing all we can to ensure our advice is good quality and evidence-based. Being a Good Pharmacist doesn't stop the moment we extract ourselves from behind the counter, or out of our office or wards. Our words are more trusted, more weighted than many of us probably realise, because to some (but not enough) people "Pharmacist" really does mean "expert in medicine", and we need to ensure that we don't take advantage of that to sell products that don't have a good evidence-base just for profit. Our integrity as medicines experts can and should shine through, even when you're standing in a cubicle failing to rock the hospital chic look, bleary eyed and in need of caffeine.

Hxxx

The Vaper Verdict

I seem to have gotten myself a bit of a reputation as a Vaper-hater. In truth, I'm actually really not.

I even once owned a disposable e-cigar. It was a good few years back now. Although I consider myself a non-smoker, I do smoke the odd cigar, but about one a week and only when the weather is nice (so about 4 days a year then) and only when someone has brought me some back from their holidays probably does not constitute a habit, or would be considered the world's most pathetic addiction. I would never dream of smoking indoors, and somebody thought it would make a nice stocking filler for me one year.

I used it a few times, and it was alright, in the same way that a Pot Noodle is mildly enjoyable in its own right, but bears no resemblance to a steaming hot bowl of freshly cooked spicy Szechuan chicken in udon noodles (no 69. on the menu at Nudo, my favourite restaurant in Newcastle. Its always giggle-worthy ordering it). E-cigarettes are the Smash mashed potato of the smoking world, a Cup-A-Soup to a home-made broth.

I can see how it would be good to have something vaguely resembling a cigarette if you're trying to give up smoking, and I can certainly see how a nicotine delivery method that avoids all the tar, chemicals and other gunk that smoking dumps in your lungs is more healthy.

My reservations are thus:

  1. If they're unregulated, you have no idea what's in them. It might say on the pack that it contains x mg of nicotine and chemicals y and z but there is no guarantee of this. Some have been found to contain toxic chemicals like ethylene glycol, for example. Its undoubtedly likely that they still contain less dangerous chemicals that cigarettes, but it would be very nice to have that guaranteed.

  2. There's no long term safety data. We literally don't know what the long term effects of these things are. For all we know, the seemingly safe-at-first ingredients could actually prove to be carcinogenic, say, when inhaled in this way in the long term. Admittedly its unlikely the products would be as bad or worse than smoking, but without the studies we just don't know. Theoretically they may seem like they're going to be harmless, but without the data there to back it up we just cannot make that assumption- its that sort of reasoning that lead to the thalidomide disaster, for instance. Unknown does not mean safe.

  3. There's evidence that products are often do not contain what it says on the label (if they even have a label at all). A study in the BMJ's Tobacco Control found that products contained variable and potentially dangerous amounts of nicotine- most often the product contained less than was stated. Now, if I'm paying for a product that says it contains 72mg/ml of nicotine, I expect that product to contain 72mg/ml of nicotine, just as I would expect a 500mg paracetamol tablet to contain 500mg paracetamol. If it contains less than this, I'm essentially being ripped off. The other available nicotine replacement products- patches, gums, inhalators etc- all have a license, and I don't really see why these electronic cigarettes should be any different.

  4. In smoking cessation, using a product which looks like a cigarette might be helpful in the short term, but it doesn't help to address the habits of smoking rituals, and in my experience of helping people quit, that's half the battle.

  5. The risk of serious accidental nicotine poisoning in both adults and children. 

  6. There is a risk that the ease of use of the products and ability to use them indoors might actually increase nicotine intake in some people.

  7. Even if nicotine itself were entirely safe (which it isn't), its still an addictive substance. Any addiction can lead to harmful effects in a person. For evidence of this, try speaking to me on a day when I have not had any caffeine. If I added up all the time and money I have spent in my life engaging in drug-seeking behaviour to feed my addiction (mainly desperately trying to find the nearest kettle or coffee shop), I suspect it would be very upsetting.

Today there has been, in my opinion, some good news. The MHRA have decided to start . This decision essentially eliminates concerns number 1, 3 and 5 and starts us on the road to also ruling out concerns 2,4 and 6. The BMA have responded enthusiastically to the news, stating:

“We can now build on this and press for good research which looks at the efficacy and health implications of e-cigarettes. It’s really important that we find out if the hand to mouth use of e-cigarettes either breaks or reinforces smoking behaviours. We need to know if e-cigarettes actually help smokers quit."


I'm also enthusiastic about this step. Whilst it may lead to decreased availability and choice of these products, it will hopefully lead to a smaller number of better quality products being legitimized and incorporated more formally into smoking cessation or harm reduction schemes- if they are proven to work in robust clinical trials. This is yet another case where, instead of waiting until we have good, robust data that a product works and is safe, it has been widely sold and adopted by users in lieu of risk or efficacy information. There will no doubt be an outcry from users and manufacturers, and wails that the MHRA have banned e-cigarette sales, that its a Big Pharma conspiracy to give everyone cancer so they can sell more drugs, that big evil corporations are trying to trample the little guys down, when all they are trying to do is save some lives. But none of this regulation means that.

All a manufacturer of e-cigarettes would need to do to continue selling their product is to prove its safety, efficacy and quality. It will take money and time, but if they have been already producing their wares safely and in accordance with Good Manufacturing Practice guidelines, they're already some of the way there. Gaining a license will of course cost time and money, but if these manufacturers are genuinely interested in saving lives- and not just unscrupulously making profit- they would see the value in the licensing process, and the opportunities available for a licensed product in the long run.

So here's to what could be start of a new dawn of smoking cessation or harm reduction. I really hope so, but will reserve judgement until the evidence starts piling in.

Hxxx

My Fantasy Pharmacy

People are allowed fantasy football teams, so why shouldn't I be allowed my own little fantasy pharmacy?

Now people, I want you to contribute to this post. So let me know if I haven't included your desert Island drug and why you think my pharmacy should stock it, and I shall put it on the shelves if I deem it worthy. Tweet me @SparkleWildfire, leave a comment, or drop me an email at inthecityofthefuture@gmail.com. I'm going to start off small with this post, and add to it gradually.

With all this talk of pharmacy as a quack trade, and the lack of evidence base for many OTC products, my pharmacy is going to have the bare minimum. Only the drugs I want to sell, ad that I think are necessary, with none of the extraneous, shiny combination packs that are purely there for profit. 

So, welcome into my emporium of evidence-base, and help yourself to some expert advice, a healthy dose of skepticism, and a pinch of thriftiness.

Shelf One: Pain Relief

  • Paracetamol: because it is an effective painkiller and antipyretic with few side effects. 
  • Ibuprofen: again, an effective painkiller and antipyretic. Needs more caution because of side effects, but still useful to have over the counter.
  • Sumatriptan: a good shout, thanks for your comment, Joanne. This is actually a really useful product to have OTC, in my opinion- its for migraines, so its great for regular sufferers to have easy access to if they don't have their usual meds to hand. But it does needs to be sold very carefully, with good questioning and counselling. 

Shelf Two: Coughs and Colds

  • Sudafed: just the plain old pseudoephedrine variety. Its the most effective decongestant over the counter (phenylephrine has much less of an effect orally) and can be combined with paracetamol or ibuprofen if there is pain associated with blocked sinuses.
  • Lemons and Honey: for combining with hot water for soothing throats and coughs. About as effective as any other cough mixture.
  • Glycerin, Lemon and Honey Mixture: as above, but ready made for when you don't have access to a kettle. Also: its quite delicious. 
  • I would include a night time product too, but I'm not sure which one yet. I don't want to include Night Nurse because its got far too many ingredients in it, and no one should have to take medicines they don't need. My product would just have diphenhydramine and paracetamol in it, probably, just something to help you sleep when you have that awful achey can't breathe feeling that comes with colds. 
  • Menthol crystals: for adding to steam inhalations. Inhaling the vapours of a  couple of those bad boys in boiling water will have your mucus cowering and crying in a corner. 
  • Xylometazoline nasal spray: an option for people with bad congestion who can't take pseudoephedrine.
  • Pholcodine cough medicine: As voted for by Kev. Its cheap enough, and acts to suppress a dry, tickly cough. Shouldn't be used in chesty coughs though. 

Shelf Three: Ear problems

  • Olive oil: there is no reason whatsoever for any of the other products to exist. Plain old cheap olive oil will do the job just as well as anything else.
  • Dropper: for administering the olive oil. 

Shelf Four: Allergies

  • Generic beclomethasone nasal spray: cheap, works if used in advance of the hayfever season.
  • Antihistamine tablets (generic): Chlorphenamine, loratadine, and cetirizine. Exactly the same as the hugely expensive branded varieties. chlorphenamine can cause drowsiness, the other two tend to be much of a muchness- some people find one works for them, some the other.
  • Cheap anti-allergy eye drops: great for people that have predominantly eye symptoms. 

  •  

That's a little start, and I shall add to it when I think of anything else or get a chance.

Hxxx

Dermalex: a superficial skin miracle?

I've written before about the guttate psoriasis which suddenly appeared at the start of this year and the impact it has had on my life.

I'm pleased to report that, after 9 weeks of phototherapy, it is much better. It has virtually gone on my top half, but the plaques on my legs are still stubbornly visible, although much better. The fact that it hasn't gone away entirely yet means its probably not going to clear up. Without wanting to sound over-dramatic, it actually feels like quite a bit to deal with- I've never had any long-term health conditions before, and although I've become slightly more confident, I'm still really conscious and nervous of having to expose any affected skin.

A while ago, my Mum rang me. "There's this new product out that says its for psoriasis, shall I buy you it so you can try it and see if it works?". To be honest, it was tempting, but when she told me the price £29.99 for just 150g, I declined. Skin diseases really can have an enormous impact on your life, and leave you desperate to try anything to find that one miracle that will get rid of it once and for all. Since then, I've seen it prominently displayed in quite a few pharmacies, hailed on shelf-edges as a 'breakthrough in psoriasis treatment'. So the big question is, is there any evidence that it works?

This poor chap obviously has some practical joker friends who like to write words of skin conditions in his sun tan lotion when he is sleeping in the sun.

This poor chap obviously has some practical joker friends who like to write words of skin conditions in his sun tan lotion when he is sleeping in the sun.

The product is Dermalex, and it is made by Omega Pharma. If their name sounds familiar to you, that may be because they also produce Prevalin, the overpriced, overcomplicated, under-evidenced Vaseline substitute for hayfever. This leaves me with a slight prickling of my skepticism, but lets keep an open mind for now.

How is it supposed to work? Well, the fact that the website itself titles this section "How its works?" (sic) begins to worry me slightly. I know this blog is liberally sprinkled with typos and spelling errors, but at least I have the courtesy of being shameful about it. In a professional website selling a quality medicinal product, I don't think spelling errors are acceptable, and there are a few dotted around the whole website. Nowhere on the website does it actually tell you what is in the product. Its said to: 

  • "Reduce Psoriasis symptoms by: Normalising skin cell production and Acceleration of the recovery of the skin barrier"
  • "Fortify the skin barrier through: The creation of a protective shield on the skin by means of Alumino silicates against outside to inside insults (bacterial superantigens & toxins) through the non-intact skin barrier."
  • "Providing a barrier to water loss"

This is helpfully illustrated by a diagram of the skin, which has labels that don't correspond to any numbers at all- either they're deliberately trying to make it look all science-like and confusing, to make the patient think "this is too complicated for me, so it must work", or its just sloppy oversight. Either way is bad enough.

Some labels on those numbers would be nice. Unless there really are little blue circles with random number in them floating about in the layers of our skin.

Some labels on those numbers would be nice. Unless there really are little blue circles with random number in them floating about in the layers of our skin.

We can pretty much entirely discount the claims for "fortifying the skin barrier". All this means is moisturising the skin, and a plain old (cheaper) emollient will do just as good a job at that. Once again, this seems to be Omega Pharma reinventing the Vaseline-greased wheel. As for the former claims, well, I need to see some evidence to corroborate them and decide if they are reasonable or not. So let's have a little lookie, shall we?

Having had a bit of a dig about on the website, I could see no clinical evidence. So of course I emailled the manufacturers, and got back a curt response after several days telling me to look at this page for references. So, here it is, the grand total of the evidence that Dermalex Psoriasis works:


"PASI based clinical efficacy study of Dermalex Psoriasis cream for the treatment of Psoriasis Vulgaris symptoms in a mono application therapy, Józsefváros Health Center, Budapest, Hungary; Open Label Clinical Study into the overall efficacy of Dermalex Psoriasis Cream, 2008, Dermatology and Psoriasis Clinics Laudau and Kandel, Germany"

For some reason, Omega Pharma seem to want to throw away the usual format of referencing- the one that is accepted and good enough for use in the rest of the medical profession. These references do not give me enough information to find the original studies, so what use are they? I've emailled them back to ask for standard reference formats, including where the studies are published, and have been greeted with a loud silence. I've tried googling the titles, and this brings up nothing, suggesting that they haven't even been published.

Why isn't the evidence published anywhere? How many patients were involved? What are the study designs? What were the results, and the statistical analysis of the results? Without answers to any of these questions, all I can do is discount this as evidence at the moment. 

Of course I didn't just leave my research there, in the hands of the manufacturers. I've also had a look myself at the medical literature. And could I find anything at all for whether Dermalex works for psoriasis? Not a sausage. 

You're supposed to apply this stuff  three times a day. 150 grams will not last you long at that rate. That makes this a whoppingly expensive product. The national minimum wage in the UK is £6.31, meaning one pack would be equivalent to just under 5 hours work. Isimply don't think that a couple of unpublished trials that may or may not say it works is a good enough reason to justify the expense. They're either being deliberately evasive about the evidence, or remarkably blase with people's hard earned cash.   

They say beauty is only skin deep. It would seem that the evidence that Dermalex is even more shallow than that. 

Hxxx

Update: I was contacted by the manufacturers of Dermalex, who promised to provide me with the references I asked for above. Here is the response I've gotten, with my response to the points they have raised below. . 

Thank you for your enquiry regarding Dermalex.
As you may be aware, the Dermalex range contains a number of different products to treat the following conditions; atopic eczema, contact eczema, psoriasis, rosacea, atopic eczema for babies and children. Please rest assured that all Omega Pharma products have been produced under strict guidelines and regulations.
range of proprietary studies have been conducted across the Dermalex product portfolio and as medical devices, these products have undergone statutory trials to ensure they meet the safety and efficacy standards required by regulatory bodies to demonstrate an impact on skin pathologies.
Medical devices are designed, engineered and formulated, in compliance with the UNI EN ISO 14971:2009 and 13485 guidelines. This means that each step of development and marketing has been strictly regulated to ensure the safety and efficacy of the products.  All testing is carried out by medical device status certified organizations, which include leading dermatology research centres. In addition, all studies were conducted by practicing clinicians. Please note that these studies include varying number of participants and study designs.
The research behind the Dermalex range is ongoing - we are working towards publishing data on the product range this year to ensure we are able to communicate the efficacy and safety of these products to healthcare professionals. We are working closely with the University of Amsterdam and are looking to publish the first set of results in theInternational Journal of Contact Eczema. We will also be presenting this data at the upcoming conference on ‘impaired skin barrier in the pathogenesis of atopic and contact dermatitis’ in Amsterdam in June.
To date, we have conducted six trials across the product portfolio involving nearly 200 patients. The products have also been used in in Belgium, France, The Netherlands, UK, Italy, Portugal, Austria, Switzerland, Ukraine, Czech Republic, Slovakia, Turkey and Australia, among nearly 3 million sufferers.
All Dermalex products are well tolerated and have been clinically proven to work. In summary, the trials showed:
  •  Dermalex Contact Eczema produces symptom improvement comparable to prescription drug treatments
  •  Dermalex Atopic Eczema (Babies & Children and Adult formulations) effectively relieves both objective and subjective symptoms of contact or atopic eczema
  •  Dermalex Psoriasis is effective against objective and subjective symptoms of psoriasis
  • Dermalex Rosacea & Couperose is effective against objective and subjective symptoms of rosacea
We hope that this information is useful and thank you for taking the time to contact us."

Firstly: I was aware that Dermalex is being sold as a medical device, but only because of those tell-tale words "Clinically proven!" and based on knowledge of Omega Pharma's other product, Prevalin. the fact it is classed as a medical device (and therefore not subject to the rigorous clinical testing of a real medicine) is even less prominent on the Dermalex website than it is on the Prevalin website.  

The rest of the e-mail appears to be a lengthy way of saying "We don't have any trials published yet, and no, you can't have any results in order to make up your own mind whether or not it works, you'll just have to take our word for it.". 

What's particularly interesting is that the International Journal of Contact Eczema doesn't appear to actually exist, as nothing at all is coming up for it on a Google search.

They say they have conducted six trials, which initially sounds reasonable. But this is across the product range, which includes at least four products and also children's versions. 200 people over six trials is not a lot- if shared equally that is only 33 patients per trial, and assuming they're placebo controlled, that would only mean that 16 patients per trial are actually exposed to the product- nowhere near enough to claim clinical significance of any results. Stating that the product has been used in other countries is meaningless, unless it is backed up by good, robust clinical trials. Its a logical fallacy- an appeal to popularity. Just being used doesn't mean it works- people might just try it once, or use it on the basis of advertising alone, but the product could still be ineffective.

So here's my main problem. How do Dermalex justify charging such an enormous price for a product before they have proven its efficacy. If good quality research had been undertaken prior to marketing, and robust results said that it worked, then that's one thing. But charging people £29.99 for "We think it might work, but we don't know yet because we're still doing research now, and the trials we've done so far that haven't been published yet in a non-existent journal are too small to decide" is, to my mind, entirely unjustified. 

Bad Pharmacy

This morning, I needed to go and buy some medicines.

So, on my way into work, I popped into the nearest pharmacy to my route into work: a branch of a very large chain of chemists. Here's what I bought:


This turned out to be a particularly disappointing example of what I wrote about in my last post- a very lackadaisical, dangerous attitude to OTC sales. And this comes merely a few weeks after publication of the latest Which? report into pharmacy, and about a week after pharmacy was referred to, by Ben Goldacre and Andy Lewis no less, as a "quack profession".

Now, I'm demonstrably not a parent, but you know when you tell off a child for doing something naughty? The usual response is to stop doing the naughty thing, and act extra-specially well-behaved for a period of time until the original naughty thing is forgotten about, then you start doing it again. On second thought, I know some adults that exactly the same thing applies to. The pharmacy profession as a whole should be in that well-behaved phase right now. We should be pulling together, and ensuring that everyone involved- including counter staff- pulls their socks up, shakes off bad habits, and works to the highest quality, to prove a point, but also just because this is how we should be operating all the time.

So, this morning I shuffled into this particular pharmacy (which I'm sure you have no idea which one it is, given I have so cleverly covered the brand in the picture) and asked for "Some Piriton and some co-codamol". The lady who served me appeared to be an experienced member of the pharmacy counter-staff. Here's how the conversation went:



Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?
Me: 30
Her: And you wanted paracetamol?
Me: No, co-codamol.
Her: Soluble?
Me: No.
Her: have you got a loyalty card? 
Me: No
Her: that'll be £5.34
Me: *pays and leaves* 

Here is how the conversation *should* have gone, as a bare minimum:

Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?"
Me: 30
Her: We've got a cheaper generic version, if you want that?"
Me: "lovely, yes please"
Her: "These can cause drowsiness, mind, so make sure you don't drive or anything when you've taken them"
Me: okay, I wont.
Her: And you said you wanted co-codamol?
Me: Yes.
Her: soluble or tablets?
Me: just tablets is fine
Her: Have you used these before? Do you take them regularly
Me: No, just when i have a headache now and again.
Her: Because of the codeine content, they should be used for no more than 3 days at a time. If you feel you still need to use them after that, see your doctor. They also contain paracetamol, so make sure you don't take any other paracetamol products with them, and no more than 8 tablets in a day.
Me: okay
Her: Do you take any other medication at all?
Me: no, just the contraceptive pill
Her: have you got a loyalty card? 
Me: No
Her: That'll be £5.34
Me: *pays and leaves* 

That extra counselling would have added on about 20 extra seconds, which might have seemed like a minor inconvenience to myself, but lets have a look at the theoretical consequences of not saying them:

Piriton: Causes drowsiness. I take one, get in my car, fall asleep at the wheel, and have an accident.
Co-codamol: I don't realise it has paracetamol in, and take 2 co-codamol tablets and 2 paracetamol tablets four times a day for a while. I get liver failure, and die a slow, painful, unpleasant death because a suitable liver isn't available for transplant.
Also: I take co-codamol regularly for a week. I then try to stop taking co-codamol, and start getting headaches, and generally feeling awful, so I restart taking it. I am now dependent on the codeine content of it. 

Yes, I am a pharmacist, so I already know the potential risks and consequences of taking these drugs. But I wasn't wearing an "I'm a pharmacist" T-shirt this morning, so its not like the member of staff knew this. Just because I asked for the products by name does not instantly mean that I know all about them and do not require full counselling on how to use them appropriately. And yes, I do also know that there is no good evidence that co-codamol is more effective than paracetamol alone, and I know I'm daft to be buying them, before anyone starts with the "aren't you supposed to be a skeptical pharmacist?"- sometimes even skeptical pharmacists like to utilize the placebo effect the promise of a tiny opioid hit provides.

Any of these theoretical problems can-and do- happen to people. We simply cannot go on providing such poor service over the counter and yet at the same time expecting the profession to be taken seriously. This is not safe selling of medicines- this is irresponsible and dangerous, and unacceptable. It makes me pretty angry because it not only gives a bad name to myself, and all the other great, conscientious pharmacists I know, but more importantly because it endangers patients on a minute-by-minute basis. 

Are we selling our souls Over The Counter?

There's something beautifully logical and satisfying about a good Over The Counter consultation.

I know what you're thinking, and yes, I should get out more. But it is true. The way I think of it is in a stepwise approach, using a systematic series of questions to eliminate products leaving you with a limited number of options to recommend. I suspect the way a patient views it may vary somewhat from "hey! I'm really being listened to!" to "oh for goodness sake shut up, I'm going to be late for the bus.".

A good consultation goes like this:
 

Step One: Establish the symptoms and check diagnosis.

Fairly self explanatory: to decide what medicine to select, I need to know what I am trying to treat in the first place. I'm also finding out if the patient has any danger symptoms which might be suggestive of a serious illness, so I can signpost them appropriately to the right services. 
Once I know what the problem is, I think about what products are available to treat it over the counter

Step Two: Find out about the patient's medical history.


I'm looking for anything that means the patient is at high risk of complications of the problem, meaning they need to be referred. I'm also thinking of the cautions and contra-indications of the available products to treat the problem and eliminating any products that these apply to.

Step Three: Find out about the patient's drug history.
 

I'm thinking about what drug interactions each of the available products has, and whether or not they are relevant to what the patient is already taking. I'm also thinking about whether or not any of the patient's medicines contain the same or similar ingredients to any of the OTC products- i don't want to risk an overdose. I then eliminate any products that have relevant drug interactions.

Step Four: Consider the evidence.


At this point, there may be only a couple of products that are suitable for the patient. If there aren't any left, I refer them to their GP or other appropriate healthcare provider.Out of the ones that are left, I think about which ones the evidence says are more effective and safe and I'll steer the patient towards that one. If there's no good evidence for at treatment, I'm always clear with the customer about it. Sometimes they listen, sometimes they don't, but its an obligation that I think needs to be done in order to sell medicines honestly and with integrity.
 

Step Five: Consider the price. 
 

Where two products are equally efficacious, I always recommend the cheapest. Because I don't want to waste a patient's hard earned cash, and I think patients appreciate that.
 

Step Six: Counsel the patient.

This involves giving them all the useful little snippets of information about how to use the product effectively and -crucially- safely. It might be pointing out that the product contains paracetamol, or that it causes drowsiness, or that it works best taken at a particular time of day. 


Hopefully all pharmacists will recognize this process, although everyone does-and should- have their own style to go about it with. These sorts of encounters can be really satisfying for both pharmacist and patient, and its often in these moments that I have the most amount of pride in my role. Here I am, giving the patient trusted, evidence based advice which will hopefully bmake the patient feel better. However, you also need a willing patient, and I'm finding more and more often that patients are unwilling to engage in such exchanges. I've also noticed through personal experience as a customer, that some pharmacies are using what i consider to be a cop-out approach to OTC sales. An offhand "you should read the leaflet" whilst I'm handing over my money does not, in my opinion, constitute provide expert advice on medicines. 

So why am I on about this at the moment? Well, there's the Which? report, which has found a disappointing quality of over-the-counter information being provided in some pharmacies. Others have given a more detailed analysis of this report, so I won't go into it too much, except to say that yes, there are methodological problems with it. However, it may well be indicative that in a world where pharmacists are under massive pressure to deliver services and dispense ever-increasing numbers of prescriptions whilst working longer hours for less pay, some are starting to lose pride in the basics. Its understandable. In the rush to get everything done, its easy to start seeing the patient as an inconvenience, who we need to get in and out of the door  as quickly as possible. I'm not saying this is what is happening in every pharmacy or in every case, but based on how I used to feel when I managed a pharmacy, I suspect it is a factor. 

The other reason I've been thinking about this is the issue of self-selection of pharmacy medicines. In my humble opinion, this is a giant backwards step for the pharmacy profession. Self selection reduces the process I described above down to a bare minimum, and reduces the possibility of introducing quality into it. Sure, we can say there will be information on the packs, but lets be realistic about this. Patients very rarely read the leaflets before purchasing, and if they have to do so in the middle of an aisle in a high street pharmacy or supermarket, i think it becomes even more unlikely. In my experience, if a patient has a preconceived idea of the product they want to buy, its very difficult to persuade them otherwise, even when there is a safety concern with their chosen product.

I remember one customer asking for Sudafed, when she was also taking phenelzine. A combination of these drugs could provoke a potentially fatal hypertensive crisis, but no matter how much I explained this, the customer was adamant that she still wanted it. It turned out her daughter, a medical student, had advised her to use this product, but when I spoke to the daughter it turned out she thought that Sudafed just had paracetamol in it.

Now imagine this situation in a self-selection age. The customer picks up the pack, wanders to the pharmacist, who then has to try to wrangle it from their fingertips in order to ensure their safety. Okay, maybe not that dramatic, but the fact that the customer has the product in their hand, and has been able to "choose" it themselves, reinforces to them that it is their right to buy it. But in pharmacy, the fact of the matter is that the customer isn't always right, and its poor customer service- and downright dangerous- to always allow them to think so. 

Imagine that self-selection scenario is also coupled with a curt "read the information leaflet first" as the only form of counselling. Why would the patient bother reading the leaflet, when she already thinks its safe for her to use? And so, what appeared to be a quick, convenient shop for the customer could so easily turn into a fatal drug interaction.

The shopping experience is becoming more and more depersonalised. With chip and pin and contactless payments, you barely even have to glance at the cashier during a transaction- if you're even in contact with a cashier at all. This may be fine when you're buying groceries, but medicines are not commodities. We're different to other shops in that the wares we sell can have fatal effects if they're not used in accordance with expert knowledge and instruction. We simply cannot safely reduce the over the counter consultation to the bare minimum of words required to take money from people as quickly as possible. 

Of course, its not like we pharmacists, will get that much say in the matter, and we'll carry on regardless if self selection goes ahead. Indeed it seems to be a near certainty, despite support from "very few" pharmacists. And it may even be the case that such scenarios never happen in real life. But all I want to do is make medicines safer for people, and to do so we have to identify areas of risk before they happen, and take action to minimise them. 

When it comes to patient care, just hoping the worst doesn't happen isn't good enough.

Hxxx

Nose gunk strikes again: Nasalguard AllergieBLOCK

What is it with people trying to produce "Revolutionary" new versions of rubbing vaseline on your nose whilst charging vastly over the odds for the privilege? Someone, somewhere has obviously decided that our noses just aren't greasy enough. Thanks to my friend Paul for bringing this to my attention.

Enter the new kid on the over-the-counter hayfever market block (see what I did there?): Nasalguard AllergieBLOCK. Firstly, how am I supposed to trust a product that can't even manage to spell allergy properly? Secondly, is that Comic Sans font that I spy on the packaging?! Okay, so it seems like the UK packaging is different, but that doesn't matter. The damage is done, and the use of Comic Sans is an unforgivable crime.

Font against humanity. 

Font against humanity. 


Thirdly, on trying to find the UK site, it seems that this is yet another company who has taken to giving free stuff to people so that they will say on their personal blogs how very marvellous it is. This sort of publicity just doesn't wash with me. It feels grimy and seedy and smells faintly of desperation. I therefore imagine this is also what Allergieblock gel smells of.

Let's have a look at what the manufacturer's say:

"NasalGuard AllergieBLOCK® Regular is a revolutionary topical gel based upon patented technology containing cosmetic grade ingredients. The FDA-approved gel creates a positive charge which blocks negatively charged allergens on contact before they enter the nasal passages."

Right, it's really not revolutionary, is it? It's hardly going to free the downtrodden masses from the grips of the evil dictatorship of pollen. It's exactly the same principle as Prevalin and Haymax, and of course good old Vaseline. I've said it before in the Prevalin post, but the idea of putting vaseline on your nostrils to reduce hayfever symptoms is as old as the hills. There's nothing revolutionary about this. This positive charge thing is new, however. It sounds like something that a bunch of marketers sat in an office having a "thinkstorm" session would come up with as being suitably science-y to wow the masses. 

But surely this can't possibly be the case, not when there is a heart-warming "Inventor's Story" on the website:


"About 20 years ago, New Jersey Professional Engineer Ashok Wahi's daughter Aikta frequently suffered from allergies after exposure to her friend's cat. He wanted her to be relieved from the constant sneezing, runny nose and congestion without taking drugs.  The conventional over-the-counter remedies made her sleepy at school, he got motivated to create a drug-free solution for his daughter that wouldn’t cause drowsiness, dry mouth and similar side effects.

The project's goal was to prevent the inhalation of allergens rather than treating the allergy symptoms after the fact.

With this in mind, Wahi put his engineering skills to work and developed a unique gel that blocks allergens on contact, therefore alleviating allergy symptoms. Hence the birth of NasalGuard® technology."


So its taken this dude 20 years to reinvent the wheel and come up with a fancy version of Vaseline. Shame really, he could have saved himself the effort if he had only spoken to a decent pharmacist or GP. Whilst I'm sure being a "Professional Engineer" is awesome and all, I'd really rather like it if people who are trying to improve my health have some sort of background or training in healthcare, thank you very much. 

Anyway, all of this is by-the-by, because of course there is going to be a wealth of good quality clinical trial evidence to say that it works, right? Dear readers, you probably know the drill by now. There's some testimonial videos on the website, a grand total of 4 of them. With Prevalin, the manufacturers tried to pass off two methodologically poor trials about products that bore no relation to Prevalin at all off as clinical proof that it works. These guys don't even bother going to that amount of effort. There is no mention anywhere on the website about any trials at all. They don't even bother cursorily referencing the Principles and Technology bit:

 "NasalGuard AllergieBLOCK® uses patented technology that works on a simple principle of electrostatic charges: opposite charges attract each other.
AllergieBLOCK gel has a slight positive charge which attracts negatively charged allergens. Allergens like pollen, ragwort/ragweed, hay, dust mites, pet dander and house dust all carry a slightly negative charge. The allergens are blocked on contact. You do not inhale allergens, which means you don’t suffer from allergic reactions"

Now, it does seem to be the case from this PLoS One study that allergens are negatively charged whereas non-allergens are more likely to be postively charged. But until there's some evidence that a mixture of "Dl Water, Polyquats, Propylene Glycol, Octoxynol-9, Glycerin, other cosmetic grade ingredients and preservatives" can definitely produce some sort of nasal forcefield against the nasty pollen, and the manufatcurers can demonstrate an ability to spell properly, I'm not interested.

I'd also rather not apply something to my face which is going to actually attract the very things I am expressly trying to keep away it, thank you very much. Without evidence to the contrary, there is nothing to say that all of those positively-charged allergens which are supposedly now attracted to the gunk on your nose will get stuck on the gunk. A few allergens with probably make it through, given that nostrils are relatively big holes in comparison to how small the allergens are. So if anything, there is a potential that you end up with more allergens than you would have done had you not bothered applying it in the first place. Imagine Justin Bieber in a young girl's school, with only one or two bouncers for protection. a fair proportion of the screaming pre-pubescent youngsters are likely to get through the bouncers to plant a kiss or two on the fresh-faced child-adonis. (If I'm honest, I have only a vague knowledge of who Justin Bieber is, but I understand he's the Jason Donovan of modern time)

How much does it cost? oh, only the princely sum of £11.99 for 3g at Boots. ELEVEN POUNDS AND NINETY NINE PENCE for THREE GRAMS!!! Think of all the other things you could buy for £11.99.

Save your money, people.

e-cigarettes: accidents waiting to happen

We all know smoking is bad for us, and we all know that giving it up is a good idea. E-cigarettes have been around for a good few years now, and they seem to be the answer to a lot of our prayers to some people: That lovely nicotine hit, without having to traipse outside, and without any of the nasty tar or other chemicals that makes smoking bad for you.

There's currently a bit of a kerfuffle going on about them as the EU look into tighter regulation of them. A quick search on Twitter reveals lots of folk stating that they save thousands of lives, are much safer than other pharmacological smoking cessation methods, and are totally safe, therefore shouldn't be banned by the EU. Others have covered the fact that e-cigarettes are unregulated, that they may actually contain chemicals and ingredients which can be carcinogenic, that they might have adverse safety effects so I'm not going to cover all of those potential issues here. .But there is one aspect of their use which I think is easily forgotten about, but has the potential to be very worrying.

It seems that e-cigarettes come in a variety of forms- none of which are regulated. Some are disposable, some have refillable cartridges, and some require refilling with a liquid. There are even some sites which encourage mixing your own nicotine liquid: a complicated process requiring mixing a nicotine concentrate with a flavouring and a diluent using a dropper.

Now, as a fairly young pharmacist (or so I keep telling myself), it has been a long time since I compounded any medicines myself, but I do remember doing so in university and I have a pretty good idea of how to work out and produce mixtures. I'm a keen baker, so used to following recipes which can be complex at times. And yet a quick glance at some of the mixing guides for nicotine liquids makes me worried. They look complicated enough for a pharmacist like me to follow, never mind anyone else. Milligrams, drops, milliliters, colours, parts etc are all terms used on the same instruction sheet, and the medicines safety part of me is crumpled and crying in a corner, wailing "HIGH RISK COMPOUNDING PROCEDURE!" loudly to anyone who will listen. And yet, because these things aren't considered a medicine, anyone can sell this stuff, and anyone can buy it. There are risks at every step of producing these mixes: not understanding the instructions, not accurately measuring amounts, mixing up the different liquids, storage of the liquids, spillages etc etc. Some sites even suggest using a syringe- complete with needle- to inject the nicotine solution into devices. A little bit of me is dying inside. 

Even the ready made liquids are problematic enough. They come in little eye-dropper type bottles, and are often pleasantly flavoured. In short, they're probably rather attractive to children. 

In my day job, which partly involves advising on poisoning cases, I have come across quite a few cases where nicotine liquid intended for use in e-cigarettes has been accidentally ingested. A lot of people don't know that nicotine itself can be horribly toxic, particularly for children. It only takes a small amount orally to get some pretty nasty, potentially fatal effects. And yet, freely available to buy without any regulation at all, a variety of attractively flavoured and packaged -and really highly concentrated- nicotine liquids are sitting ready to be bought by eager punters. You can even buy multi-packs of large bottles of highly, highly concentrated nicotine liquid. They don't even have child-resistant tops on them- and why should they, as they're not even considered a medicine? The websites selling these things aren't particularly clear about the dangers of them- again, why should they be, when they're trying to sell them as a safe alternative to smoking?

I've had a quick look around the medical literature and as of yet there is very little information published on this aspect of e-cigarette usage. And that's part of the problem: the technology has been widely adopted without a thorough understanding of all the different aspects of its safety. Even if they were tightly regulated and highly safe, this aspect of accidents with refills will still remain, and in my opinion it is only a matter of time until there are some very serious accidents of this nature. 

So, whilst e-cigarettes might be a useful ally in giving up smoking for some people, we really need to put some thought into the safety issues surrounding them, and not just the obvious ones which might affect the person using them.

All of this is without even considering the fact that using them can sometimes make you look a bit daft, especially the ones that light up at the end like a pretend-y cigarette. Others, frankly, look like "discreet" vibrating devices for ladies. You'd be better off with those yummy candy cigarettes from the eighties, if you ask me- they look more like an actual cigarette than most of the e-cigs and they're a whole lot cheaper too. 

Hxxx 
 


Minor Update (2nd May 2015): Some time has passed since I wrote this, and I think my fears have started to be borne out in the evidence. Poisons Centres around the world are starting to report evidence of toxicity. Deaths in both humans and animals are being reported. Its a real shame that it came to this, but hopefully with proper regulation the safety of e-cigarettes can be improved.