Medications: An Important Part of Health Care, But Not Without Risks

The Proper Use of Medications

At the turn of the century, the typical pharmacy offered only a handful of patent medicines and preparations mixed by the pharmacist. Few were truly effective and many were addictive or dangerous. In contrast, today's pharmacies stock thousands of different prescription and over-the-counter (OTC) medications. Many also offer homeopathic, herbal, and other natural preparations. Faced with such an array of choices, its understandable that the average patient is often confused as to when and how drugs should be used, often with serious consequences; more than 50,000 Americans are hospitalized each year with medication-induced illness.

Thus, it is essential for anyone taking a medication to be as knowledgeable as possible about how it should be used. This includes not only reading any written material provided by a doctor and pharmacist, but also being aware of the drugs proper dosage, possible side effects, adverse reactions, and interactions with other drugs.

How Drugs Work

Drugs work in many ways; in some cases, even medical scientists do not fully understand the precise mechanism of action. For example, lithium is highly effective in treating the manic phase of manic-depression, but how and why this medication affects the brain is unknown. For the most part, however, most drugs work in one of three ways:

1. By replacing or augmenting natural body chemicals. The body is a complex biological structure made up of thousands of different chemicals and compounds; many diseases are a consequence of chemical deficiencies or imbalances. Diabetes, for example, results from a deficiency of insulin; an imbalance of brain chemicals can cause a variety of disorders, ranging from seizures to depression and Parkinson's disease. Drugs used to treat such diseases are designed to restore normal body chemistry.
2. By attacking harmful organisms or abnormal cells. Numerous diseases are caused by the invasion of infectious organisms or the development of abnormal cells within the body. Drugs in this category work by destroying the source of such diseases, either by killing it directly or by preventing it from multiplying. Antibiotics and cancer chemotherapy are the most familiar examples of such medications.
3. By interfering with cell function. Cells function as a system, directed by various chemical and electrical signals, or neurotransmitters. Millions of such messages are constantly being sent out from one part of the body to another; when some of these messages go awry, cells cease to function normally. Depending upon what organ is affected, drugs may be given to either speed up or slow down the cellular activity. For example, lupus and other autoimmune diseases are generally treated with drugs that reduce actions of the immune system. Ulcers and other digestive disorders are treated with drugs that slow down the production of digestive juices.

Adverse Side Effects

All medications can cause unwanted effects because it is impossible to design a drug that acts only on its target organ or cells. Unwanted responses vary from person to person and from one drug to another; some may cause nausea and constipation, others may produce drowsiness or insomnia, and still others may provoke rashes and other allergic responses. Some side effects appear immediately; others show up years later. In many instances, adverse effects lessen with time or can be eliminated by altering the dosage or trying an alternate drug.

Before taking a medication, ask the prescribing doctor and the pharmacist to list the most common side effects, also the more dangerous ones, and what to do if they should occur. Prior to using it, inform your doctor and pharmacist if you have ever had either an allergic or severe reaction to a particular drug, food, or any other substance, such as food dyes or sulfites. In addition, be sure to make a note of all reactions you have when you begin taking a new medication and relate them to your physician when you have a follow-up visit.

Some people face an increased risk of adverse side effects because they fall into one of the following groups:

Children. In regard to taking medications, anyone under the age of 12 should be considered a child. Usually, infants and children are given lower dosages of drugs than adults to compensate for their smaller size and lower body weight. Also, some medications that are safe for adults may be hazardous for a child. For example, aspirin given to a child who has a viral infection increases the risk of Reye's syndrome, a potentially fatal disease, liquid cough medicines and other over-the-counter drugs may contain alcohol; read ingredient labels and look for nonalcoholic versions. Some OTC medications are specifically designed for children; others may have alternative instructions for children on the package. In most cases, a doctor or pharmacist should be consulted before giving a baby or young child any medication.

The elderly. As people age, the liver becomes less efficient at breaking down drugs, and the kidneys may take longer to excrete toxic remnants. As a result, even a regular dosage may produce severe side effects. This risk is compounded by the fact that many elderly people take different drugs simultaneously. Problems usually can be prevented by prescribing a reduced dosage and paying attention to potential drug interactions.

Pregnant and breast-feeding women. Almost any medication taken by a pregnant woman travels through her bloodstream and into that of the fetus. Some drugs are known to cause birth defects; others retard growth and some cause fetal death. Therefore, any over-the-counter or prescription drug should be taken during pregnancy only after consulting a doctor. Similarly, most drugs taken by a nursing mother can pass into her breast milk and may harm her infant. Consult a doctor beforehand about the safety of a medication.

Drug Allergies

Caution is critical in dealing with drug allergies. The first use of a medication cannot produce an allergic reaction, but it may prompt the body to create antibodies against the drug. If so, any future exposure to it could result in an allergic reaction.

Symptoms during the first reaction are likely to be mild, and may include fever, nausea, headache, a rash, or localized hives. Future responses may be more severe, producing widespread or intense itchiness, flushed skin, vomiting, muscle weakness, bleeding, impaired vision and hearing, and extensive swelling, which can interfere with breathing. These are the signs of possible anaphylaxis, a life-threatening medical emergency. You should report any allergic drug reaction to your doctor immediately, and avoid that drug, as well as any chemically related agents, in the future.

Drug Overdose

Many people mistakenly assume that a drug overdose implies drug abuse or attempted suicide. While this may apply sometimes, the fact is that most overdoses are unintentional, A patient may exceed the recommended dosage when he forgets he has already taken his medication — an especially common problem among the elderly. Or circumstances may increase a drug's effect. In most situations, one extra dose of a drug is not harmful, but in other cases, the consequences can be disastrous. The overdose threshold varies from drug to drug, so it is important to follow all dosage instructions carefully.

If you suspect that someone has overdosed, try to determine exactly how much was ingested. Review any package instructions on what to do in case of overdose. Symptoms vary from one drug to another; some resolve themselves, but medical treatment is often necessary, especially for drugs that affect the brain and nervous system. The first step is to call right away the doctor who prescribed the medication and follow her instructions. If the doctor cannot be reached, call the local poison control center and emergency medical services.

Drug Interactions

Many drugs interact with each other to produce effects not seen with the individual medications. This problem has been growing because more patients are taking multiple drugs, often to treat different problems — for example, a medication for blood pressure, an anti-inflammatory for arthritis, vitamin and mineral supplements, and perhaps an OTC allergy or cold preparation. Not only can each individual medication produce side effects, but any particular combination can also interact to create additional adverse reactions. In some cases, a combination may enhance the effects of one or all of the drugs being used; in others, the medications may cancel each other out, rendering them all ineffective.

Similarly, interactions may occur when drugs are combined with alcohol or certain of types of food. Taking aspirin with orange juice or other acidic foods, for instance, increases stomach irritation; taking certain antibiotics with food reduces or delays the drug's impact; the combination of alcohol with sleeping pills, tranquilizers, or even some cold pills can be deadly.

To minimize the risk of a dangerous drug interaction, always inform both your doctor and pharmacist of all other medications, including nonprescription drugs and vitamin and mineral supplements you are taking, as well as any herbal preparations, some of which have strong pharmacologic effects. Also, be sure to ask about any restrictions on alcohol or diet.

Taking Medication

Read all instructions before taking a medication and follow them precisely. When in doubt, ask your doctor or pharmacist to clarify any uncertainties. If, for example, the directions say “take three times a day,” find out if this means morning, noon, and evening, or every eight hours. Also ask whether the drug should be taken with food or on an empty stomach.

Follow the doctors instructions with regard to how long the drug should be taken. Certain medications, particularly over-the-counter remedies used to treat pain and other symptoms, are used only as needed. For instance, a person might take aspirin, acetaminophen, or ibuprofen when a headache develops, and stop when the pain subsides. In contrast, some drugs, such as anti-hypertensives and insulin, are taken for a lifetime. In other cases, medications must be taken for the full duration of time instructed by a doctor or pharmacist for it to be effective. Many patients who have been prescribed an antibiotic regimen for 7 to 10 days stop taking the drugs as soon as their symptoms disappear, assuming they have been cured. However, while symptoms may have abated, some of the infecting organism may still be present, and can cause a recurrence of the infection. This time, the situation may be more serious, because the surviving organisms may have developed resistance to the first antibiotic, necessitating a switch to a different, more potent drug.

If you need a particular medication in the event of a medical emergency — such as insulin for diabetes or nitroglycerin for an attack of angina — carrying the drug on your person at all times is an important precautionary measure. Similarly, always carry this medical information on your person, written either on a card in your wallet or on a special MedicAlert bracelet. This will insure that any individuals assisting you in a medical emergency can aid you effectively and safely. Any drug allergies also should be noted.

Medication Labels

All medications — both OTC and prescription — should bear a label and additional written information regarding proper use and administration. Every prescription drug should come in a container with a label that includes all of the following information:

• Patients name
• Pharmacy name, address, and phone number
• Physician's name
• Drug name and dosage
• Instructions for usage (when and how often to lake the drug)
• Any special instructions for preparation or storage
• Date the prescription was filled
• Whether or not the prescription can be refilled

Check to make sure that the label information is written clearly and remember to question the pharmacist about how you should take the drug. If you have any questions after you get home, don't hesitate to call your doctor or pharmacist. It is in everyone's best interest to see that you take a medication properly.

Choosing Between Generic and Brand-Name Drugs

Check with your doctor and pharmacist to find out if a generic version of a particular medication is available and appropriate for your needs. Typically, generic forms are less expensive than their brand-name counterparts. In many cases, the only difference will be the price, and the generic drug will have the same effect as its brand-name version. In a few instances, however, the active ingredients of the two drugs may be the same, but the inert ingredients (binders, fillers, and other substances) may alter the absorption, or bioavailability, of the drug. Therefore, it is unsafe to assume that two versions of the same medication will produce the same effects during the same amount of time. These differences are especially critical in some heart medications and thyroid drugs and other hormone products; always check with your doctor about the advisability of switching to a generic product.

Storing Drugs

How drugs are stored determines whether they remain fresh, safe, and effective for as long as possible, to avoid confusion, keep all drugs in their original labeled containers. If a drug must be put into another container, affix to it the exact information as on the original label.

Most drugs should be kept in a dry place away from direct sunlight. A bedroom or hallway cabinet may be the best choice, as drugs placed in a bathroom or kitchen cabinet may be adversely affected by heat and moisture. If the household includes children, store all medications either in a locked cabinet or in a place inaccessible to them. Follow the same precautions when other children visit. Also, you may want to ask your pharmacist to use child-proof safety bottles as an extra precaution.

Some medications must be refrigerated, but room temperature is fine for most of them. Keep containers away from all heat sources and always close the cap tightly after each usage. Remember, too, that drugs deteriorate over time.They should be labeled with a manufacturer's expiration date. Review all your medications every few months and discard those whose expiration dates have expired.

Never keep more than one drug on a bedside table; even then, get up and turn on the light before taking it. It is not uncommon for people to overdose inadvertently or take the wrong drug in the dark while half asleep.

Nonprescription Drugs

Over-the-counter (OTC) medications can be purchased at a pharmacy, supermarket, or other outlet without a physician's prescription. However, their widespread availability should not be interpreted as a sign that they are risk-free; while many drugs are appropriate and safe for self-treatment, they still have potential adverse side effects. Also, many former prescription drugs, such as ibuprofen and certain allergy and anti-fungal preparations, are now sold OTC. Although the dosage may be smaller than their prescription counterparts, they have a similar potential for side effects.

Most nonprescription drugs are designed to treat minor medical problems, such as coughs, colds, and minor infections. Regardless of the nature of the ailment, carefully follow all instructions for use, paving particular attention to dosage. This is especially important if you are taking medication for coexisting medical problems. Many OTC cold and allergy medications, for example, can exacerbate high blood pressure and glaucoma; others interact with medication to alter their effectiveness. If in doubt, ask your pharmacist. He can outline various options, and may suggest seeing a doctor if self-treatment is ill-advised or prolonged treatment with an OTC drug is unwise. Be especially cautious about administering OTC medication to children; in such cases, it is always best to check with a doctor beforehand.

Drug Dependency

Some drugs are potentially habit-forming, or addictive, meaning the user can become physically or psychologically dependent on them. Physical dependence is manifested by withdrawal symptoms when the user attempts to abstain from the drug. At the same time, increasing amounts are needed to forestall withdrawal symptoms. Psychological dependence is marked by constant craving for the drug and its effects. Physical and psychological dependence often coexist, making it even more difficult to stop taking the drug.

The amount of lime it takes to develop drug dependency varies according to the drug, its dosage, and frequency and duration of use. People who are already addicted to nicotine, alcohol, or other substances are especially vulnerable to dependency on a habit-forming medication. Fortunately, only a few groups of medications result in physical dependence; examples include morphine and other opium derivatives, narcotics, antidepressants and anti-anxiety drugs, sleeping pills, and stimulants. Although many of these medications have important medical uses, they also have a high potential for abuse as so-called recreational drugs. To differentiate among their potential risks, addictive drugs have been placed in the following controlled substance categories:

• C-I, which has a high risk for physical and psychological abuse. Prescriptions are strictly limited and may not be refilled. Examples of drugs falling into this group include some opiates (derivatives of opium) and hallucinogens.
• C-II, which has a high risk of both physical and psychological dependence. Prescriptions must be written and signed by a physician and cannot be refilled. Some examples include narcotics, amphetamines, and some barbiturates.
• C-III, which may result in a high psychological dependence and a low-to-moderate physical dependence Prescriptions for these drugs may be written or issued verbally by a doctor to a pharmacist. Up to five refills are allowed during a six-month period. Examples include certain antianxiety drugs, sleeping pills, and many other psychotropic drugs.
• C-IV, which has a low potential for physical and psychological dependence. Physician prescriptions may be written or verbal. Up to five refills of the prescription may be filled during a six-month period. Examples include some barbiturates, propoxyphene, and benzodiazepines.
• C-V, which has a low potential for physical and psychological dependence but may be subject to regulations in some states. A prescription may not always be needed, and there is no limit on refills. Examples include antidiarrheal agents and cough medicines containing mild narcotics.