Posts Tagged ‘pseudoephedrine’

What’s Behind The Pharmacy Counter?

Q: What does the phrase “behind-the-counter” mean?

Medications that are stocked behind the pharmacy counter but are sold without a prescription from a doctor are often referred to as being “behind the counter”. In my career as a pharmacist, I’ve seen two types of medicines that fit this definition: those that require me to check the identification of someone purchasing it, and those that don’t require any ID.

Two non-prescription medicines that require ID are specially labeled bottles of cough syrup with codeine and anything containing pseudoephedrine. To reduce abuse and diversion of codeine and pseudoephedrine, there are restrictions on how much you can buy in a single purchase and also how much you can buy within a certain time period.

Small 4-ounce bottles of cough syrup with codeine can be sold without a prescription in Washington State, but many pharmacies stopped keeping them on hand because of the hassle of maintaining the registry of who purchased them. The extra time spent documenting each purchase wasn’t worth it.  Also, Delsym® cough syrup is available without any restrictions, which works nearly as well and doesn’t cause the drowsiness that codeine often does.

Sudafed® PE and any combination allergy and cold medicine that contains psuedoephedrine as an ingredient requires showing ID when purchasing it in order to reduce easy access by those who use it to make methamphetamine. The Food and Drug Administration is considering restricting access to psuedoephedrine even further, from a non-prescription medicine to a prescription-only controlled substance like Vicodin® (hydrocodone/acetaminophen).

Medications that don’t require a prescription but are only available from a pharmacist include insulin syringes and some older types of insulin. Insulins that you can buy without a prescription include Novolin®-NPH, Novolin-R® and Novolin® 70/30. The newer insulins, such as Humalog®, Novolog®, Lantus®  and Levemir® require a prescription.

One very old medicine called quinine used to be available from the pharmacist without a prescription, but the only form now available in the United States is the prescription form called Colcrys®.

Those of a certain age may remember when another type of product was only available “behind the counter”. After graduating from pharmacy school in the spring of 1979, I moved to Moses Lake, Washington working as a relief pharmacist at the Pay n’Save pharmacy every Wednesday from 3pm to 9pm and most Sundays from noon to 5pm. Because I looked young for my age, when seeing me behind the pharmacy counter for the first time many customer assumed I was a new clerk instead of the new pharmacist.

Customers would walk up to the pharmacy counter, see me, step back to look around, then ask me, “Is the pharmacist in?” Answering them, I’d say, “I’m your pharmacist tonight. How can I help you?” and watch their eyes widen in surprise.

Back then, I didn’t mind being a female pharmacist who looked barely old enough to drive, except for one thing: every time I worked, I kept losing money! Back then, condoms were kept “behind the counter” and every time I was the only pharmacist working I’d lose 2 out of every 3 condom sales.

It wasn’t that I wasn’t willing or able to sell them. In pharmacy school me and my classmates learned how to help a customer select just the right condom: lubricated or non-lubricated, reservoir tips or without, ribbed or smooth, latex or non-latex, flavored or colored.  It made me feel bad to see guys walk toward the back of my store where our pharmacy counter was, look up and see me, stop, look around for another pharmacist and then turn around to walk right back out the front door without buying a thing. Sometimes they’d be striding back toward me only to glance up, see me by myself and make a quick U-turn back out the front door. “Drats, I just lost another sale!”

Later that year and thankfully before the store decided I was losing them too much money, the laws in Washington State changed to allow condom sales without restrictions. Halleluiah! After relocating the condom display to a side aisle, whenever I saw a man striding back to the pharmacy it was a relief to be able to catch his eye before he turned around and instead, smile and direct him to Aisle 19B.

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Which Medicines to Pack?

Q: What medicines should I travel with? We have several vacations planned this summer and I want to make sure I pack the right stuff.

Vacations are wonderful opportunities to get away from your usual routine and see new horizons. Just because you are on vacation doesn’t mean you can’t get injured or sick. Motion sickness, aches and pains and intestinal disturbances can derail your vacation if you aren’t prepared.

First, before you walk out the door make sure you’ve packed all of your regular prescription medicines plus a current list of all your medications and your doctor’s name. Using pillboxes for taking your medicines on the road keeps your main bottles at home (less hassle in case you accidently leave your pills behind) and takes up less space. Filling up your pillboxes before you leave also alerts you to whether you’ll need any refills before you return.

If you’re going to need a refill before you get back into town you can either ask for a larger quantity from your doctor or ask if your pharmacist could refill your medicine a little early. Some insurance programs have a grace period of one “vacation refill” per year. If you take prescription pain or anxiety medicines, talk with your doctor or pharmacist beforehand about what to do about refills during the time you will be gone. Some medicine requires a new printed prescription each time you get it filled, which can be very difficult to get if you need another fill while out of town.

When traveling outside the United States, you can avoid spending your vacation visiting the local bathrooms instead of the beaches or museums by being extra cautious about your food and drinks. My daughter made it through 9 months as an exchange student in Bangkok, Thailand with no sickness until buying a snack from a street vendor. She got so sick her host family had to take her to a hospital. Avoid unpeeled fruits, uncooked veggies like salads, and prepared meals that may have been stored at improper temperatures or not completely cooked. With beverages, “boil it, cook it, open it, or forget it”. And watch out for ice cubes or shaved ice: don’t drink a freshly opened bottle of water or soda that has been poured over ice!

If you do end up with nausea, vomiting or diarrhea, DON’T take NSAIDs (non-steroidal anti-inflammatory drugs) such as naproxen (Aleve®) or ibuprofen (Advil®, Motrin-IB®) for pain, swelling or fever. Taking an NSAID like naproxen or ibuprofen while dehydrated can damage your kidneys. Take acetaminophen (Tylenol®) instead.

Along with your prescription medicines be sure to pack some non-prescription medications for common conditions.

Here’s what I bring with me when I travel:

1. Acetaminophen (Tylenol®). Good for tension headache from staring at maps, backache from riding all day in a car, or fever.
2. Meclizine (Bonine®, Dramamine® Non-Drowsy Formula). The chewable 25mg tablets are my go-to motion sickness medicine for trains, planes, boats and cars. Also helpful for amusement park roller coasters that go backwards and upside down.
3. Loperamide (Imodium®-AD). This is the very best way to stop diarrhea in its tracks. I NEVER leave home without it.
4. Pseudoephedrine (Sudafed®). Since my ears can really plug up when traveling by plane, I make sure I have the original (most effective) formulation with me since in some states it’s now only available by prescription.
5. Diphenhydramine (Benadryl®). This is a miracle worker for bee stings, bug bites, minor rashes and allergic reactions. If you have any swelling around your face or tongue, though, seek medical help immediately.
6. Naproxen, 220mg tablets. This NSAID is great for emergencies like tooth pain or muscle aches. Avoid if you take a blood thinner (like aspirin, warfarin or clopidogrel), have serious heart failure, are allergic to aspirin, or have had a bleeding ulcer. Use acetaminophen (Tylenol®) for aches and pains if you can’t safely take an NSAID like naproxen or ibuprofen.
7. Dried Prunes. Prunes, you ask? I pack these as insurance against constipation. It’s been shown that eating 5 prunes is just as effective as taking a stool softener, and I can adjust the “dose” up or down according to my needs. You can pack your favorite laxative instead. I recommend Miralax® because it’s powerful yet gentle on the body.
Bon voyage and safe travels!

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Death By Caffeine?

In an article published online by Forbes on 10/22/12 by David DiSalvo, titled, Can Energy Drinks Cause Heart Attacks?, Mr. DiSalvo reports that the FDA is conducting an ongoing investigation into the deaths of several people who had consumed large amounts caffeine through energy drinks, including the recent death of a 14-year old girl who died after drinking two 24-oz Monster energy drinks in a 24 hour period. Her death is now suspected to be from the combination of excessive caffeine intake and an underlying condition of her blood vessels.

Mr. DeSalvo concluded that killing yourself with coffee or energy drinks is highly unlikely, mostly because the lethal dose of caffeine for an adult is 10 grams, which is significantly higher than any adult is likely to consume. Ten grams of caffeine? Let’s see, that would be 50 tablets of maximum strength No-Doz®, 66 cups of brewed coffee, or 125 cans of Red Bull®.

Caffeine is found in a variety of plants from all over the world which are prized for their ability to stimulate thinking and improve alertness. Common botanical sources of caffeine include coffee beans, cacoa beans, tea leaves, kola nuts and mate, which are brewed into a hot or cold beverage. More recently, purified caffeine is added to sodas, chewing gum and mints.

Not all caffeine is labeled as caffeine. Guarana and yerba mate are natural sources of caffeine, which should not be overlooked when you read the label of an energy drink or supplement.

Caffeine increases alertness and the ability to perform physical tasks more quickly and relieves signs of fatigue.

Some people can drink multiple cups of coffee with minimal effects, while for others having just one cup of joe keeps them tossing and turning all night. Others are susceptible to elevations in blood pressure or a rapid heart beat, which caffeine can aggravate.

Both pseudoephedrine, which is in the original formulation of Sudafed®, as well as phenylephrine, found in the formulation of Sudafed PE®, can add to caffeine’s effect and cause nausea, stomach burning, and headache.

Although caffeine can be useful to improve alertness during studying or while driving, some of the symptoms of caffeine use can be downright unpleasant, such as an increase in stomach acid secretion and a “burning”sensation, restlessness, tremor, an increase in urination, insomnia, and heart palpitations. If you are taking medicine to decrease heartburn or to slow down a rapid or an irregular heart beat, if you have uncontrolled blood pressure, or if you suffer from a bladder problem such as urinary incontinence, you should minimize your intake of caffeine.

Here are some examples of the amount of caffeine contained in common beverages:

Cola, Mtn Dew® (16 oz): 47-73mg

Espresso, one shot:  60-75 mg

Red Bull®, No Fear®: 80 mg

Black tea, brewed: 40-120mg

Coffee, brewed, 1 cup: 120-150mg

Espresso, two shots: 120-150mg

Full Throttle® (16 oz): 144mg

Monster® (16 oz): 160mg

Some common medicines that contain caffeine are:

Anacin® Max Strength (2 tabs): 64mg

5-Hour Energy®: 120-150mg

Extra Strength 5-Hour Energy®: 180-220mg

Midol® Complete (2 tabs): 120mg

Excedrin® Extra Strength (2 tabs): 130mg

No-Doz®, Vivarin® (1 tablet): 100mg, 200mg

 Note:   Guarana and Yerba Mate are natural sources of caffeine

Although the maximum dose of caffeine is quite high, mixing caffeine with other weight loss products or decongestants can cause problems at much lower doses such as 500mg daily, the equivalent of 4 cups of brewed coffee or three 16 ounce cans of a Monster energy drink.

In April of 2004, the FDA banned the supplement ephedrine through the Dietary Supplement Health and Education Act (DSHEA) of 1994. Ephedrine was an ingredient in popular weight loss products and in energy boosters for improved athletic performance. Steve Baechler, a major league pitcher for the Boston Orioles, was taking a product containing ephedra when he died suddenly at the age of 23. Taking ephedra along with caffeine can increase your risk of experiencing serious side effects such as heart palpitations, heart attacks, strokes, seizures, and even death.

If you aren’t looking to give up your morning cup of coffee but are interested in how much caffeine is in some of the products you consume, visit www.mayoclinic.com/health/caffeine/AN01211 for details, or stop by this website, completely devoted to caffeine: www.energyfiend.com.

Dr. Louise Achey, Doctor of Pharmacy is a 30-year veteran of pharmacology. She’d love to answer your question about medication and explain how to prevent misadventures with medicines. Send your questions and comments to www.AskDrLouise.com.

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Sudafed, Sudafed PE and Sudafed PSE

October 16th, 2012. Filed Under: Cough and Cold.
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Q: I just bought some Sudafed® but it doesn’t seem to work for me any more. Is there anything else I can take that would work better?

If you purchased Sudafed® from the allergy and cold medicine section of your local pharmacy or grocery store, it’s not the same medicine. In fact, if you look closely, the box has Sudafed PE® on it.

Sudafed PE® is different than the Sudafed® you remember. The original formulation of Sudafed® contains pseudoephedrine. The newer version of it has phenylephrine, which is why the name on the package is Sudafed PE®. Both pseudoephedrine and phenylephrine are decongestants designed to relieve stuffy nose symptoms but their potency and effectiveness are different.

Phenylephrine is effective as the topical decongestant in Neo-Synephrine® nose spray but Sudafed PE® doesn’t work as well. For one thing, phenylephrine is not well absorbed into your body from your stomach. Some of the phenylephrine is left behind instead of getting into your bloodstream, where it needs to be to do its job.

The other reason Sudafed PE® doesn’t work as well as Sudafed® is because it is less potent. Phenylephrine and pseudoephedrine are both effective as nasal decongestants when taken as a 30mg dose. Phenylephrine has caused high blood pressure and stroke at that dose, so the Food and Drug Administration (FDA) has limited it to a 10mg dose, only 1/3 of the adult dose considered equivalent to pseudoephedrine. Sudafed PE® is unlikely to cause any serious side effects at this dose, but it’s also unlikely to give you much relief from your stuffy nose.

Why was an effective and popular non-prescription medicine replaced with a wimpy one? Pseudoephedrine became too popular for its own good by being a key ingredient in making methamphetamine. In 2005, the USA Patriot Act restricted the sale of key ingredients of methamphetamine, called precursors, in an attempt to combat meth production, trafficking and abuse.

The compounds identified as precursors are ephedrine, phenylpropanolamine, and pseudoephedrine. Beginning on September 30, 2006, products containing any of these were to be kept “behind the counter” in pharmacies or under lock and key by grocery stores or other vendors. Today, except in Oregon and Mississippi, you can still purchase the original formulation of Sudafed® if you ask for it, show your ID and sign for it. You cannot purchase more than 3.6 grams in a 24-hour period or 9 grams in a month.

My pharmacy moved our stock of cold medicines with pseudoephedrine behind our counter nearly a year before the restrictions took effect because we were getting ripped off. When we first noticed the problem we tried moving them to where they were in plain view of the pharmacist. Despite that, the shelf would be bare again within a day or two. Pretty brazen, shoplifting them right in front of the pharmacist!

Did these restrictions on pseudoephedrine work? Not according to a report published April 30, 2012 by the National Association of State Controlled Substances Authorities (NASCSA). Titled Impact of State Laws Regulating Pseudoephedrine on Methamphetamine Trafficking and Abuse, the report describes how “smurfing” – the practice of buying pseudoephedrine frequently by using various fake IDs at multiple locations, has circumvented the federally mandated restrictions and recommends a different approach.

The state of Oregon took the Patriot Act restrictions on methamphetamine precursors even farther and changed pseudoephedrine into a prescription-only controlled substance with restrictions and monitoring just like the narcotic pain reliever Vicodin®. Oregon is one of the only states to experience a consistent and dramatic decline in meth lab incidents and trafficking since 2006 and NASCSA is now petitioning the Drug Enforcement Administration (DEA) to follow Oregon’s example and reclassify pseudoephedrine as a controlled substance.

If Sudafed® becomes a prescription-only medicine it would be more expensive and require a clinic visit, driving an inexpensive and effective systemic nasal decongestant out of reach of many Americans.

For now, except in Oregon and Mississippi you can buy the old formulation of Sudafed® or generic pseudoephedrine by stopping by a pharmacy, showing your ID and signing for it.

Dr. Louise Achey, Doctor of Pharmacy is a 30-year veteran of pharmacology. Please send your questions and comments to www.AskDrLouise.com.

©2012 Louise Achey

 

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