A pharmacist's look at the supermarket and beyond

Month: October 2014

Trick or Treatment?

Walking the aisles the other day, we came across a couple products that at first intrigued us, then confounded us, and finally concerned us. What caught our eye was Dr. Cocoa’s cough syrup for children. Most large chains carry this stuff, or at least the “non-drowsy” version and the nighttime version. I found it in my market, Wal-Mart and a couple others that I looked at.

The non-drowsy version is a sweetened, chocolate flavored syrup containing 7.5mg/5ml of dextromethorphan (DM). Things like Robitussin DM contain 10mg/5ml of DM and do not have dosing for ages under 12. Dr. Cocoa’s has a 6 to 12 year old take a maximum of 40ml per day for a total of 60mg of DM in a day. The nighttime Dr. Cocoa’s is in the same syrup but has diphenhydramine as its cough controller. Disregarding the possible duplication of active ingredients, there are many reasons why I think Dr. Cocoa may be an over-priced shot of chocolate syrup. I hope you remember diphenhydramine is Benadryl and is also found in many OTC sleep aids.

We just had to try this stuff! I bought a bottle of the non-drowsy syrup and several of our staff, myself, and the interns gave it a try. Reactions varied from, “Wow! This stuff is just like Hershey’s syrup!” to “Um, that made me nauseous.” It did have the look and mouth feel of chocolate syrup, although its main sweetener is sucralose. It does have actual cocoa in it and is very sweet and chocolate-y. So much like chocolate syrup that I was tempted to try it on some plain vanilla ice cream that we had in the freezer. One staff did comment that this stuff would have to be locked up in the liquor cabinet to keep her kids from chugging it down.

Dr. Cocoa’s is marketed for ages 4 to 13, with 5ml every 6 to 8 hours for ages 4 to under 6, 10ml for ages 6-12, and then a big jump to 20ml every 6 to 8 hours for those lucky 13-year-olds. With 20ml, you could warm it up a bit and have yourself a nice hot fudge sundae! No nuts on mine, please.

This whole category is somewhat of a trick though. A study by Penn State published in JAMA showed that neither DM nor diphenhydramine worked any better than placebo! In fact, the winner of the blinded study was plain honey! It is not unreasonable to conclude that the hundreds of cough syrups that we sell are easily replaced by a couple teaspoonfuls of honey. Oh sure, maybe the drowsiness helps us get a good night’s rest and perhaps the sweet syrupy vehicle is what quiets our cough, but the “active ingredients” are really a big waste of money. It’s all in the marketing. Customer belief is one of the strongest indicators of product success.

Let me clear, however, dextromethorphan is a serious drug, just not a great cough suppressant. It is being studied for its neuroprotective abilities in the treatment of Parkinson’s disease and traumatic brain injury. For the clinical minded, DM has “inhibitory effects on glutamate-induced neurotoxicity via NMDA receptor antagonist, sigma-1 receptor agonist, and voltage-gated calcium channel antagonist actions.” Whew! DM is also an abused drug, popular as a cheap and available alternative to Ecstasy. In high doses, DM antagonism of the NMDA receptors can lead to hallucinations and other mental breaks with reality (dissociative effects) and it has SSRI like effects that can lead to serotonin syndrome when coupled with ubiquitous SSRI antidepressants. Do we really want to get our four-year-olds started on a drug like this? In a tasty, sweet, chocolate syrup?

Coughs are often needed.

Let’s take a brief side-track to revisit Robitussin DM. The regular stuff has, per teaspoonful (5ml), 10mg of DM and 100mg of guaifenesin. The Peak Cold version has the same DM but bumps the guaifenesin to 200mg. Either concentration is likely sub-therapeutic since you likely need over 2,000mg/day of guaifenesin to have an effect which means the whole bottle would last an adult for two days and would need to be taken around the clock. Guaifenesin works best in a well-hydrated patient. Mucus should be 90% water and all the guaifensin in the whole bottle will not help if the patient is not well hydrated. On yet another side-track, guaifenesin may help thin cervical mucus as well and so is used to enhance fertility. Sperm much prefer swimming through nice, thin, watery mucus. Guaifenesin is also being tried in fibromyalgia patients. One of the main drawbacks to these high doses is that the effective dose for expectorant action is very close to the emetic dose, resulting in a significant patients that vomit and so discontinue the drug. Just drink your water, your body will thank you.

Last time I had a cold, I drank hot lemonade sweetened with honey and with a bit of ginger. It made me feel better, although that’s all in my mind.

Oh, by the way, if you visit the Dr. Cocoa web site, you’ll likely get a cookie that will pop up ads or coupon offers on other cough and cold pages that you visit. Trick or treat, indeed.

A Decade of Errors

The latest issue of Pediatrics from the American Academy of Pediatrics presents some distressing news for pharmacists and parents. The researchers looked at data from the National Poison Database for the span of 2002 to 2012 and found 696,358 medication errors for patients less than six years old. This calculates to a dosing error in our kids every 8 minutes!

There were some changes in types of errors over the decade, some from changes in which OTC products were available or labeled for use in children under six. After the 2007 review of pediatric meds by the FDA, manufacturers stopped selling cough and cold OTC products for kids under 2, and when the American Academy of Pediatrics stated that these meds were not effective in kids under 6, the product labeling was revised. Pharmacists were in a pickle and many stopped giving any advice on the use of these meds for these kids. Many parents appropriately stopped using them and so this category of dosing error decreased although the rate for meds such as analgesics and antihistamines increased 37%.

The study provides some important data for pharmacists to consider. Notably, over a quarter of the errors occurred in infants under one year old. Dosing errors for analgesics and cough and cold meds were over half the errors. kids' analgesicsNearly 82% of the errors involved liquids. About 27% of the errors were from double dosing the medication. Most errors (93.5%) were managed without hospital intervention, although over 2,000 were admitted to a critical care unit and 25 children died.

Earlier this year the same journal (August 2014) cited the use of kitchen utensils to measure and administer liquid medications was the cause of many dosing errors due to the inaccuracy, variation, and understanding by parents of the differences in teaspoons, tablespoons, and other kitchen devices.

Pharmacists should be providing liquid measuring devices with each and every pediatric liquid dispensed. In our pharmacy we provide oral syringes and can insert a plastic plug into the bottle neck that acts as a port to access and withdraw the medication cleanly and accurately. Moms love it! The syringes bear the corporate logo and are freebies and the plastic ports cost us about a nickel each. Money very well spent to help prevent these dosing errors. Parents can watch David demonstrate these devices in the opening video. (if you cannot see the video, try clicking on the title of this post)

At the end of 2011, The U.S. Food and Drug Administration (FDA) informed the public that the concentration of liquid acetaminophen marketed for “infants” (160 mg/5 mL) would be the standard concentration for both the drops and other children’s liquids. liquid Looking at other children’s analgesics, it is apparent that we should do the same with ibuprofen. In this case, the children’s liquid is 100mg/5ml while the infant drops are 50mg/1.25ml or 250mg/5ml. Although that results in infants given a smaller volume of liquid, many parents are confused by the differing concentrations and dosing tables provided on the packaging. drops I find it interesting that a child aged 6 months may be given 50mg of ibuprofen as per the dosing chart on the drops but a child under 2 may not be given 50mg of ibuprofen when consulting the dosing chart on the liquid medication. It is past time to get consistent labeling of these pediatric medications. This is why I feel that pharmacists should be giving dosing instructions for these meds despite what may be on the label. We have the resources and expertise to interpret them!

I appreciate Pediatrics for making the entire text of the study, “Out-of-Hospital Medication Errors Among Young Children in the United States, 2002-2012,” as a free access PDF on their web site. Have a look, and more importantly, let’s all ramp up our vigilance and effort to provide our children with rational, compassionate, and accurate pharmaceutical care.

Video assist and images by David Szeto, student pharmacist, Midwestern University College of Pharmacy, Glendale, AZ and Dr. Trang Vo, graduate intern, University of Arizona College of Pharmacy, Tucson, AZ.

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Contrast Media

I find it interesting that many of the people ranting about our awkward response to the Ebola virus are many of the same demagogues that are in positions where they have stymied basic scientific research, crippled education, and promulgated Luddite thinking. Our own Arizona Congressman, Matt Salmon, insulted Dr. Tom Frieden, the director of the CDC, saying on live radio, “That guy is an idiot, he needs to go.” Now, perhaps Dr. Frieden will have to fall on his sword because of the perception of mishandling of the Ebola situation, but he is by no means an idiot. Matt Salmon, on the other hand, shows remarkable hubris and a stunning lack of integrity in his comments. Of course, we are depending on science and our scientists to save us from Ebola, so this seems a bad time to be calling one of their leaders an idiot.

This situation reminds me of a young scientist I had learned about years ago while studying microbiology…

Young Hans Christian, the son of a law professor, was born in Copenhagen in 1853. He got interested in plants at a young age which led him to the study of pharmacology and the use of the microscope. He obtained his BA in 1871, interned with a zoologist named Steenstrup and decided to pursue the study of medicine, obtaining his MD in 1878. He studied across Europe and was a renowned expert on human red blood cells, becoming one of the first to note macrocytes as a characteristic of pernicious anemia. But that’s not what really made him famous. In 1884, Hans Christian Gram published his method for staining bacteria and the Gram Stain was born. Gram understated his discovery in that original publication, stating, “I have therefore published the method, although I am aware that as yet it is very defective and imperfect; but it is hoped that also in the hands of other investigations it will turn out to be useful.” The Gram stain is now the most widely used bacteriological staining method, it is almost always the first test performed for the identification of bacteria.

If only we could see more of this kind of humility and integrity in our elected officials. The media is a muddle of hyperbole and misinformation. Always remember to use your critical thinking skills when deciphering the cacophony of messages coming from all those screens in our lives. Please support education that fosters critical thinking.

Profitable Care

In merry olde England in the 1700’s betting men would hang out at Edward Lloyd’s Coffee House in London wagering on just about anything. They would bet on the deaths of celebrities, outcomes of battles or wars, Louis XV’s next mistress or the outcomes of trials. Historian Marieke deGoede writes that in 1771, Londoners bet over 60,000 pounds on whether French diplomat Charles de Beaumont was male or female. “Charles” declined to provide definitive evidence, but a judge ruled in favor of female settling all bets. Patrons of the coffee house could also bet on if a ship and cargo might be lost at sea. This win-by-losing sort of gambling lives on today and is called insurance. The coffee house eventually evolved into one of the world’s most notable insurers, Lloyd’s of London.

Modern insurance has gamed the system to the point of absurdity, setting premiums that makes sure the “house” always wins. This is true in all types of insurance, home, health, auto, you name it. The insurance companies have all the statistics and their CEO rake in millions in salaries and other perks for winning these rigged “bets.” This is especially egregious to me when it comes to health care, with executives of companies like Cigna, Aetna, UnitedHealth and others enjoying salaries in the realm of $10 million or more per year, while the insured patients wonder whether their critical health care needs will be covered.

“Families and patients are being asked to tighten their belts in the face of rising healthcare costs, while our premiums are being used to subsidize even more astronomical compensation for the already wealthy,” said Benjamin Day, Director of Organizing at Healthcare-NOW!, a nonprofit group that advocates for a single-payer system, sometimes called “an improved Medicare for all.”

We have a long way to go in this country to attain an equitable health care system. Make sure that your representatives are actively challenging corporate greed, especially in the health care arena. Ask yourself if the delivery of health care should be a highly profitable endeavor.

By the way, Lloyd’s has announced a profit of £1.67 billion (about $2.66 billion) for the six-month period ending June 30, 2014. In six months! That’s over ten grand per minute, around the clock!

Quicksilver Message Service

I’ve already given a bunch of flu shots this season and only one person wanted to know if the vaccine I was going to inject into them contained mercury. In that case, the answer was no. It makes me wonder about the irrational anti-vaccine people that are not immunizing their children. These folks apparently deny the virtual eradication of smallpox, polio, etc., or mistakenly believe that thimerosal causes autism. The CDC has responded to many of these misconceptions and I’ll not repeat them here.

About two-thirds of the 2014-2015 flu vaccines are mercury-free. Multi-dose vials contain a tiny amount of thimerosal and single-dose Fluvirin contains trace amounts of thimerosal. Thimerosal rapidly dissociates after entering the bloodstream, releasing ethylmercury which is eliminated mostly in feces and somewhat in urine. The half-life of ethylmercury is about 7 days. Note that we are talking about very tiny amounts here, on the order of 10 parts per billion!

Other than the flu vaccines mentioned above, absolutely no childhood vaccine contains mercury or thimerosal. NONE. I tell patients that if they are concerned about mercury exposure they should be much more worried about environmental exposure to mercury. The most common form of environmental mercury is methylmercury. The half-life of the methylmercury found in the environment is about 70 days, ten times that of ethylmercury. Now that is a reason to worry! So I say: Please have your child vaccinated according to the CDC recommendations!

Methylmercury is toxic to the immune system, alters genetic and enzyme systems, and damages the nervous system. This form of mercury is ingested by eating fish and game and the closer to the top of the food chain, the higher the concentration of mercury. You see, this form of mercury bioaccumulates, meaning that it stays in living tissue so that as the smaller fish are eaten by bigger and bigger fish, more and more mercury accumulates in the organism.

Tuna from a can is likely America’s number one source of mercury, with virtually every can tested showing some level of mercury, ranging from 18 parts per billion (PPB) to over 700 PPB. If it is any consolation, light tuna usually has the lower mercury level when compared to white (albacore) tuna. The FDA claims it can recall any tuna with greater than 1,000 PPB (or 1 part per million) but says it never has issued such a recall. There you go folks, that tuna sandwich is much more dangerous than any vaccination.

Dental filling amalgam is typically up to 50% mercury, 35% silver, and 15% tin (called “silver” fillings). Many dentists have replaced amalgam fillings due to concern of mercury exposure. However, the FDA, the U.S. Public Health Service and the World Health Organization, say that amalgam is a safe, strong, inexpensive material for dental restorations. Turns out that replacing the amalgam may actually result in an increased mercury blood level! If you have “silver” fillings, think twice before having them replaced. Most studies show that once in place the amalgam fillings do not pose a threat.

Industrial metal processing, burning coal, medical and other waste, and mining contribute to mercury concentrations in local environments, but atmospheric distribution is the dominant source of mercury over most of the landscape. Once in the atmosphere, mercury can circulate for years, leading to wide-spread contamination. Mother nature releases some mercury from the eruption of volcanoes and some gets into the atmosphere as ocean water evaporates taking some volatile mercury molecules along for the ride. Once in the water supply it accumulates in fish and other wildlife. My beautiful home state of Maine has a state-wide advisory warning of mercury in game fish. How sad.

Mercury is found in nature most commonly as cinnabar which is mercury sulfide, mercury plus sulfur, HgS. China extracts most mercury from cinnabar these days, a process that releases sulfur dioxide, an irritating, foul-smelling gas. That’s probably just a small portion of China’s air pollution.

For those of us that have been around a while, mercury was that silver stuff that was in thermometers. If you dropped and broke a thermometer, tiny beads of metallic mercury rolled around the floor and could be gathered together. I recall having a glob of mercury rolling around the palm of my hand, pushing it around or breaking it up with my fingers. That was quicksilver, mercury as a metal (Hg). I also remember heating mercury in a test tube and capturing the resulting mercuric oxide, a more toxic, soluble form of mercury. Amazingly, I’m still here and relatively sane. Considering all the things that my body and brain have been exposed to, both voluntarily and involuntarily, I feel pretty lucky to be able to put together a complete sentence.

Urine Charge

Here in the U.S., most of us urinate into some type of toilet and flush the voided urine away to a waste water treatment plant. I started considering the ramifications of this when I took a leak in a urinal that indicated it used 1 gallon of water per flush. I wondered if we really needed a gallon to flush away three or four hundred milliliters of pee. That’s typical adult pee volume, by the way.

With our population at 319 million, we can calculate some staggering numbers that should piss you off. Conservatively, let’s say that most folks urinate 5 times a day, or at least they should, and that we just consider 200 million adults and then postulate that only half of them pee in a urinal or toilet, we see that we are flushing 500 million gallons of water per day to clear away just over 52 million gallons of urine. In a year that is close to 200 billion gallons of water used and that’s a low estimate. Thankfully, much of this water goes to a water treatment plant where it can be returned to the environment as irrigation water or other uses than human consumption.

Throughout history urine has been a valuable commodity with urine used in a variety of ways. Pee from the public urinals in ancient Rome was collected and sold (and taxed) to be used in leather softening and even by ancient launderers. The ammonia in urine is a good cleanser of dirt and grease. Laundry workers would add urine and water to a vat of clothes and stomp around on it, agitating the clothes much like a modern washing machine, and mimicking the stomping of grapes for wine-making. Let’s hope they didn’t get their vats mixed up! Some Romans found this cleansing property made urine a good teeth-whitening rinse. Urine went on to be very useful to 16th century textile workers. Early producers of gunpowder used dung and pee to harvest potassium nitrate. A big pile of dung was kept wet with urine and stirred repeatedly. After weeks of this, the outer layer would be allowed to dry and relatively pure crystals of potassium nitrate could be gathered in abundance.

Our use of water has been irresponsible for most of our history. We are beginning to realize that this continued flagrant disregard for the implications of our wasteful use of water will diminish our quality of life and imperil the planet. Surely we could be much smarter in our use of human piss. Yes, I’m staying away from poop for now, that will be another blog post one day, you can be sure.

When examining these numbers, I found that the US electric energy sector uses 200 billion gallons of water per day to cool coal and nuclear power plants. This water is “withdrawn” versus “consumed,” meaning it is only borrowed and returned to the environment, in this case, much warmer than before it was withdrawn. It makes me wonder if this also could contribute to global warming. That’s 42 trillion gallons of warm water per year added to the environment. These plants return water that is 17 degrees Fahrenheit warmer than when it entered the coal or nuclear plant. You just know that has to have an impact on plants and animals downstream.

Every drop counts!

Pharmacists, Youth and Nicotine

Much has been said about the need for more studies on new nicotine delivery systems such as e-cigarettes, vapor devices and other tobacco products. Although more information is always desirable, we already have numerous studies that demonstrate the deleterious effects of nicotine. Adolescents are particularly susceptible to the addictive power of nicotine as well as neurotoxic effects on the developing brain. Impaired cognitive function and changes in emotional behaviors have been seen and may persist later in life. Numerous studies have shown a relationship between nicotine use and increased risk of developing mental issues such as academic problems, antisocial behavior, depression, panic attacks, and increased use of other addictive substances.There are similar, more profound, finding with marijuana.

A recent CDC study published in Nicotine and Tobacco Research found that a quarter-million young people that had never smoked a cigarette previously used an e-cigarette in 2013. That number is triple what was found in 2011. More disturbing is that nearly half of these young e-cig users stated that they intended to smoke conventional cigarettes in the coming year. More than 70% of adolescents have tried some kind of cigarette. Despite these findings, “Big Tobacco” claims that they do not market to youth. Yeah, right.

A 2014 study published in Pediatrics found that “youth exposure to television e-cigarette advertisements, measured by target rating points, increased 256% from 2011 to 2013. Young adult exposure increased 321% over the same period. More than 76% of all youth e-cigarette advertising exposure occurred on cable networks and was driven primarily by an advertising campaign for 1 e-cigarette brand.” At last count, over 3/4 of these ads were for blu cigs (sic), a brand owned by Lorillard Tobacco Company. Lorillard is being acquired by Reynolds American for about $27 billion. Lorillard recently touted their 3.7% increase in Earnings Per Share (EPS) “as the Company continued to incrementally invest in its global blu electronic cigarette business.”

Although FDA banned certain flavors in cigarettes in 2009, other flavored tobacco products exist and are also presented in flavors designed to appeal to youngsters. Flavored little cigars are taxed at a lower rate than cigarettes and are often sold individually at under a dollar. Flavored tobacco for pipes and hookahs are also available. This price, coupled with alluring flavors such as chocolate, gummi bear, dreamsicle, every fruit imaginable, and others with names like Purple Thunder, Golden Honey, Caribbean Chill, and Mocha Taboo, fuel the fires of youthful addiction.

Nicotine solutions to recharge vapor devices, in concentrations from from 2mg/ml to 100mg/ml in various sizes, are readily available for as low as $85 per liter. A liter! This is another worrisome development, considering that, depending on route of administration, an adult lethal dose of nicotine is somewhere between 60mg and 300mg. Some simple math illustrates the danger of having such quantities of nicotine in unknowing or dastardly hands. On-line videos provide detailed instruction on how to use vapor devices for other drugs, including DEA Schedule I substances.
We are seeing ER visits due to nicotine ingestion by babies!

Pharmacists can and should have a significant impact on the young people in their communities. Visits to middle schools and high schools can highlight pharmacy as a career and promote healthy lifestyle choices regarding drugs, including nicotine, alcohol, and prescription controlled substances. Pharmacists are resources for drug information and explaining the adverse effects of nicotine on the adolescent brain is a role that should be a component of community practice.

Constant vigilance and continuing education are required for pharmacists to maintain their credibility regarding the cornucopia of new nicotine delivery systems. Electronic cigarettes, vapor devices, strips, orbs, and snus are all marketed as cleaner versions of tobacco products and some are even hailed as tools for smoking cessation. Pharmacists must be aware and knowledgeable of these products whether offered in their practice settings or not. It is likely that at least one out of five of our patients uses tobacco or tobacco-derived nicotine.