LEARNING OBJECTIVES
After reading this chapter, the student pharmacist, community practice resident, or pharmacist should be able to:
1. Understand the importance of self-care and over-the-counter (OTC) products and how to integrate into daily workflow.
2. Describe the key components of obtaining a medication history for an OTC consult.
3. Assess and counsel a self-care patient using a structured process.
4. Be familiar with advanced services that are provided in a community pharmacy setting and how OTC products can be incorporated into these services.
INTRODUCTION
Self-care is defined as “the independent act of preventing, diagnosing, and treating one’s own illnesses without seeking professional advice.”1 Self-care includes dietary interventions, dietary supplements, nonprescription or OTC products, home diagnostics, and monitoring and lifestyle modifications.1 Self-care plays a vital role in health-care, and pharmacists are in a key position to assist patients with these interventions. Two of the most rewarding aspects of a community pharmacist’s responsibilities are assisting patients in the selection of OTC medications and counseling patients on the proper use of these products.
OTC medicines are important to America’s health-care, providing $102 billion annually in value to the U.S. healthcare system.2 There are more than 300,000 marketed OTC medications in the market in 80 different therapeutic classes.3,4 OTC medicines are available in the following categories: pain and fever, gastrointestinal, respiratory, ophthalmic, otic, reproductive, and genital and dermatologic disorders.1
OTC product sales in 2010 were estimated at $17 billion dollars compared with $2 billion dollar in 1965.5 As more products come to market and as brand-extension products expand, pharmacists must be proactive when talking with consumers about these medications. Since OTC products are readily available to consumers, they need to be able to identify the problem and be able to identify exclusion for self-treatment and select the correct product for treatment. An incorrect diagnosis by a consumer, such as mistaking heartburn for symptoms of a heart attack, or improper product selection, such as selecting the incorrect dose of a pediatric analgesic, may lead to an adverse event or hospitalization.6
According to the 2010 American Pharmacists Association (APhA) Annual Survey, pharmacists make an average of 29 OTC recommendations each week, approximately 81% of consumers purchase an OTC product that their pharmacists recommended and the average time for an OTC consultation was about 3 minutes.7 Convenience is cited as a primary reason patients choose OTC medications. In a 2008 National Council on Patient Information and Education (NCPIE) survey of 1005 Americans, 78% of participants stated they self-medicate because it saves a trip to the doctor’s office, 78% of participants stated that their illness was not serious enough to warrant a doctor’s visit, and 77% of participants stated that it saves time.8 In addition to convenience and time, OTC medicines also save consumers money.8
A study conducted in 2010 shows that “90% of both consumers and physicians recognize that there are safe and effective OTC medicines for the first-line treatment of minor, repetitive and sometimes chronic conditions.”9 This study also showed that greater self-management of health-care and increased use of OTC medicines would save consumers and taxpayers approximately $5.2 billion annually.9 Consumer demand for OTC products and physicians acknowledgement of the need for proper use of OTC medicines require student pharmacists and pharmacists to be proactive in assisting patients with the proper selection of these products.
In addition to patients using OTC products and pharmacists and providers recommending OTC products, many treatment guidelines include OTC product recommendations. For example, the American College of Chest Physicians recommends using dextromethorphan for short-term relief of a cough.10 Some guidelines include OTC products as first-line therapies. For example, some of the first-line medications for tobacco cessation include nicotine gum, nicotine lozenge, and nicotine patch, which are all available OTC.11
OTC products can be purchased in a variety of retail outlets, including nonpharmacy locations, such as vending machines and gas stations. Therefore, the availability of pharmacists to assist with product selection and to assess patients and counsel on how to use the appropriate OTC medication can be a vital marketing tool to consumers when making the choice of where to purchase OTC products. Since these products are readily available and there are a variety of active ingredients in various combinations, it is important that patients use these products safely and effectively.4 According to the FDA, each product’s Drug Facts Label must include the following information: active ingredient and dose in each unit, purpose and use for the product, warnings for this product, and instructions for use and inactive ingredients.12 It is imperative that pharmacists educate patients on the importance of reading the Drug Facts Label so they are aware of the information that is available to them to assist in product selection.
The Affordable Care Act (ACA) increases the role of the pharmacists in many settings where self-care is involved, including medical homes, transitions of care, medication reconciliation, continuity of care, and medication therapy management (MTM) opportunities.13 Self-care and OTC medications are included in all aspects of MTM, including medication therapy review, personal medication record, medication-related action plan, intervention and/or referral, and documentation and follow-up.14 Some examples how OTCs can be incorporated into MTM include, but not limited to, a review of all medications (including nonprescription, herbals, and dietary supplements), lifestyle modifications (nutrition and physical activity), and wellness support (weight management and tobacco cessation). You may be performing an MTM session for a patient who has hypertension, hyperlipidemia, diabetes, and COPD. When reviewing the patients’ social history, they tell you that they smoke one pack per day. You can counsel and educate the patient on the importance of tobacco cessation and how it will affect and improve their other disease states that they currently have and are being treated for with prescription medications.
OBTAINING A MEDICATION HISTORY
It is crucial to obtain a thorough medication history when recommending an OTC product. Pharmacists are in a unique position to assess patients’ medication history. Pharmacists need to be proactive when asking patients what medications they are currently taking including prescription, nonprescription, and complementary and alternative therapies. When patients utilize multiple healthcare providers, including pharmacists, accurate information and communication with other healthcare providers becomes vital. When asking about medications, the patient’s adherence and compliance should be assessed. Patients may get their refills on time, but may not take their medications as directed. In addition to collecting a thorough medication history, patients disease states, economic status, dietary intake, and social support need to be collected.15 When interviewing a consumer, keep in mind that the purchaser is not always the patient for whom the OTC product is intended.
During a medication history interview, the following information needs to be obtained15:
Demographic information
Dietary information
Social habits
Current and past prescription medications
Current and past nonprescription medications
Current and past complementary and alternatives therapies
Allergies
Adverse drug reactions
Compliance and adherence
It is important to use open-ended questions when asking about medication history and listen to the patient’s response. Effective listening is as important as effective questioning and the pharmacist needs to stay focused on the patient. A good statement to start the interview with is, “Tell me about your medications that you take on a regular basis.” As the interview progresses, closed-ended questions may need to be used to get more information out of the patient. Remember, do not use leading or multiple questions.
After an appropriate history is collected from the patient, you have three options to provide to the patient1:
1. No product recommendation and non-pharmacological options are discussed (e.g., proper sleep hygiene rather than an antihistamine)
2. Self-care product recommendation
3. Refer to physician or other healthcare provider
ASSESSMENT OF PATIENT SYMPTOMS
When asking patients about their ailment or condition, it is important to ask all of the appropriate questions. There are two mnemonics that are utilized by self-care practitioners: QuEST/SCHOLAR or SCHOLAR-MAC and PQRSTA.1,16
QUEST/SCHOLAR OR SCHOLAR-MAC1,16
Quickly and accurately assess the patient by asking about the following:
Symptoms
Characteristics
History
Onset
Location
Aggravating factors
Remitting factors
Medication use (including prescription and nonprescription products)
Allergic reactions
Coexisting conditions
Establish that the patient is able to use a self-care product
Suggest an appropriate self-care product
Talk with the patient about the product
PQRST Mnemonic for Symptom Analysis1,16
Palliation (What caused the condition?)
Quality (describe the condition)
Region (What has helped the condition?)
Signs and symptoms (Where is the problem?/How severe is it?)
Temporal factors (When did the problem begin?/How often does it occur?)
INCORPORATE OTCs INTO PHARMACIST-PROVIDED CLINICS
As the number of patients that community pharmacists and student pharmacists see on a daily basis increases, it is important that we assist patients in proper OTC selection ofproducts based on their symptoms, current disease states, and medications. In addition to the dispensing role, many community pharmacists are offering advanced pharmacy services and patient care clinics, including MTM, heart health clinics, osteoporosis clinics, diabetes support and education, and smoking cessation. These advanced services can also assist with appropriate OTC selection based on disease states and medications. While these services can lead to an OTC sale, adherence to both prescription and nonprescription medicines should be emphasized.
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