Patient Self-Care and Nonprescription Drugs in Health Care

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Patient Self-Care and Nonprescription Drugs in Health Care Jeff Taylor, PhD Date of Revision: January 2013

Introduction

Self-care has been common practice across centuries of human history. From perhaps the dawn of humanity, we have been applying mud packs and wraps, chewing on leaves and roots and offering up chants, all for the betterment of our health. Modern therapies are obviously more sophisticated, but self-care still represents a cornerstone of health care. Self-care is in fact being promoted in many countries as part of a public policy agenda. The main impetus is to divert people from the formal system to save resources while hopefully still meeting acceptable levels of care. Health-related activity can be described as a continuum, from 100% self-care (e.g., brushing one's teeth) to 100% professional care (e.g., neurosurgery).1 Self-care represents the actions taken by individuals for their own well-being and involves healthy choices, avoidance of risk factors, recognition of one's symptoms and aspects of self-management. Minor illnesses represent an important aspect of self-care, given that the public is more apt to self-treat such ailments. Generally speaking, minor illnesses are short term, trivial and self-limiting. The types that occur are diverse and common. The most common in Canada have been muscle aches and pains, cold or flu, headaches, cough, back pain, heartburn or indigestion, allergies, insomnia and menstrual cramps.2 Ten situations accounted for 75% of the costs associated with minor ailment consultations in the United Kingdom: back pain, indigestion, dermatitis, nasal congestion, constipation, migraine, acne, cough, sprains/strains and headache.3 Over 90% of British citizens have experienced at least 1 minor health problem in their past, with an average of 5.2 occurring within a 2-week period.4 The bulk of these events do not enter the formal health care system, yet a substantial number of medical visits still occur each year for such reasons. Obviously, when symptoms become chronic or more severe, they would no longer be considered minor. Discussions of self-care and minor illness often go hand in hand, but they are not the same. Self-care is the broad approach taken for the target illness, be it minor or otherwise. The following examples aid in differentiating the two. A person might seek medical care for a minor illness, disregarding any self-care measures in the process. A common example would be visiting a doctor for a cold rather than staying home and drinking hot fluids. On the other hand, a person can engage in self-care activities for a serious illness. Elevating one's feet when they are swollen due to heart failure is an example. Recognition is growing that serious chronic conditions do involve a tremendous investment of self-care.5

The Public's Response to Illness

When people feel ill, a complex process is initiated to determine how best to return to health. This includes an assessment of symptom severity and the impact on day-to-day life, all within the context of their present health, social circumstances, finances and other forces. Several options may be considered: do nothing (wait-and-see approach), use a nonmedicated form of treatment (like a warm compress or bed rest), take some form of medication or opt to seek professional care. In the United Kingdom, 87% report self-treating minor illnesses often, with 42% saying they do it all the time.6 Americans took the following actions for their most recent health condition (multiple responses allowed): used a nonprescription/over-the-counter (OTC) drug (77%), adopted a wait-and-see approach (69%), consulted a doctor (43%) or used a prescription medicine (38%).7 Symptom-specific management is shown in Table 1. In broad terms, people tend to self-treat symptoms such as cold, flu, cough, sore throat, headache, heartburn, constipation and indigestion. When people experience backache, red eyes, depression and chesty cough, they prefer to consult health professionals.2,4,8,9

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If minor ailments do not overly interfere with normal activities, doing nothing is the common approach. Situations most likely to be left untreated in the United Kingdom have been thinning hairline, bruises and tiredness.10 If the situation exceeds the comfort level for self-assessment, a person may ask for advice. This is not a given, of course, as some may still engage in self-care inappropriately. Before involving professional care, however, many may have already attempted some form of action.11,12 Research in the 1970s found that an OTC medicine was used within the first 4 hours in nearly half of acute minor illnesses.13 More recently, 81% of American adults claimed to use OTC medicines as a first response to minor ailments.14 In Scotland, 45% of patients seeing their doctor reported using OTC medicines in the past 7 days.15 Table 1: Treatment Options Chosen by American Patients When Experiencing a Health Condition for the First Time Health Condition

Use an OTC

Wait-and-See Approach

7

Consult Doctor

Headache

54%

34%

4%

Skin problems

51%

26%

8%

Heartburn/indigestion

43%

35%

8%

Cough/cold/flu/sore throat

42%

34%

not available

Allergy/sinus

40%

31%

13%

Muscle/joint/back pain

30%

37%

16%

Minor eye problems

29%

37%

19%

Constipation/diarrhea

26%

40%

not available

Self-Medication Pros and Cons of Self-Medication

There is benefit in the self-medication of minor ailments; it is safe and effective when done within appropriate parameters. Self-medication can free up both patient time and physician workload, reducing costs and the number of emergency-room visits. Physicians have stated that many consults involve minor illnesses that could be handled by less formalized care.3,14,16,17,18,19,20 Another benefit is there may be a sense of accomplishment in effectively caring for one's own health, which may motivate a person to take on more responsibility in that regard. Conversely, attempts at self-care and self-treatment can sometimes delay professional care and may worsen some conditions, leading to serious and/or costly complications. Less monitoring by a health care professional carries a degree of risk. At the time H2-receptor antagonists were switched to nonprescription status, British physicians were concerned that serious conditions could be masked, diagnoses missed, control by the doctor lost and that drugs could potentially be used inappropriately by patients.21 While nonprescription medications have favourable safety profiles, as medicines they still have the potential for side effects and drug interactions. Self-medication has financial implications. OTC medicines may be less expensive than those prescribed for a patient (depending on insurance coverage). Self-medication can reduce the financial burden on government health care budgets, with those costs tending to be transferred to the public. American industry data suggest that every dollar spent on OTC medicines saves the American health care system $6–7.22 Canadian industry figures determined that if the 16% of people who saw a doctor for mild cold or flu symptoms practised self-care instead, it would save $98 million annually.23

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Several authorities have considered using OTC sales figures as an early detection system for public health concerns (including infectious outbreaks).24,25,26

Patterns of Medicine Use Approximately 3000 OTC products (excluding herbals with NHP status) are available for human use in Canada.27 More than 100 000 OTC products (encompassing about 1000 active ingredients) were available in the United States in 2001.28 The self-care product industry in Canada generated approximately $4 billion in sales in 2010.29 A year earlier, OTC medicines and personal health supplies represented 16.1% of all drug expenditure in Canada.30 By category, some of the main areas were analgesics ($530 million), vitamins ($356 million), cough and cold ($218 million), allergy and sinus ($171 million), upset stomach ($138 million), first aid ($110 million) and laxatives ($104 million).29 Many people frequently turn to these agents for symptom relief; they are an essential component of most health care systems. Six of the 10 most frequently used medicines in the United States (including the top 4) were available without prescription.31 More Americans (59%) had taken an OTC during a 6-month period in 2001 than a prescription drug (54%).8 Those who did used an average of 2.2 OTCs per month; slightly over one-quarter were taking 3 or more agents. Almost three-quarters of older adults using prescribed medicines were concurrently using OTC medicines, dietary supplements, or both.32 Over a 30-day period, 53.7% of 3-year-old children had been given an OTC product.33 In Canada, the Be MedWise survey found that 66% had purchased a nonprescription product within the past 6 months; as many as 12% were using 1 daily.34 Industry data found the figure for daily use more likely to approach 40%.35 Over half of Ontario seniors were reported to be using one or more OTC medicines.36 The propensity for use varies with social factors such as gender, age, geographic location, social class (education and income), marital status, health status and race. Women appear to have higher consumption rates than men.7,37,38,39 Young adults can also be prominent users of OTCs.40,41 The specific types of OTCs change with age.42 The elderly use more laxatives than youths, while the opposite trend has been found for analgesics.43 In Canada, young adults have tended to use a wide range of products on an infrequent basis, whereas the elderly have lower consumption rates overall but are heavier users of a limited number of products. Seniors may be more inclined to seek professional care for symptoms.44 People with higher levels of education and household incomes may be more likely to use OTCs.41,43,45,46

Sources of Health Care Advice

Most people are likely to suffer through multiple episodes of minor ailments. Action will be taken and its value ascertained by the user. Over time, a repertoire of skills will evolve based on those experiences. People likely learn about health issues by first attempting to deal with them on their own. They consider the information they already have: things they have read or seen in the media and learned from personal experience. If this fails, they will look beyond themselves to seek advice from a circle of family, friends and other trusted intimates.47 The role of lay information channels such as family and friends cannot be underestimated. Perhaps because they possess less experience, younger adults may consult family and friends more often than older adults. If they are still unsuccessful, they will move on to a third circle to consult with experts. This could be more common for first instances or in rare situations. As might be expected, people tend to look for information on a condition once it affects them, not before. Few participants in Canadian focus groups (besides young mothers) had made any attempt to learn about self-care before being afflicted with a specific ailment.48 Canadians do, however, claim they seek out information on the products they use, albeit more for prescribed agents than OTCs.40 Women and those 35 years and over were among those most likely to regularly seek information for first-time medicine use. In a survey in which people were asked to consider an antacid, a cold medicine, a laxative or an analgesic, young and older adults responded similarly regarding the extent to which they read product labels.49 Older adults took almost twice as much time as younger adults to view information, but were also more organized in their searches. Both groups took less time to

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review information about pain relievers as almost all subjects had previously used or purchased them. Package labelling provides critical information to OTC medicine users. In most countries, a medicine that cannot be taken safely and effectively by following directions provided on (and in) the package is likely to remain on prescription. Accordingly, much interest has been shown in the readability of information and the public's propensity to read it. Of further concern are adult literacy and numeracy skills. Industry data indicate that 91% of Canadians claim to read labels carefully before using a product for the first time37 and appear to be satisfied with it.45 Re-reading a label was necessary for 77% of Americans when giving the agent to a child or if they hadn't read the label for some time (70%).8 British patients surveyed during medical visits also indicated strong agreement for reading package instructions when taking a medicine for the first time.50 There are less enthusiastic results. Older Canadian government data (1990) found that 62% of participants stated they always read labels, 16% often read them, 9% reported sometimes, 6% did this seldom, while 7% never read them.51 National consumer surveys in the United States and Canada suggest that most people do not read all of the information appearing on the package prior to first purchase.8,52 Only 40% of Canadians read active ingredients, followed by the dosage (34%), the symptoms the drug treats (26%), possible side effects (23%), directions for use (18%) and warnings (10%) when buying a product for the first time.52 Americans were asked to indicate which information source(s) they had used within a 6-month period. The top 4 sources were advertising or promotion from TV/newspaper/magazines (49.7%), followed by a doctor (47%), articles or information from TV/newspaper/magazines (46%) and a pharmacist (38%).8 A Canadian survey showed that 65% of respondents always/often obtained OTC information from pharmacists, followed by advertising (63%), media reports (57%), word of mouth (53%), physicians (34%), product labels (20%) and the Internet (10%).53 Internet use has undoubtedly grown. A keyword search of “health” on the Internet in 2005 netted 473 000 000 hits.54 Yet, some evidence at the time suggested most people actually searched for health information rather infrequently.55,56 Today, to be used successfully it still requires a skill set (eHealth literacy) that not all possess.57,58 Nonprescription medicine purchases over the Internet may have inherent risks as well.59,60 Many in health care may question its value, but at least one review suggested the Internet has generally had a positive impact on consumer health.61 For many, doctors and pharmacists are the most accessed sources of information; doctors are seen as a first choice for some.62 Mothers in the United Kingdom often consulted a pharmacist if their children had coughs, colds, aches and pains, but turned to their doctor for childhood fever, sickness, diarrhea and rashes.63 Other people turn to their pharmacist first when professional intervention is considered. Patients may have a breakpoint as to when it is acceptable to seek care. Subjects were asked to consider situations such as cough today versus cough for several days and diarrhea today versus diarrhea for several days.64 While higher risk was attributed to the longer-lasting scenarios, it appeared to be less risky from a social perspective to discuss a problem if it had persisted for several days. In other words, it may be less embarrassing at that point. A desire not to bother a doctor or waste his/her time has been observed.65,66 With the advent of telehealth help lines in some jurisdictions and the rise of sharing health experiences using social media,67 the dynamics of how or when the public turns to physicians or pharmacists (or any other source) may change.

Regulations Global Perspectives

Nonprescription medications are regulated in all Western countries. Differences exist, however, among the drugs that are classified as nonprescription and the nature of these restrictions.68,69,70 The Netherlands added a new OTC category in 2007 to allow greater product access. Before that, all agents were restricted to pharmacy sale. Contact with a pharmacist is now not required. Italy recently relaxed requirements for sale by making all OTCs

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available in nonpharmacy outlets, but a pharmacist must be on the premises in any outlet that sells them. Australia and New Zealand have a prescription category and 3 OTC categories: behind-the-counter (BTC), pharmacy-only and OTC. France has 4 drug schedules. Britain has BTC and OTC categories for nonprescription medicines, where the OTC category allows for sale from nonpharmacy outlets. Its BTC category is under the supervision of a pharmacist, but counter assistants can be involved in some transactions. In Britain, pharmacists have been advised to use structured counselling protocols when discussing OTC medicines with the public.71 There is less pharmacy control in the United States, where a nonprescription product may be sold from any retail outlet. However, many drugs available without prescription in other parts of the world require prescriptions in the United States. The American pharmacy profession has lobbied for years to obtain a pharmacist-only category of drug distribution (a third category of medicine). Supporters state such a move would better ensure public safety as agents are switched to OTC status. There is also concern that the sale of potent agents is increasingly in the hands of unskilled retailers. Opponents of the category argue that it goes against free-market principles and that stringent labelling requirements are enough to ensure public safety. Some states have adopted the spirit of a pharmacistcontrolled category in an effort to curb pseudoephedrine diversion to crystal meth production. As of 2012, the Food and Drug Administration (FDA) is considering the value of approving drugs that would otherwise require a prescription for OTC status if specific restrictions are followed.72

Canadian Drug Schedules

In 1991, Health Canada initiated steps to change the drug scheduling system. The main thrust was to harmonize the 10 provincial systems already in place, enabling firms to advertise nationally and allowing the public to purchase products under similar conditions in each province. Previously, significant differences existed across jurisdictions; a product sold in 3 provinces could have had 3 different conditions of sale. The legislation resulted in 4 drug categories: a prescriptive schedule, sale by pharmacists only (BTC, no public access), pharmacy-only sale and a category where no sales restrictions apply (unscheduled). The National Association of Pharmacy Regulatory Authorities (NAPRA) developed scheduling criteria corresponding to the level of professional intervention and advice necessary for the safe and effective use of drugs by consumers. Drug scheduling is now guided by an advisory committee of NAPRA, the National Drug Scheduling Advisory Committee (NDSAC). When NDSAC considers the placement of a drug, the drug is assessed for a series of factors for each schedule. The factors are based on differing degrees of counselling or supervision necessary to encourage appropriate use. Progressively less professional control is required in moving from Schedule I to Unscheduled (Table 2). The usual impetus for considering a change in drug status is by manufacturer request. Table 2: Canadian Drug Schedules Schedule I

Drugs that require a prescription as a condition of sale.

Schedule II

Drugs that are available only from a pharmacist and without a prescription. There is no opportunity for patient self-selection.

Schedule III

Drugs that are available without a prescription from the self-selection area of a pharmacy, which is operated under the direct supervision of a pharmacist.

Unscheduled

Drugs not listed in Schedules I, II, or III that may be sold from any retail outlet. Unscheduled drugs can be sold without professional supervision.

A drug under review is first assessed using the factors for Schedule I (prescription). Should sufficient factors apply, the drug remains in this schedule. If not, the drug is assessed against the factors for Schedule II. One factor in Schedule II is as follows: the drug may cause serious or significant adverse drug reactions or drug interactions that cannot be adequately addressed through product labelling. If the agent fails to meet the stipulations of this schedule, it is subsequently assessed against the factors in Schedule III (pharmacy-only). One Schedule III example is: the drug is a new ingredient for self-medication and the availability of the pharmacist to provide advice can promote appropriate use. Should the drug not meet the factors for any schedule, it becomes unscheduled and can be sold in any retail outlet. Canadian pharmacists appear to favour tighter control for some existing

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unscheduled agents,73 and have reservations about lessening restrictions on 3 agents used in chronic conditions (simvastatin, omeprazole, fluticasone).74

Professional Control of Pharmacist-Only (Schedule II) Products

When a patient describes symptoms to a pharmacist, the course of action to be taken is clear: the patient and symptoms will be assessed and a recommendation made. Most requests for a pharmacist-only product, however, occur as a result of a product request at the counter specifically by name. Symptoms may not even be mentioned. When a patient directly asks for a Schedule II product by name, to what extent should pharmacists assess the purchase? Product requests made in this manner can be problematic.75 British pharmacists have stated that detailed questioning may not be necessary when consumers request specific products and may even be counterproductive in terms of customer satisfaction.76 A similar position is that pharmacists must be readily available to advise pharmacy customers, but do not necessarily have to be involved in every request for a medicine.77 Pharmacists may face a professional dilemma in this area. Many customers request medicines they have used before. Under these circumstances, questioning from a pharmacist may be perceived as interference or interrogation. Conversely, the sale of medicines without professional input could impact on patient care and may weaken the argument for restricting them to BTC status. Previous use does not guarantee the agent is being used correctly. In recognition of the problem, the International Pharmaceutical Federation stated:78 When a nonprescription medicine is requested by name, the pharmacist should not assume that the inquirer has adequate knowledge of the medicinal product. In all cases the person should be asked if any other medication is being taken and if the medicine has been used previously before deciding whether the medicine requested is appropriate for supply or whether it is necessary to ask additional questions before deciding on the advice to be given.

The Role of the Pharmacist in Self-Care

Advising consumers on self-care is one of the pharmacist's main responsibilities. Duties are outlined in the standards of pharmacy practice, including those of NAPRA. In general, when requested or deemed appropriate, a pharmacist will assess the patient's situation and then consider one of three recommendations: provide assurance that drug therapy is unnecessary; suggest treatment with nondrug measures or a nonprescription drug, or both; or refer the patient to the appropriate medical practitioner. Controlling abuse of such agents as codeine, dextromethorphan, dimenhydrinate and pseudoephedrine continues to be an important aspect of practice. Pharmacist roles have grown to include prescribing for minor ailments as well as post-marketing surveillance.79 A tremendous number of consultations take place every year in pharmacies. Over a 5-month period in British Columbia, pharmacists in 56 pharmacies were involved in 3480 interventions involving OTC products.80 On a national scale, the Community Pharmacy Intervention Study (CPhIS) provided data from 524 pharmacies.81 According to pharmacist records, requests for advice on minor illness were made an average of 2.8 times a day (range 0 to 36), although significant underreporting was possible. Accounting for that (then extending the figures to a national level), Canadian pharmacies would have made nearly 50 000 interventions each business day or over 15 million interventions during the year (1993). When consumers make purchases in pharmacies, however, most transactions occur without a pharmacist's assistance. Product sales have been tracked in pharmacies in Ireland; 632 medicines were purchased during the study period, of which 22.3% were sold with advice.38 In Australian pharmacies, 27.5% of transactions involved advice following symptom presentation.82 A small Canadian study observed 860 consumers in one city making purchases; 11.6% received advice when selecting a product.83 Consumers generally initiate the interaction and appear ready to accept recommendations made by pharmacists. Pharmacist assistance in the product selection process has shown value for the health care system. CPhIS data suggested that pharmacist interventions could save the system $265.6 million per year.81 Interventions by pharmacists

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have been tracked to assess the impact on identification of drug-related problems (DRPs).84 Researchers in California directed pharmacy students to offer help to consumers as they were inspecting a particular product. Over 12 weeks, 277 encounters took place and of these, it was felt that 7.2% involved the potential for people to purchase the wrong medication.85 The same team later expanded the project to 5 pharmacies within the state.86 1.3% of customers were referred to a physician, 13.4% ended up not buying a product and 25.4% purchased a different product than intended (although this was mainly based on trade name-to-generic conversion).

Implications/Conclusions

Self-care and self-medication will continue to be powerful forces in society and for health care professionals. Understanding how consumers use them for minor illnesses is important, more so as growing numbers of increasingly potent prescription products are considered for reclassification to nonprescription status.87,88,89,90,91 Concern continues about adverse events associated with all medicines, including OTCs. Pharmacists have a key role in reducing risk during use. It is also crucial that the public appropriately perceive OTCs as medicines that require careful use. That said, the potential to safely self-medicate has never been better. Hundreds of self-help brochures are available to aid the consumer. Pharmacists and physicians continue to provide support. The Internet has many portals for minor illness and phone-in lines (either stand-alone or associated with a product) are available. Perspective on the dynamics of product use is important. For example, one report found that over a 1-year period, 41% of consumers used 3–5 agents, with 7% using 6 or more.37 Though this amount of medication use may seem concerning, 6 items in 1 year could simply mean a muscle relaxant and topical external analgesic used in January (for a slip on the ice), using acetaminophen several times for headaches, a decongestant for 3 days in November for a cold, an eyewash in June on particularly dusty days and doses of antacid after big family suppers during various holidays. Depending on the data collection approach, adding dry skin lotion and a multivitamin increases the number to 8 agents, all conceivably being used appropriately. While information of this type must continue to receive attention, the raw numbers may not adequately describe safety of use. Pharmacists have a balancing act to perform: being aware of patients' need for information, intervening when problems arise, continuing to build public perception that nonprescription products are medicines requiring due care, but at the same time not being paternalistic and impinging on patients' opportunity to choose medication.

Suggested Readings

Blenkinsopp A, Bond C. Over-the-counter medication. British Medical Association; May 2005. Boardman H, Lewis M, Croft P et al. Use of community pharmacies: a population-based survey. J Public Health 2005;27:254-62. Brass EP, Shay LE, Leonard-Segal A. Analysis of multiple endpoints in consumer research in support of switching drugs from prescription to over-the-counter status: the concept of end-point hierarchies. Clin Pharmacol Ther 2009;85:369-74. Ertmann RK, Reventlow S, Soderstrom M. Is my child sick? Parents' management of signs of illness and experiences of the medical encounter: parents of recurrently sick children urge for more cooperation. Scand J Prim Health Care 2011;29:23-7. Gray NJ, Cantrill JA, Noyce PR. Health repertories: an understanding of lay management of minor ailments. Patient Educ Couns 2002;47:237-44.

References 1. Webber DE, Williams JR. A discussion paper on the future of self care and its implications for physicians. World Med J 2006;52:66-72. 2. Consumer Health Products Canada. Treatment choices for common ailments. August 1999.

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3. Moberly T. Making the case for a pharmacy-based minor ailments scheme for England. Pharm J 2008;280:111. 4. Proprietary Association of Great Britain. Moss C, Kennedy J. Encouraging self-care in a primary care setting. Available from: www.medicinechestonline.co.uk. Accessed September 21, 2012. 5. Royal Pharmaceutical Society of Great Britain. The self-care challenge: a strategy for pharmacists in England. London: RPSGB; March 2006. 6. U.K. National Health Services. Department of Health. Public attitudes to self care: baseline survey, February 2005. 7. Self-care in the new millennium: American attitudes towards maintaining personal health and treatment. Consumer Healthcare Products Association and Roper Starch Worldwide Inc; 2001. 8. Harris Interactive; National Council on Patient Information and Education. Attitudes and beliefs about the use of over-the-counter medicines: a dose of reality: a national survey of consumers and health professionals. January 2002. Available from: www.bemedwise.org/survey/final_survey.pdf. Accessed September 21, 2012. 9. Vingilis E, Brown U, Hennen B. Common colds. Reported patterns of self-care and health care use. Can Fam Physician 1999;45:2644-52. 10. British Market Research Bureau International; Proprietary Association of Great Britain. Every day healthcare 2. June 5, 1997. Available from: www.pagb.co.uk/information/PDFs/BMRBstudy1997.pdf. Accessed December 1, 2009. 11. Banks I. Self care of minor ailments: a survey of consumer and healthcare professional beliefs and behavior. SelfCare 2010;1:1-13. 12. Consumers tough it out in tough times. Over-the-counter medications. The Nielsen Global Online Consumer Survey, The Nielsen Company, March 2009. 13. Knapp DE, Oeltjen PD, Knapp DA. Anatomy of an illness (as perceived by consumers in a longitudinal study). Med Market Media 1974;9:20-2. 14. Consumer Healthcare Products Association. In: Your health at hand: perceptions of over-the-counter medicine in the U.S. Washington: CHPA; 2010. 15. Urquhart G, Sinclair HK, Hannaford PC. The use of non-prescription medicines by general practitioner attendees. Pharmacoepidemiol Drug Saf 2004;13:773-9. 16. Hassell K, Whittington Z, Cantrill J et al. Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies. BMJ 2001;323:146-7. 17. Hammond T, Clatworthy J, Horne R. Patients' use of GPs and community pharmacists in minor illness: a crosssectional questionnaire-based study. Fam Pract 2004;21:146-9. 18. Morris CJ, Cantrill JA, Weiss MC. GPs' attitudes to minor ailments. Fam Pract 2001;18:581-5. 19. Porteous T, Ryan M, Bond CM et al. Preferences for self-care or professional advice for minor illness: a discrete choice experiment. Br J Gen Pract 2006;56:911-7. 20. Welle-Nilsen LK, Morken T, Hunskaar S et al. Minor ailments in out-of-hours primary care: an observational study. Scand J Prim Health Care 2011;29:39-44. 21. Erwin J, Britten N, Jones R. General practitioners' views on the over-the-counter availability of H2-antagonists. Br J Gen Pract 1997;47:99-102. 22. Consumer Healthcare Products Association. The value of OTC medicines to the United States. Washington: CHPA; 2012. 23. Willemsen KR, Harrington G. From patient to resource: the role of self-care in patient-centered care of minor ailments. SelfCare 2012;3:43-55. 24. Das D, Metzger K, Heffernan R et al. Monitoring over-the-counter medication sales for early detection of disease outbreaks–New York. MMWR Morb Mortal Wkly Rep 2005;54:41-6. 25. Vergu E, Grais RF, Sarter H et al. Medication sales and syndromic surveillance, France. Emerg Infect Dis 2006;12:416-21. 26. Edge VL, Pollari F, Lim G et al. Syndromic surveillance of gastrointestinal illness using pharmacy over-thecounter sales. A retrospective study of waterborne outbreaks in Saskatchewan and Ontario. Can J Public Health 2004;95:446-50. 27. Personal communication. Gerry Harrington, Director of Public Affairs, Consumer Health Products Canada; September 11, 2012. 28. Consumer Healthcare Products Association. Press Room: Media materials on important topical issues. Available from: www.chpa-info.org/pressroom/OTC_FactsFigures. Accessed September 7, 2012. 29. Wood V. 2011 OTC Market Report: non-prescription sales hold steady. Drugstore Canada 2011;4:13-4, 21.

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30. Canadian Institute for Health Information. Drug expenditure: prescribed and non-prescribed drugs. Outlook–2010 and 2011. In: Drug expenditure in Canada, 1985 to 2011. Ottawa: CIHI; 2011 31. Kaufman DW, Kelly JP, Rosenberg L et al. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone Survey. JAMA 2002;287:337-44. 32. Qato DM, Alexander GC, Conti RM et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 2008;300:2867-78. 33. Kogan MD, Pappas G, Yu SM et al. Over-the-counter medication use among US preschool-age children. JAMA 1994;272:1025-30. 34. Canadian Pharmacists Association; Drug Information and Research Centre. Survey on Canadians' use of OTC medications: the Be MedWise Survey 2004. Available from: www.bemedwise.ca/english/usagesurvey.html. Accessed September 21, 2012. 35. Consumer views of safety and efficacy issues related to consumer health products and natural health products. Redfern Research; July 2010. 36. Ballantyne PJ, Clarke RJ, Marshman JA et al. Use of prescribed and non-prescribed medicines by the elderly: implications for who chooses, who pays and who monitors the risks of medicines. Int J Pharm Pract 2005;13:133-40. 37. Consumer usage and attitude study: volume I. Toronto: Canadian Facts; 1991. 38. Fisher CM, Corrigan OI, Henman MC. A study of community pharmacy practice: 3. Non-prescribed medicines sales and counseling. J Soc Admin Pharm 1991;8:69-75. 39. Obermeyer CM, Price K, Schulein M et al. Medication use and gender in Massachusetts: results of a household survey. Health Care Women Int 2007;28:593-613. 40. Health Canada. Public opinion survey on key issues pertaining to post-market surveillance of marketed health products in Canada: final report. Toronto: Decima Research; 2003. Available from: www.hc-sc.gc.ca/dhpmps/alt_formats/hpfb-dgpsa/pdf/medeff/decima_2003_final_rep-rapp-eng.pdf. Accessed September 21, 2012. 41. Boardman H, Lewis M, Croft P et al. Use of community pharmacies: a population-based survey. J Publ Health (Oxf) 2005;27:254-62. 42. Barat I, Andreasen F, Damsgaard EM. The consumption of drugs by 75-year-old individuals living in their own homes. Eur J Clin Pharmacol 2000;56:501-9. 43. Stoehr GP, Ganguli M, Seaberg EC et al. Over-the-counter medication use in an older rural community: the MoVIES project. J Am Geriatr Soc 1997;45:158-165. 44. Consumer Health Products Canada. NDMAC consumer profile: the nonprescription drug user. Ottawa: NDMAC; 1997. 45. Consumer Health Products Canada. HealthVision 1999/2000. Ottawa: NDMAC. 46. Ryan A, Wilson S, Taylor A et al. Factors associated with self-care activities among adults in the United Kingdom: a systematic review. BMC Public Health 2009;9:96. 47. Wallace P. On the edge of great change: linking health information resources in the Thames Valley District: a report to the Health Information Access Committee. London: Thames Valley District Health Council; June 1996. 48. Focus groups findings: the BC HealthGuide. Ipsos Reid for the Nonprescription Drug Manufacturers Association of Canada; September 2003. 49. Johnson MM, Drungle SC. Purchasing over-the-counter medications: the influence of age and familiarity. Exp Aging Res 2000;26:245-61. 50. Bradley CP, Riaz A, Tobias RS et al. Patient attitudes to over-the-counter drugs and possible professional responses to self-medication. Fam Pract 1998;15:44-50. 51. Attitudes, perceptions and behaviour relating to ethical medicines: a research report to the Department of National Health and Welfare. Ottawa: Decima Research; 1990. Available from: dsp-psd.pwgsc.gc.ca/Collection /H42-2-43-1990E.pdf. Accessed September 21, 2012. 52. OTC habits and practices—Be MedWise survey. Toronto: Drug Information and Research Centre; 2002. 53. Wood V. OTC knowledge from spectrum of sources. Pharm Post 2002:67. 54. Ybarra ML, Suman M. Help seeking behavior and the Internet: a national survey. Int J Med Inform 2006;75:29-41. 55. Rice RE. Influences, usage, and outcomes of Internet health information searching: multivariate results from the Pew surveys. Int J Med Inform 2006;75:8-28. 56. Eysenbach G, Kohler C. Health-related searches on the Internet. JAMA 2004;291:2946. 57. Norman CD, Skinner HA. eHealth literacy: essential skills for consumer health in a networked world. J Med

03-Mar-16 2:12 PM

Patient Self-Care and Nonprescription Drugs in Health Care

10 of 11

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

Internet Res 2006;8:e9. 58. Hill JH, Burge S, Haring A et al. Communication technology access, use, and preferences among primacy care patients: from the Residency Research Network of Texas (RRNeT). J Am Board Fam Med 2012;25:625-34. 59. Bessell TL, Anderson JN, Silagy CA et al. Surfing, self-medicating and safety: buying non-prescription and complementary medicines via the internet. Qual Saf Health Care 2003;12:88-92. 60. Wallace LS, Rogers ES, Turner LW et al. Suitability of written supplemental materials available on the Internet for nonprescription medications. Am J Health Syst Pharm 2006;63:71-8. 61. Renahy E, Chauvin P. Internet uses for health information seeking: a literature review. Rev Epidemiol Sante Publique 2006;54:263-75. 62. Statistics Canada. Health access services survey 2001—key findings. 63. Hodgson C, Wong I. What do mothers of young children think of community pharmacists? A descriptive survey. J Fam Health Care 2004;14:73-9. 64. Charupatanapong N, Rascati KL. An analysis of consumers' risk perceptions of their self-medication practices. J Pharm Mark Manage 1991;5:53-78. 65. Hassell K, Harris J, Rogers AE et al. The role and contribution of pharmacy in primary care. National Primary Care Research and Development Centre, University of Manchester; December 1996. 66. McIntyre J, Conroy S, Collier J et al. Use of over-the-counter medicines in children. Int J Pharm Pract 2003;11:209-15. 67. Ziebland S, Wyke S. Health and illness in a connected world: how might sharing experiences on the internet affect people's health? Milbank Q 2012;90:219-49. 68. U.S. Government Accountability Office. Nonprescription drugs. Considerations regarding a behind-the-counter drug class. GAO; February 2009. Available from: www.gao.gov/products/GAO-09-245. Accessed September 21, 2012. 69. Gilbert A, Rao D, Quintrell N. A review of pharmaceutical scheduling processes in six countries and the effect on consumer access to medicines. Int J Pharm Pract 2006;14:95-104. 70. Association of the European Self-Medication Industry. OTC ingredients. Available from: www.aesgp.eu/factsfigures/otc-ingredients. Accessed September 13, 2012. 71. Medicine sales to need written protocols and staff training. Pharm J 1994;253:89. 72. Soller RW. Editorial: Safe use conditions proposed by FDA may re-open door for switch in us: has the OTC drug facts label fallen victim to the Peter Principle? SelfCare 2012:3:19-20. 73. Taylor J, Landry E, Lalonde L et al. Results of a national survey on over-the-counter medicines, Part 1: Pharmacist opinion on current scheduling status. Can Pharm J 2012;145:40-4. 74. Lalonde L, Tsuyuki RT, Landry E et al. Results of a national survey on OTC medicines, Part 2: Do pharmacists support switching prescription agents to over-the-counter status? Can Pharm J 2012;145:73-6. 75. Kelly FS, Williams KA, Benrimoj SI. Does advice from pharmacy staff vary according to the nonprescription medicine requested? Ann Pharmacother 2009;43:1877-86. 76. Missed professional and commercial opportunities, says POM to P group. Pharm J 1996;257:205. 77. CA criticism “confusing”, says President. Pharm J 1994;252:768. 78. FIP adopts policy on self-care and self-medication. Pharm J 1996;257:373-4. 79. Sinclair HK, Bond CM, Hannaford PC et al. Pharmacovigilance of over-the-counter products based in community pharmacy: a feasible option? Pharmacoepidemiol Drug Saf 1999;8:479-91. 80. Kerr-Eng S, Stratton T. Nonprescription drug counselling. Can Pharm J 1993;126:464. 81. Loh E, Waruszynski B, Poston J. Cost savings associated with community pharmacist interventions in Canada: a preliminary economic evaluation of the CPhIS data. Can Pharm J 1996;129:43-7,52-5. 82. Stewart K, Garde T, Benrimoj S. Over-the-counter medication sales in community pharmacy: A. Direct product requests and symptom presentation. Aust J Pharm 1985;66:979-82. 83. Taylor J, Suveges L. Frequency of consumer-pharmacist interaction during the selection of non-prescription medications. Can Pharm J 1994;127:27-30. 84. Eickhoff C, Hammerlein A, Griese N et al. Nature and frequency of drug-related problems in self-medication (over-the-counter drugs) in daily community pharmacy practice in Germany. Pharmacoepidemiol Drug Saf 2012;21:254-60. 85. Nichol MB, McCombs JS, Boghossian T et al. The impact of patient counseling on over-the-counter drug purchasing behavior. J Soc Adm Pharm 1992;9:11-20.

03-Mar-16 2:12 PM

Patient Self-Care and Nonprescription Drugs in Health Care

11 of 11

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

86. Nichol MB, McCombs JS, Johnson KA et al. The effects of consultation on over-the-counter medication purchasing decisions. Med Care 1992;30:989-1003. 87. McIntosh J. Rafie S, Wasik M et al. Changing oral contraceptives from prescription to over-the-counter status: an opinion statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2011;31:424-37. 88. Symonds T, Dean JD, Carr A et al. A feasibility study comparing pharmacist and physician recommendations for sildenafil treatment. J Sex Med 2011;8:1463-71. 89. Kirby M, Phillips G, Carr A. The professional competence of pharmacists in recommending Flomax Relief MR (tamsulosin) to men with lower urinary tract symptoms. Pharm J 2011;286:440. 90. Gauld N, Kelly F, Shaw J. Is non-prescription oseltamivir availability under strict criteria workable? A qualitative study in New Zealand. J Antimicrob Chemother 2011;66:201-4. 91. Gauld N, Emmerton L, Kelly F et al. A new model of prescription to nonprescription reclassification: the calcipotriol case study. Clin Ther 2012;34:1324-32. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 02:11 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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