tag:theconversation.com,2011:/africa/topics/medications-33440/articlesMedications – The Conversation2023-10-20T00:26:59Ztag:theconversation.com,2011:article/2077362023-10-20T00:26:59Z2023-10-20T00:26:59ZWhy do I bruise so easily? Could it be something serious?<figure><img src="https://images.theconversation.com/files/553635/original/file-20231013-29-abv74g.jpg?ixlib=rb-1.1.0&rect=21%2C12%2C2828%2C1879&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bruise-on-woman-arm-injection-bruises-1187048224">Shutterstock</a></span></figcaption></figure><p>After a bump, we can expect a bruise. But what if we find ourselves bruising without any noticeable cause? What might be behind it? Should we worry?</p>
<p>Around <a href="https://pubmed.ncbi.nlm.nih.gov/20942847/">18%</a> of adults report easy bruising. As haematologists (blood doctors), we are often asked for advice when people are worried they might bruise too easily. </p>
<p>Here is how we think about the problem. </p>
<h2>What the blood does</h2>
<p>Firstly, it helps to understand the complex, carefully balanced systems in our body that protect us from bleeding. </p>
<p>Blood flows as a liquid through our blood vessels, carrying red cells with their cargo of oxygen and immune cells to defend us from infections, to our brain, muscles and internal organs. Blood contains ingredients that are carefully balanced to protect us from bleeding if we are injured, while simultaneously minimising the risk of dangerous blood clot formation.</p>
<p>If a “puncture” occurs in a blood vessel, blood can rapidly thicken to form a jellylike clot, to minimise blood loss until the vessel repairs itself. To achieve this, tiny cell fragments called <a href="https://www.redcrossblood.org/donate-blood/dlp/platelet-information.html#:%7E:text=Platelets%2C%20or%20thrombocytes%2C%20are%20small,white%20blood%20cells%2C%20and%20platelets.">platelets</a> that circulate in the blood bind to the damaged blood vessel wall. </p>
<p>A host of proteins (<a href="https://www.ncbi.nlm.nih.gov/books/NBK507850/">clotting factors</a>), attracted by the platelets and damaged vessel wall, then combine to thicken the blood at the site and form a blood clot. Like all blood cells, platelets are made in the bone marrow, while clotting factors are mostly made in the liver. </p>
<p>So what can go wrong? If we have a problem affecting either our clotting factors, our platelets, or our blood vessel walls, we can find ourselves developing easy bruising or even problematic bleeding. </p>
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Read more:
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<h2>Could it be a problem?</h2>
<p>In many patients who report easy bruising, haematologists can’t find any particular cause. </p>
<p>Blood doctors are usually more cautious when a person has a constellation of problems related to bleeding. For example, a disorder is more likely if the bruising is widespread with <a href="https://www.webmd.com/first-aid/ss/slideshow-bruise-guide">large bruises</a>, is accompanied by frequent <a href="https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis">nosebleeds</a>, <a href="https://www.cdc.gov/ncbddd/blooddisorders/women/symptoms.html">heavy periods</a>, problems with bleeding after major dental work, surgery or childbirth – or even <a href="https://pubmed.ncbi.nlm.nih.gov/30017659/">spontaneous serious bleeding</a> into joints or into the brain. </p>
<p>A few simple tests can help us figure out if there is likely to be a serious problem. </p>
<p>The first we would perform for any person reporting easy bruising is a <a href="https://www.healthdirect.gov.au/full-blood-count">full blood count</a>. This will include a measurement of the platelet count and reliably show if the platelet numbers are normal. </p>
<p>Our platelets can be reduced for a number of reasons – either because they are not being produced in the bone marrow appropriately or in sufficient quantity, or because they are being removed from the circulation too quickly. </p>
<p>The latter scenario happens in a common condition called <a href="https://www.ncbi.nlm.nih.gov/books/NBK537240/#:%7E:text=Immune%20thrombocytopenic%20purpura%20(ITP)%20is%20an%20autoimmune%20disease%20characterized%20by,autoantibodies%20sensitize%20the%20circulating%20platelets.">immune thrombocytopenic purpura</a>. This condition can affect children or adults out of the blue or following a viral infection. Patients can develop severe reductions in their platelet count and come out in a fine rash, which is actually small bruises. </p>
<p>In children, it is usually a short-term condition that recovers by itself. In adults, severe cases may need treatment with medicines that suppress the immune system or boost platelet production. Sometimes adults need surgery to remove the spleen.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="gloved hand hold vial of blood" src="https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553636/original/file-20231013-15-8i85py.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A full blood count is a good starting point for investigating the cause of easy bruising.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-holding-blood-sample-vacuum-tube-730030978">Shutterstock</a></span>
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<h2>Problems with clotting proteins and diseases</h2>
<p>Clotting factors – the proteins mentioned earlier – can be affected by a range of inherited or acquired causes. </p>
<p>Some people are born with low levels of important factors that help the blood clot when it needs to control bleeding. </p>
<p><a href="https://www.hemophilia.org/bleeding-disorders-a-z/types/hemophilia-a">Haemophilia A</a> is seen almost exclusively in men and is caused by a genetic reduction in Factor VIII (a key clotting factor). Both men and women can have <a href="https://www.cdc.gov/ncbddd/vwd/facts.html">von Willebrand Disease</a>, which involves reduced production or function of another key clotting factor. </p>
<p>Liver disease can also cause clotting problems. That’s why the second test we perform in any person reporting easy bruising is to measure clotting function. If we find an abnormality, we’ll follow up by testing the levels of key clotting factors. </p>
<h2>Problems with blood vessels</h2>
<p>Though rare today, severe vitamin C deficiency used to more commonly cause easy bruising and gum bleeding (“<a href="https://www.healthdirect.gov.au/scurvy">scurvy</a>”) and <a href="https://www.webmd.com/skin-problems-and-treatments/ss/slideshow-why-bruise-easily">deficiencies</a> can still cause bruising. </p>
<p>Several diseases can cause blood vessel thinning or inflammation, including <a href="https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/">Henoch-Schonlein purpura</a> – an autoimmune condition that results in leg and thigh bruising.</p>
<p><a href="https://www.healthline.com/health/senile-purpura">Older people</a> can have fragile skin and blood vessels, making bruising more likely.</p>
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<a href="https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hands in blue gloves examine arm showing bruising" src="https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554195/original/file-20231017-25-inuz90.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Doctors may do blood tests to rule out some causes of bruising.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-palpates-examines-large-bruise-on-2178146115">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/why-do-we-bleed-a-hematologist-explains-how-the-body-prevents-blood-loss-after-injury-174581">Why do we bleed? A hematologist explains how the body prevents blood loss after injury</a>
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<h2>Medicines and supplements</h2>
<p>We always ask patients about their medication and alternative medicine use. </p>
<p><a href="https://www.nhs.uk/medicines/low-dose-aspirin/side-effects-of-low-dose-aspirin/#:%7E:text=Because%20aspirin%20helps%20to%20stop,an%20injury%20or%20a%20cut.">Aspirin</a> – often prescribed to prevent platelets from worsening the risk of cardiac disease or stroke – can also reduce platelet function. </p>
<p>Medications like clopidogrel (to stop problem clotting) and non steroidal anti-inflammatory drugs (like ibuprofen or others taken for pain and inflammation) can <a href="https://www.uptodate.com/contents/nonsteroidal-antiinflammatory-drugs-nsaids-beyond-the-basics">reduce platelet function</a>. <a href="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.029541">Blood thinners</a> such as warfarin, apixaban and rivaroxaban, prescribed to people with a higher risk of clots leading to stroke, can affect bruising. </p>
<p>People using oral or inhaled <a href="https://www.ncbi.nlm.nih.gov/books/NBK531462/#:%7E:text=Oral%20Administration&text=Long%2Dterm%20oral%20corticosteroid%20therapy,sclerosis%2C%20organ%20transplantation%2C%20etc.">corticosteroids</a> for a prolonged period (such as for chronic illnesses) may notice increased bruising because of thinning of the skin and weakened blood vessel walls. </p>
<p>Over-the-counter supplements including <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760599/">gingko and vitamin E</a> can also promote easy bruising, as can some <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5035804/">antidepressant</a> medications. </p>
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Read more:
<a href="https://theconversation.com/a-history-of-blood-clots-is-not-usually-any-reason-to-avoid-the-astrazeneca-vaccine-161889">A history of blood clots is not usually any reason to avoid the AstraZeneca vaccine</a>
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<h2>Questions of abuse and trauma</h2>
<p>Finally, blood vessels can be damaged by trauma. Clinicians should carefully ask if the person has experienced any injuries, including a sensitive <a href="https://www.aafp.org/pubs/afp/issues/2016/0215/p279.html">consideration</a> of child abuse or intimate partner violence. </p>
<p>While there are many medical conditions that can cause easy bruising, if you don’t have a strong history of other forms of excessive bleeding, and your blood counts and clotting function tests are normal, it shouldn’t be a cause for concern.</p><img src="https://counter.theconversation.com/content/207736/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sant-Rayn Pasricha receives funding from the National Health and Medical Research Council and the Bill and Melinda Gates Foundation. He consults for CSL-Vifor and has consulted pro bono for the World Health Organization. </span></em></p>Lots of people report bruising easily. What do doctors look for to see if it might be caused by something serious?Sant-Rayn Pasricha, Division Head, Population Health and Immunity, Walter and Eliza Hall InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114362023-10-16T00:45:00Z2023-10-16T00:45:00ZAll the reasons you might be having night sweats – and when to see a doctor<figure><img src="https://images.theconversation.com/files/546140/original/file-20230904-29-37baqi.jpg?ixlib=rb-1.1.0&rect=61%2C24%2C8118%2C5395&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/menopausal-mature-woman-suffering-insomnia-bed-2281774371">Shutterstock</a></span></figcaption></figure><p>You’ve finished a workout, so you’re hot and drenched with perspiration – but soon you begin to feel cool again. Later, it’s a sweltering summer evening and you’re finding it hard to sleep, so you kick off the covers. </p>
<p>Sweating is a normal part of the body’s cooling system, helping to release heat and maintain optimal body temperature. But regularly waking up during the night, soaked through from excessive sweating is not.</p>
<p>Night sweats are <a href="https://www.mayoclinic.org/symptoms/night-sweats/basics/definition/sym-20050768">repeated episodes</a> of excessive or intense sweating at night. They are an unpleasant part of life for many people. </p>
<p>Many conditions and factors can trigger night sweats by changing the body’s tightly regulated temperature set point, at which the body attempts to maintain its <a href="https://www.tandfonline.com/doi/full/10.4161/temp.29702">core temperature</a>. Some triggers are harmless (a hot bedroom) or even related to positive lifestyle changes (exercise). Others have an underlying cause like menopause, infection, disease or medication.</p>
<h2>Temperature control and sweating</h2>
<p>The hypothalamus, located in the brain, is part of the <a href="https://www.hormones-australia.org.au/the-endocrine-system/">endocrine system</a> and the temperature control centre for the body. It contains <a href="https://www.statpearls.com/point-of-care/29920#ref_19631766">temperature sensors</a> that receive information from nerve cells (thermoreceptors) located centrally (in the organs) and peripherally in the skin. </p>
<p>Thermoreceptors detect changes in body temperature, sending signals back to the hypothalamus. These <a href="https://www.sciencedirect.com/science/article/pii/S1876034111000256">signals</a> will either activate sweating to cool the body or shivering to warm the body.</p>
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Read more:
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<h2>Hormones and night sweats</h2>
<p>Anyone, regardless of age or gender, can experience night sweats. But women experience night sweats more often than men, largely because menopause and associated changing hormone levels are <a href="https://www.tandfonline.com/doi/abs/10.3109/13697137.2011.608596">a leading cause</a>.</p>
<p>Approximately 80% of women experience <a href="https://link.springer.com/article/10.1007/s00737-007-0209-5">hot flashes</a> (also called hot flushes) or night sweats after <a href="https://www.menopause.org.au/hp/information-sheets/what-is-menopause">menopause</a> (when periods have ceased for 12 months) and during <a href="https://www.healthdirect.gov.au/perimenopause">perimenopause</a> (the time leading up to it).</p>
<p>While both hot flashes and night sweats produce a feeling of overheating, they are different experiences associated with menopause. Hot flashes occur during the day, are transient episodes of flushing and may involve sweating. Night sweats occur at night and involve an intense period of <a href="https://www.proquest.com/docview/2821423865?accountid=14649">sweating</a>. Changing oestrogen levels are thought to impact norepinephrine and serotonin levels, two neurotransmitters that influence <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459071/#:%7E:text=%5B21%5D%20Estrogens%20stimulate%20the%20production,norepinephrine%20which%20disturbs%20hypothalamic%20thermostat">temperature regulation</a> in the hypothalamus.</p>
<p>Hormones also influence night sweats in men, particularly those with low <a href="https://www.healthdirect.gov.au/testosterone">testosterone</a> levels, known as <a href="https://www.hormones-australia.org.au/endocrine-diseases/hypogonadism/">hypogonadism</a>. Around 38% of men aged 45 years or older have low testosterone <a href="https://www.scielo.br/j/ibju/a/RZqqfTn5tY6BFpV6rp3GMxJ/">levels</a> but it can affect men at any age.</p>
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<a href="https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="doctor checks patients neck glands" src="https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546141/original/file-20230904-19-jduqa5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Night sweats that come with other symptoms could be a sign of illness.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/checkup-lymph-node-doctor-sweeping-flu-1317004679">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/lots-of-women-try-herbs-like-black-cohosh-for-menopausal-symptoms-like-hot-flushes-but-does-it-work-211272">Lots of women try herbs like black cohosh for menopausal symptoms like hot flushes – but does it work?</a>
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<h2>Infections, disease and medications</h2>
<p>When fighting infection, our body temperature often <a href="https://europepmc.org/article/nbk/nbk562334">rises</a>. This can stimulate sweating to cool and decrease body <a href="https://www.sciencedirect.com/science/article/pii/S1876034111000256">temperature</a>.</p>
<p>Minor infections like the common cold can cause night sweats. They are also a symptom of serious infections such as human immunodeficiency virus (HIV) and diseases such as <a href="https://www.aafp.org/pubs/afp/issues/2020/0101/p34.html">Hodgkin’s</a> and <a href="https://link.springer.com/article/10.2165/00002018-200831020-00002">non-Hodgkin’s lymphoma</a>. However, night sweats are rarely the only symptom present.</p>
<p>Medications such as selective serotonin reuptake inhibitors (SSRIs), corticosteroids, thyroid hormone replacement and methadone can cause night sweats. These medications affect parts of the <a href="https://link.springer.com/article/10.2165/00002018-200831020-00002">brain</a> and neurotransmitters that control and stimulate sweating.</p>
<p>Regular alcohol (particularly alcohol dependence) and recreational drug use can also <a href="https://link.springer.com/article/10.2165/00002018-200831020-00002">increase the risk</a> of night sweats. </p>
<h2>Stress, snoring and strenuous exercise</h2>
<p>Night sweats are commonly reported by people with <a href="https://karger.com/spp/article-abstract/26/2/92/295722/Psychological-Sweating-A-Systematic-Review-Focused?redirectedFrom=fulltext">anxiety</a>. </p>
<p>Psychological stress activates the body’s fight or flight system releasing neurotransmitters that increase heart rate, respiration, and blood pressure. This causes the body to heat up, at which point it starts sweating to cool the body back down. Night sweats may also increase anxiety, causing more sweating which in turn leads to less sleep and more anxiety. </p>
<p>If anxiety causes night sweats and this causes distress, it’s best to get up, move around and engage in a <a href="https://www.calmclinic.com/anxiety/symptoms/night-sweats">calming routine</a>, preferably in a dark or dimly lit room.</p>
<p>Night sweats have similarly been connected with sleep disorders like <a href="https://www.healthdirect.gov.au/obstructive-sleep-apnoea">obstructive sleep apnoea</a>, where the airway is repeatedly blocked during sleep and there is loud snoring. About one third of people with obstructive sleep apnoea regularly <a href="https://link.springer.com/article/10.1007/s11325-011-0502-4">experience night sweats</a>. The exact cause is undetermined but research shows it is linked with low blood oxygen levels (<a href="https://link.springer.com/article/10.1007/s11325-022-02701-3">hypoxemia</a>) and/or <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2869.2009.00743.x">high blood pressure</a>. </p>
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<a href="https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="man in bed with mouth open" src="https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546142/original/file-20230904-17-f3q8jz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People who snore have a higher likelihood of night sweats.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-man-sleeping-snoring-loudly-lying-1017259303">Shutterstock</a></span>
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<strong>
Read more:
<a href="https://theconversation.com/my-snoring-is-waking-up-my-partner-apart-from-a-cpap-machine-what-are-the-options-188825">My snoring is waking up my partner. Apart from a CPAP machine, what are the options?</a>
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<p>People can experience night sweats after high-intensity workouts. Vigorous exercise can stimulate the thyroid, <a href="https://www.ncbi.nlm.nih.gov/books/NBK500006/#:%7E:text=Thyroid%20hormone%20increases%20the%20basal,respiration%20rate%2C%20and%20body%20temperature">increasing basal metabolic rate</a> and body temperature for up to <a href="https://journals.lww.com/acsm-msse/Fulltext/2011/09000/A_45_Minute_Vigorous_Exercise_Bout_Increases.6.aspx">14 hours post exercise</a>. So night sweats can occur even after a vigorous morning workout. </p>
<p>Night sweats can indicate overtraining and/or under-fuelling. If not enough calories are consumed to support the increase in training, blood sugar could drop and you could experience <a href="https://www.aafp.org/pubs/afp/issues/2003/0301/p1019.pdf">hypoglycaemia</a>, which can cause night sweats.</p>
<h2>When to seek help and 5 things to try</h2>
<p>There are <a href="https://www.aafp.org/pubs/afp/issues/2020/1001/p427.html">numerous</a> health conditions and medications that can cause night sweats and interfere with sleep. </p>
<p>If night sweats are regular, distressing, interfere with sleep or are accompanied by symptoms such as fatigue or weight loss (not related to lifestyle or diet changes) talk to a doctor to help determine the cause. They might suggest alternative medications to any you’re taking or recommend tests or investigations.</p>
<p>In the meantime, you can try the following ideas: </p>
<p><strong>1.</strong> sleep in a cool room and use a fan if needed</p>
<p><strong>2.</strong> don’t overdress for bed. Wear breathable cotton or linen pyjamas</p>
<p><strong>3.</strong> choose lightweight bedding you can kick off. Avoid synthetic fibres and flannel bedding</p>
<p><strong>4.</strong> consider a cooling mattress or pillow and avoid those (such as foam ones) that can limit airflow</p>
<p><strong>5.</strong> avoid spicy foods, caffeine or alcohol before bed.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/9-signs-you-have-inflammation-in-your-body-could-an-anti-inflammatory-diet-help-210468">9 signs you have inflammation in your body. Could an anti-inflammatory diet help?</a>
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<img src="https://counter.theconversation.com/content/211436/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Siobhan Banks receives funding from NHMRC. </span></em></p><p class="fine-print"><em><span>Linda Grosser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sweating is the normal way the body cools itself off. But waking up every night with sweat-drenched sheets is not – especially if you have other symptoms too.Siobhan Banks, Research professor, University of South AustraliaLinda Grosser, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2098102023-08-04T12:30:37Z2023-08-04T12:30:37ZCollege students with loans more likely to report bad health and skip medicine and care, study finds<figure><img src="https://images.theconversation.com/files/539773/original/file-20230727-29-hz1qlc.jpg?ixlib=rb-1.1.0&rect=70%2C151%2C7629%2C4428&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study found that those with student loans are more likely to delay medical, dental and mental health care. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/burnout-anxiety-and-fatigue-creative-student-royalty-free-image/1445373401?phrase=college+students+mental+health">PeopleImages/iStock via Getty Images </a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Students who took out loans to pay for college rated their overall health and mental health as being worse than those who didn’t take out student loans. They also reported more major medical problems and were more likely to report delaying medical, dental and mental health care and using less medication than the amount prescribed to save money. </p>
<p>We <a href="https://doi.org/10.1080/07448481.2022.2151840">reported these findings</a> in an article published in the Journal of American College Health. The findings are based on surveys collected in 2017 from over 3,200 college students at two public universities in the United States.</p>
<p>We asked students to rate their physical and mental health on a 4-point scale – excellent, good, fair and poor. We also asked if they had experienced any major medical problems in the past year or whether they had ever postponed medical, dental or mental health care to make ends meet since starting college. Those who indicated they were taking regular medication for physical health problems, such as for asthma or high blood pressure, were asked if they ever took less medication than prescribed to save money. </p>
<p>Students with loans reported worse outcomes than those without loans, even after accounting for differences between them in terms of race, age and gender, as well as their parents’ education level and marital status.</p>
<p>Despite their worse self-reported mental health, students with loans were equally likely as students without loans to have received a new mental health diagnosis or treatment for a mental disorder in college. They also were equally likely to have visited a mental health practitioner in the past year or to use mental health medication. But they were almost twice as likely as those without debt to report delaying mental health care. </p>
<h2>Why it matters</h2>
<p>Our findings suggest that student loans may have hidden costs in the form of worse physical and mental health, more medical problems and diminished use of medical and mental health care. Stress from student loans <a href="https://eric.ed.gov/?id=EJ1141137">can affect students</a> while they are still in college, <a href="https://doi.org/10.1037/cdp0000207">harming both mental and physical health</a>.</p>
<p>College students are often at a <a href="https://doi.org/10.1037/11381-002">crucial juncture</a> when they are first leaving their parents’ home and <a href="https://doi.org/10.1038/oby.2008.365">establishing habits</a> – such as those related to medical and dental care – that may persist beyond college. Declining to seek medical care <a href="https://doi.org/10.1016/j.jchf.2021.05.010">can result</a> in <a href="https://doi.org/10.7326/0003-4819-114-4-325">worse medical problems</a>, potentially leading to diminished health and shorter lives for college graduates with loans.</p>
<p>One of the advantages of getting a college degree is <a href="https://doi.org/10.2105/AJPH.2011.300216">improved</a> <a href="https://www.forbes.com/sites/michaeltnietzel/2019/06/17/new-evidence-for-the-broad-benefits-of-higher-education/?sh=a4e88834c5c1">health</a>. But students who take out loans to attend college may not see those benefits, especially if they defer medical care or use less medicine to save money.</p>
<p>Previous generations had greater access to free or low-cost <a href="https://press.jhu.edu/books/title/12165/history-american-higher-education">public higher education</a> – access that has eroded as state budgets <a href="https://doi.org/10.1525/ctx.2009.8.1.76">failed to keep up</a> with the <a href="https://www.acenet.edu/Documents/Anatomy-of-College-Tuition.pdf">rising demand for and costs</a> of higher education. The current system of higher education funding <a href="https://educationdata.org/student-loan-debt-statistics">requires most people to take on debt</a> to get a college degree; the <a href="https://ticas.org/affordability-2/student-aid/student-debt-student-aid/student-debt-and-the-class-of-2019/">most recent national data</a> indicates that among 2019 graduates of public or private nonprofit, four-year universities, 62% had student debt.</p>
<h2>What’s next</h2>
<p>We are writing a book that explores how debt affects life after college, including the consequences for health, housing, romantic relationships and career trajectories. So far, we have found that inequalities in health and delays in doctor visits persist after graduation. We have also found that college graduates who put off doctor visits to save money in college were a little over twice as likely to experience a recent major medical problem 15 months and 3.5 years after graduation. We also found they were over four times as likely to be be putting off medical care to save money after graduation, showing these habits persist well after they leave college.</p><img src="https://counter.theconversation.com/content/209810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arielle Kuperberg receives funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Joan Maya Mazelis receives funding from the National Science Foundation.</span></em></p>College students who postpone medical care to save money end up paying for it down the line in the form of worse health, a researcher contends.Arielle Kuperberg, Professor of Sociology, University of North Carolina – GreensboroJoan Maya Mazelis, Associate Professor of Sociology, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2100492023-07-25T19:48:45Z2023-07-25T19:48:45ZExtreme heat is particularly hard on older adults – an aging population and climate change put ever more people at risk<figure><img src="https://images.theconversation.com/files/539318/original/file-20230725-27-j9q9a4.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8243%2C5450&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Without home cooling, Phoenix's weeks with temperatures over 110 F in July 2023 became dangerous. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/richard-verduzco-keeps-cool-on-his-porch-ahead-of-his-air-news-photo/1546524292">Brandon Bell/Getty Images</a></span></figcaption></figure><p>Scorching temperatures have put millions of Americans in danger this summer, with heat extremes stretching from coast to coast in the Southern U.S. </p>
<p>Phoenix hit 110 degrees Fahrenheit (43.3 Celsius) or higher every day for over three weeks in July. Other <a href="https://www.washingtonpost.com/weather/2023/07/17/heat-wave-southwest-south-records-climate/">major cities</a>, from Las Vegas to Miami, experienced relentless high temperatures, which residents described as “<a href="https://www.theguardian.com/us-news/2023/jul/14/phoenix-heatwave-summer-extreme-weather-arizona">hell on earth</a>.”</p>
<p>While the evening news runs footage of miserable sunbathers on Miami Beach and joggers in Austin, Texas, dousing themselves with water, these images conceal a growing hidden crisis: the millions of older adults who are suffering behind closed doors.</p>
<p>As researchers who study <a href="https://scholar.google.com/citations?user=ABRogW4AAAAJ&hl=en">older adults’ health</a> and <a href="https://scholar.google.com/citations?user=x756kywAAAAJ&hl=en">climate</a> <a href="https://scholar.google.com/citations?user=Hl912v8AAAAJ&hl=en">change</a>, we have found that two societal trends <a href="https://doi.org/10.1093/geront/gnad050">point to a potentially dire future</a>: The population is getting older, and temperatures are rising.</p>
<figure class="align-center ">
<img alt="A man rests while propping his head up with his arm on a table. A woman dozes in a chair in a room with several other people." src="https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/539313/original/file-20230725-25-cpxebf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">During the July 2023 heat wave, people gathered at the Justa Center, a day cooling center in downtown Phoenix for people age 55 and older who are homeless.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PhoenixLeavingtheHeat/18a7e05d8150417cb82ce50c852d9eb1/photo">AP Photo/Matt York</a></span>
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<p>Some of the country’s hottest states, including Arizona, are forecast to see dramatic growth in their older adult populations. But heat isn’t just a problem in the South: Northern populations also face rising risks from extreme heat that many people aren’t accustomed to. </p>
<p>Communities, families and older residents need to understand these risks and be prepared.</p>
<h2>Why older adults face higher heat risks</h2>
<p>Triple-digit temperatures are miserable for everyone, but for <a href="https://www.cdc.gov/aging/emergency-preparedness/older-adults-extreme-heat/index.html">older adults they can be deadly</a>.</p>
<p>Older adults don’t sweat or cool down as efficiently as younger people. Heat stress can worsen underlying conditions like heart, lung and kidney disease, and extreme heat can <a href="https://doi.org/10.1002/cphy.c140017">trigger delirium</a>.</p>
<p>Poor <a href="https://www.epa.gov/climateimpacts/climate-change-and-health-older-adults#">air quality</a> makes it harder to breathe, especially among people who already have breathing difficulties. For older adults with physical health problems, temperatures as <a href="https://doi.org/10.1080/23328940.2018.1456257">low as 80 degrees F</a> (26.7 C) – to say nothing of 110 degrees – can pose a grave danger.</p>
<p><a href="https://www.kff.org/report-section/data-note-prescription-drugs-and-older-adults-methodology/">Prescription medications</a> make older people more sensitive to heat. Anticholinergics, used to treat <a href="https://www.cdc.gov/copd/index.html">chronic obstructive pulmonary disorder, or COPD</a>, reduce our capacity to sweat. Dehydration is a side effect of <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/beta-blockers/art-20044522">beta blockers</a> and <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/diuretics/art-20048129">diuretics</a>, which are used to help control blood pressure.</p>
<p>Medications also work best when <a href="https://www.medscape.com/viewarticle/562416?form=fpf">stored at room temperatures</a> of 68 to 77 degrees and may lose their effectiveness if not kept in a cool place on a very hot day.</p>
<figure class="align-center ">
<img alt="A man sits in a chair under a tree in a shopping center parking lot. He's wearing a baseball cap and his shirt is open to let the breeze in." src="https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/539311/original/file-20230725-22-vefahc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Randy Twede, 70, sits in the shade while waiting for the bus on July 10, 2023, in Austin, Texas. ‘These temperatures are no joke. I’m just trying to survive, that’s all,’ he told the photographer.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/randy-twede-sits-in-the-shade-while-waiting-for-the-bus-on-news-photo/1531835627">Brandon Bell/Getty Images</a></span>
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</figure>
<p>And it’s not just physical health that suffers.</p>
<p>Having to stay indoors all day to keep cool and enduring the stress of heat emergencies can make older adults <a href="https://www.heat.gov/pages/who-is-at-risk-to-extreme-heat">depressed and isolated</a>. Those with <a href="https://health.gov/healthypeople/tools-action/browse-evidence-based-resources/cognitive-impairment-older-adults-screening">cognitive problems</a> or dementia may not understand their health risks or may not take proper precautions. Seniors with physical disabilities, limited mobility or lack of access to transportation can’t easily travel to a public cooling center – if there is one nearby.</p>
<h2>Drawn to high-risk regions</h2>
<p><a href="https://www.census.gov/library/publications/2022/demo/p23-218.html">Retirees are often drawn</a> to the South’s sunny skies, low taxes and costs of living and amenities, like golf courses, beaches, health care facilities and age 55+ residential communities tailored to their needs. In Phoenix, the share of residents over age 65 is projected to rise from 10% of its 1.6 million residents today <a href="https://doi.org/10.1093/geront/gnad050">to roughly 17% by 2050</a>.</p>
<p>At the same time that these populations are rising, the number of days people will need air conditioning is rising, too.</p>
<p>We used <a href="https://doi.org/10.1088/1748-9326/ab4a3a">scenarios of future county-level population</a> and <a href="https://www.nccs.nasa.gov/services/data-collections/land-based-products/nex-gddp-cmip6">climate model output from NASA</a> to assess the consequences of moderate and dramatic warming. <a href="https://doi.org/10.1093/geront/gnad050">Our projections show</a> that ever-rising numbers of older people are at risk of the harmful physical and mental health consequences of heat extremes.</p>
<p><iframe id="taoGc" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/taoGc/13/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>We found that populations in historically hot locations like Arizona and desert regions of California are aging at a rapid clip, placing demands on cities, counties and states to meet the pressing needs of older residents during heat waves.</p>
<p>These include providing cooling centers and ensuring that they are physically accessible to those with mobility challenges, and training first responders to be sensitive to the special needs of older adults who may be reluctant to leave their homes during a heat emergency.</p>
<p>Communities also need to find effective ways to warn “snowbirds,” vacationers or recent migrants who might hail from cooler climates and be less aware of, or adapted to, the risks of extreme heat.</p>
<h2>Northern regions are at risk, too</h2>
<p>Our research finds that historically cooler places like New England, the upper Midwest and the Pacific Northwest also have rising heat risks.</p>
<p>These regions – historically home to high shares of older adults – are projected to experience the steepest increases in heat exposure relative to temperatures historically experienced. Older adults who are accustomed to the New England chill may not fully understand the threats an extreme heat wave can pose, and they may <a href="https://doi.org/10.1073/pnas.1813145116">underestimate the harm</a> they might suffer from a day in the hot sun.</p>
<figure class="align-center ">
<img alt="Two women stand in a large fountain in Washington Square park. It has steps designed for people to sit or walk down to the water." src="https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/539315/original/file-20230725-20-1moa7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Standing in a fountain can help cool a person off to a point, but being exposed to the sun when the heat index is 100 F, as this day in New York City was in 2021, can be dangerous, especially for older adults.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/two-women-stand-in-the-fountain-in-washington-square-park-news-photo/1333649056?adppopup=true">Alexi Rosenfeld/Getty Images</a></span>
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</figure>
<p><iframe id="fMTok" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/fMTok/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Older homes in the Northeast also tend to have <a href="https://www.eia.gov/todayinenergy/detail.php?id=52558">less efficient cooling systems</a>. <a href="https://www.cnn.com/2023/06/30/weather/nighttime-heat-danger-climate-change-xpn-scn/index.html">Nighttime heat</a> can be particularly harmful for those without air conditioning, including people who live in densely populated Northeastern and Rust Belt cities where “heat islands” trap temperatures. For older adults with health conditions, <a href="https://www.sleepfoundation.org/insomnia/older-adults">a night of restless sleep</a> may make one more depressed and confused during waking hours.</p>
<h2>What you can do about it</h2>
<p>Older adults and their caregivers can take <a href="https://www.cdc.gov/aging/emergency-preparedness/older-adults-extreme-heat/index.html">some steps to adapt</a>.</p>
<p>Stay indoors. Use air conditioning. Drink plenty of water. Don’t use the oven, especially in small homes. Help an older adult with transportation to a cooling center. Place medications in the coolest spot in one’s home. Be sensitive to symptoms like dizziness and call for medical attention as needed.</p>
<p>However, <a href="https://doi.org/10.1080/08959420.2011.605642">community-scale adaptations also are needed</a>. <a href="https://doi.org/10.2105/AJPH.2022.307217">Public investments</a> in early <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15757-x">warning systems</a> for extreme weather, ride services to transport older adults to cooling centers and hospitals, geographic information systems to help first responders identify neighborhoods with high concentrations of older adults, and installation of energy-efficient air conditioning in homes and public settings can help to fight back against sweltering days in the future.</p><img src="https://counter.theconversation.com/content/210049/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Carr receives funding from National Institutes of Aging and RRF Foundation for Aging.</span></em></p><p class="fine-print"><em><span>Giacomo Falchetta receives funding from the Euro-Mediterranean Centre on Climate Change (CMCC).</span></em></p><p class="fine-print"><em><span>Ian Sue Wing received funding from the U.S. Department of Energy.</span></em></p>Health and climate change researchers explain the risks and why older adults, even those in northern states, need to pay attention.Deborah Carr, Professor of Sociology and Director of the Center for Innovation in Social Science, Boston UniversityGiacomo Falchetta, Postdoctoral Research Scholar in Energy, Climate and Environment, International Institute for Applied Systems Analysis (IIASA)Ian Sue Wing, Professor of Earth and Environment, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1988802023-02-27T19:16:01Z2023-02-27T19:16:01ZConsidering going off antidepressants? Here’s what to think about first<figure><img src="https://images.theconversation.com/files/511353/original/file-20230221-20-otku8g.jpg?ixlib=rb-1.1.0&rect=20%2C0%2C6689%2C3780&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">sh</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-girl-hold-white-pills-jar-1702567036">Shutterstock</a></span></figcaption></figure><p>Mental health is key to health and wellbeing. Yet two in five Australians aged 16 to 85 (44%) <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health">experience a mental illness</a> during their lifetime, commonly anxiety or depression. And more than <a href="https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions">32 million</a> antidepressant prescriptions are dispensed on the Pharmaceutical Benefits Scheme each year for these diagnoses. </p>
<p>Use of antidepressants has <a href="https://pubmed.ncbi.nlm.nih.gov/34963328/">increased</a> since the beginning of the COVID pandemic at a greater rate than past decades. As we return to some semblance of normality, people may well be thinking about going off their mental health medicines, particularly antidepressants. </p>
<p>But what are the risks of stepping down or stopping these medicines? Here’s what to consider.</p>
<h2>Is there ever a good time to stop antidepressants?</h2>
<p>It can take several weeks after starting an antidepressant before symptoms begin to improve. During this time, the person may feel worse before they feel better, as side effects often occur before symptoms improve. Troublesome symptoms (nausea, diarrhoea or insomnia) will <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181894/">usually improve</a> once the body adjusts to the new medicine. So, it is important to give the antidepressant a “fair go” and not stop too early in this process.</p>
<p>For people who have been diagnosed with their first episode of anxiety or depression and are responding to their antidepressant, <a href="https://www.nice.org.uk/guidance/ng222/chapter/recommendations">guidelines</a> recommend a six- to 12-month duration of use, followed by medical review to assess if taking medication is still indicated.</p>
<p>Of course, there are reasons you might be thinking about discontinuing your antidepressant. They could include:</p>
<ul>
<li><p>no longer experiencing symptoms of depression or anxiety</p></li>
<li><p>finding other ways of coping</p></li>
<li><p>medicine seeming ineffective</p></li>
<li><p>long-term use and wanting a break</p></li>
<li><p>a life event such as pregnancy, divorce or job change</p></li>
<li><p>media influences, such as reports about treatments or portrayals of people taking similar medications</p></li>
<li><p>side effects, stigma or pressure from family and friends.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-chemical-imbalance-theory-of-depression-is-dead-but-that-doesnt-mean-antidepressants-dont-work-187769">The chemical imbalance theory of depression is dead, but that doesn't mean antidepressants don't work</a>
</strong>
</em>
</p>
<hr>
<h2>Go slowly</h2>
<p>In animal studies, <a href="https://pubmed.ncbi.nlm.nih.gov/36057649/">restricted plasticity in specific brain parts </a> (that is, the brain’s ability to modify connections or rewire itself) can cause features of depression or anxiety. How antidepressants work is not completely understood. However, <a href="https://pubmed.ncbi.nlm.nih.gov/34053675/">recent evidence</a> suggests they protect against or reverse some of these maladaptive neuroplastic changes. </p>
<p>Beneficial effects take time, and stopping antidepressants quickly can unwind the medicine’s neurophysiological adaptations. This can create a “shock to the system” and potentially lead to unwanted side effects such as withdrawal symptoms. </p>
<p>Slower reduction allows the brain time to gradually readjust.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">The TGA has approved certain psychedelic treatments: the response from experts is mixed</a>
</strong>
</em>
</p>
<hr>
<h2>What can go wrong when you abruptly stop antidepressants?</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/36400895/">Stopping antidepressants abruptly</a>, especially after a long period of use, will make most people – although not everyone – unwell. It’s impossible to tell in advance who will be affected, so slow dose reduction is advisable.</p>
<p>Stopping antidepressants (or tapering down the dose) too rapidly can cause <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449237/">antidepressant discontinuation syndrome</a> in around 20% of people. </p>
<p>Withdrawal symptoms are variable but can include flu-like symptoms (lethargy, fatigue, headache, achiness, sweating), insomnia, nausea (sometimes vomiting), dizziness, sensory disturbances (such as burning or tingling) and hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness). </p>
<p>Symptoms typically occur within ten days and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970174/">usually resolve</a> in two to three weeks. But occasionally, a protracted withdrawal syndrome lasting many months can occur. </p>
<p>People who’ve had irregular doses, switched antidepressants, overlooked side-effects or previous withdrawal symptoms are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970174/">more likely</a> to experience protracted symptoms and take longer to recover.</p>
<h2>Is this withdrawal or a relapse?</h2>
<p>In mental illness, the cause of symptoms can be difficult to differentiate. Antidepressant side-effects can mimic withdrawal symptoms or disease relapse, causing confusion for both patients and prescribers.</p>
<p><iframe id="DU2ve" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DU2ve/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Withdrawal symptoms tend to <a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18060692">surge irregularly</a> like waves. This makes them different to a relapse of the original condition, which has a more consistent pattern and <a href="https://pubmed.ncbi.nlm.nih.gov/16456219/">takes longer</a> to develop.</p>
<p>Antidepressant discontinuation is an important decision. Consider whether you are in the right mindset to make this change. Work with a trusted mental health professional to tailor a strategy for your individual circumstances to minimise withdrawal or relapse risk. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman sits on couch with hands clasped" src="https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511354/original/file-20230221-18-pluj3c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chat to your prescriber about tapering down slowly at the right time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-clasped-her-hands-lap-closed-1756005818">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/can-taking-vitamins-and-supplements-help-you-recover-from-covid-182220">Can taking vitamins and supplements help you recover from COVID?</a>
</strong>
</em>
</p>
<hr>
<h2>4 things to think about</h2>
<p>Once you’ve considered your reasons for wanting to stop taking an antidepressant and whether you’ve given it a fair shot to work, think about whether you feel well physically and emotionally and have supportive people in your life.</p>
<p>If you still want to embark on a process of stepping down or ceasing medication:</p>
<p><strong>1. approach your prescriber</strong> honestly with your reasons for discontinuation and work towards a shared decision to reduce the dose</p>
<p><strong>2. plan dose reduction</strong> at a rate suitable for your personal health and duration of antidepressant use (months versus years). Longer use requires a longer taper. Dose reduction can be by as little as 10% or as much as 25% every one to two weeks, followed by another two to four weeks when you can observe how you feel and manage the reduced dose. If symptoms are tolerable, continue tapering as before. But be prepared to move back to the previous or a 10% dose increase if symptoms emerge</p>
<p><strong>3. monitor any symptoms</strong> and health by using a daily diary that records the drug dosage throughout the taper</p>
<p><strong>4. maximise the chances of success</strong> with self-care: a healthy diet, regular exercise and sleep.</p>
<p>Every medicine we take should have a reassessment date. People taking antidepressants should have their medication reviewed no later than 12 months after they started. </p>
<p>This gives an opportunity for the patient to discuss the risks versus benefits of remaining on their medicine or developing a shared strategy for safe discontinuation.</p><img src="https://counter.theconversation.com/content/198880/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Treasure McGuire does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are lots of reasons someone might want to stop taking antidepressants, from a life change to wanting to take a break. But the process of tapering off medications needs to be carefully managed.Treasure McGuire, Assistant Director of Pharmacy, Mater Health SEQ in conjoint appointment as Associate Professor of Pharmacology, Bond University and Associate Professor (Clinical), The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1990852023-02-10T01:50:05Z2023-02-10T01:50:05ZIs my medicine making me feel hotter this summer? 5 reasons why<figure><img src="https://images.theconversation.com/files/508796/original/file-20230208-24-lf74uh.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/overheated-woman-sitting-on-couch-waving-1707953323">Shutterstock</a></span></figcaption></figure><p>If you’re really feeling the heat this summer, it might be down to more than the temperature outside.</p>
<p>Some types of medicines can increase your core body temperature or make you feel hotter than you really are. Some can affect your body’s ability to cool down.</p>
<p>Here’s what you need to know about heat intolerance and medicines.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-cope-with-extreme-heat-days-without-racking-up-the-aircon-bills-128857">How to cope with extreme heat days without racking up the aircon bills</a>
</strong>
</em>
</p>
<hr>
<h2>What is heat intolerance?</h2>
<p>Some people simply dislike the feeling of feeling hot, while others feel hot at temperatures most people find comfortable. Both are examples of
<a href="https://www.medicalnewstoday.com/articles/325232#symptoms">heat intolerance</a>.</p>
<p>Typical symptoms during warm weather include excessive sweating (or not sweating enough), exhaustion and fatigue, nausea, vomiting or dizziness, and changes in mood.</p>
<p>A number of factors can cause heat intolerance.</p>
<p>This includes the disorder <a href="https://my.clevelandclinic.org/health/diseases/6004-dysautonomia">dysautonomia</a>, which affects people’s autonomic nervous system – the part of the body that regulates the automatic functions of the body, including our response to heat. </p>
<p>Conditions such as diabetes, alcohol misuse, <a href="https://theconversation.com/what-causes-parkinsons-disease-what-we-know-dont-know-and-suspect-57579">Parkinson’s disease</a>, the autoimmune disease <a href="https://theconversation.com/explainer-what-is-guillain-barre-syndrome-and-is-it-caused-by-the-zika-virus-53884">Guillain-Barré syndrome</a> and <a href="https://theconversation.com/explainer-what-are-mitochondria-and-how-did-we-come-to-have-them-83106">mitochondrial disease</a> can cause dysautonomia. People in old age, those with some neurological conditions, or people less physically fit may also have it.</p>
<p>But importantly, medications can also contribute to heat intolerance.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-reasons-to-check-on-your-elderly-neighbour-during-a-heatwave-196218">5 reasons to check on your elderly neighbour during a heatwave</a>
</strong>
</em>
</p>
<hr>
<h2>1. Your body temperature rises</h2>
<p>Some medicines directly increase your body temperature, which then increases the risk of heat intolerance. </p>
<p>These include <a href="https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bph.15465">stimulant medications</a> to treat ADHD (attention deficit hyperactivity disorder), such as methylphenidate, dexamfetamine and lisdexamfetamine.</p>
<p><a href="https://www.healthdirect.gov.au/antipsychotic-medications">Antipsychotic medications</a> (such as clozapine, olanzapine and quetiapine) used to treat mental health conditions, such as schizophrenia and bipolar disorder, are other examples. </p>
<p>These ADHD and antipsychotic medicines raise your temperature by acting on the hypothalamus, the region of the brain essential for cooling.</p>
<p>The drug levothyroxine, used to treat an under-active thyroid, also increases your body temperature, this time by <a href="https://www.ncbi.nlm.nih.gov/books/NBK500006/">increasing your metabolism</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Medical illustration of hypothalamus region of brain" src="https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508840/original/file-20230208-28-ki6965.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some medicines raise your body temperature directly by acting on the hypothalamus region of the brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-hypothalamus-1292650669">SciePro/Shutterstock</a></span>
</figcaption>
</figure>
<h2>2. Your blood flow is affected</h2>
<p>Other medicines constrict (tighten) blood vessels, decreasing blood flow to the skin, and so prevent heat from escaping this way. This means your body can’t regulate its temperature as well in the heat. </p>
<p>Examples include <a href="https://www.healthdirect.gov.au/beta-blockers">beta-blockers</a> (such as metoprolol, atenolol and propranolol). These medications are used to treat conditions such as high blood pressure, angina (a type of chest pain), tachycardia (fast heart rate), heart failure, and to prevent migraines. </p>
<p><a href="https://www.nhs.uk/conditions/decongestants/">Decongestants</a> for blocked noses (for example, pseudoephedrine and phenylephrine), triptans for migraines (such as sumatriptan and zolmitriptan) and the ADHD medications mentioned earlier can also act to decrease blood flow to the skin.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/forget-nose-spray-good-sex-clears-a-stuffy-nose-just-as-effectively-and-is-a-lot-more-fun-167901">Forget nose spray, good sex clears a stuffy nose just as effectively — and is a lot more fun</a>
</strong>
</em>
</p>
<hr>
<h2>3. You can get dehydrated</h2>
<p>Other medicines can cause dehydration, which then makes you more susceptible to heat intolerance. The best examples are <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/diuretics/art-20048129">diuretics</a> such as furosemide, hydrochlorothiazide, acetazolamide and aldosterone.</p>
<p>These are used to control high blood pressure and heart failure by forcing your kidneys to remove more fluid from your body. </p>
<p>Laxatives, such as senna extract and bisacodyl, also remove water from your body and so have a similar effect.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-how-do-i-tell-if-im-dehydrated-107437">Health Check: how do I tell if I'm dehydrated?</a>
</strong>
</em>
</p>
<hr>
<h2>4. You can sweat less</h2>
<p>Other medicines have a drying effect. This can be needed for medicines to do their job (for instance, to dry up a runny nose). For others, it is an unwanted side effect. </p>
<p>This drying reduces the amount you sweat, making it harder to lose heat and regulate your core temperature. A number of medicines have these effects, including:</p>
<ul>
<li>some antihistamines (such as promethazine, doxylamine and diphenhydramine)</li>
<li>certain antidepressants (such as amitriptyline, clomipramine and dothiepin)</li>
<li>medicines used to treat <a href="https://www.healthdirect.gov.au/urinary-incontinence#:%7E:text=Urinary%20incontinence%2C%20or%20poor%20bladder%20control%2C%20is%20very%20common%20in,to%20cure%20or%20improve%20it.">urinary incontinence</a> (for example, oxybutynin and solifenacin) </li>
<li>nausea medicine (prochlorperazine)</li>
<li>medicines for stomach cramps and spasms (for instance, hyoscine) </li>
<li>the antipsychoptics chlorpromazine, olanzapine, quetiapine and clozapine.</li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-do-men-really-sweat-more-than-women-73903">Health Check: do men really sweat more than women?</a>
</strong>
</em>
</p>
<hr>
<h2>5. You don’t feel thirsty</h2>
<p>Finally, some medicines, such as the antipsychotics haloperidol and droperidol, can aggravate heat intolerance by reducing your ability to feel thirsty. </p>
<p>If you don’t feel thirsty, you drink less and are therefore at risk of dehydration and feeling hot.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman staring at glass of water on counter" src="https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508849/original/file-20230208-31-oak7ni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People taking some medications just don’t feel thirsty.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/upset-young-woman-looking-through-glass-754782025">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-how-can-extreme-heat-lead-to-death-91480">Health Check: how can extreme heat lead to death?</a>
</strong>
</em>
</p>
<hr>
<h2>What can you do about it?</h2>
<p>If you are feeling hot this summer and think your medicine may be contributing, it’s very important you keep taking your medicine.</p>
<p>Speak to your pharmacist or doctor about your symptoms. They will offer advice and discuss alternatives.</p><img src="https://counter.theconversation.com/content/199085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vairea Skincare LLC and a Standards Australia panel member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Jessica Pace does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you think your medicine may be contributing to overheating, it’s very important you keep taking your medicine. Discuss your symptoms with your pharmacist or doctor.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyJessica Pace, Associate Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1966462022-12-21T19:11:54Z2022-12-21T19:11:54ZDrinking alcohol this Christmas and New Year? These medicines really don’t mix<figure><img src="https://images.theconversation.com/files/502253/original/file-20221220-22-w0zd44.jpg?ixlib=rb-1.1.0&rect=8%2C17%2C5742%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/champagne-glasses-hands-people-party-1377409880">Shutterstock</a></span></figcaption></figure><p>A glass or two of champagne with Christmas lunch. A cool crisp beer at the beach. Some cheeky cocktails with friends to see in the New Year. There seem to be so many occasions to unwind with an alcoholic drink this summer.</p>
<p>But if you’re taking certain medications while drinking alcohol, this can affect your body in a number of ways. Drinking alcohol with some medicines means they may not work so well. With others, you risk a life-threatening overdose.</p>
<p>Here’s what you need to know if you’re taking medication over summer and plan to drink.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-different-drinks-make-you-different-drunk-88247">Do different drinks make you different drunk?</a>
</strong>
</em>
</p>
<hr>
<h2>Why is this a big deal?</h2>
<p>After you take a medicine, it travels to the stomach. From there, your body shuttles it to the liver where the drug is metabolised and broken down before it goes into your blood stream. Every medicine you take is provided at a dose that takes into account the amount of metabolism that occurs in the liver.</p>
<p>When you drink alcohol, this is also broken down in the liver, and it can affect how much of the drug is metabolised. </p>
<p>Some medicines are metabolised <em>more</em>, which can mean not enough reaches your blood stream to be effective. </p>
<p>Some medicines are metabolised <em>less</em>. This means you get a much higher dose than intended, which could lead to an overdose. The effects of alcohol (such as sleepiness) can act in addition to similar effects of a medicine.</p>
<p>Whether or not you will have an interaction, and what interaction you have, depends on many factors. These include the medicine you are taking, the dose, how much alcohol you drink, your age, genes, sex and overall health. </p>
<p>Women, older people and people with liver issues are more likely to have a drug interaction with alcohol.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-are-50-75-more-likely-to-have-adverse-drug-reactions-a-new-mouse-study-finally-helps-explain-why-195358">Women are 50–75% more likely to have adverse drug reactions. A new mouse study finally helps explain why</a>
</strong>
</em>
</p>
<hr>
<h2>Which medicines don’t mix well with alcohol?</h2>
<p>Many medicines interact with alcohol regardless of whether they are prescribed by your doctor or bought over the counter, such as <a href="https://www.drugs.com/article/herbal-supplements-alcohol.html">herbal medicines</a>.</p>
<p><strong>1. Medicines + alcohol = drowsiness, coma, death</strong></p>
<p>Drinking alcohol and taking a medicine that depresses the <a href="https://adf.org.au/drug-facts/depressants/">central nervous system</a> to reduce arousal and stimulation can have additive effects. Together, these can make you extra drowsy, slow your breathing and heart rate and, in extreme cases, lead to coma and death. These effects are more likely if you use more than one of this type of medicine. </p>
<p>Medicines to look out for include those for depression, anxiety, schizophrenia, pain (except <a href="https://www.nps.org.au/australian-prescriber/articles/alcohol-and-paracetamol">paracetamol</a>), sleep disturbances (such as insomnia), allergies, and colds and flu. It’s best not to drink alcohol with these medicines, or to keep your alcohol intake to a minimum. </p>
<p><strong>2. Medicines + alcohol = more effects</strong></p>
<p>Mixing alcohol with some medicines increases the effect of those medicines. </p>
<p>One example is with the sleeping tablet zolpidem, which is <a href="https://www.tga.gov.au/news/product-recalls/zolpidem-stilnox">not to be taken with alcohol</a>. Rare, but serious, side effects are strange behaviour while asleep, such as sleep-eating, sleep-driving or sleep-walking, which are more likely with alcohol.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-cant-sleep-what-drugs-can-i-safely-take-102343">I can't sleep. What drugs can I (safely) take?</a>
</strong>
</em>
</p>
<hr>
<p><strong>3. Medicines + craft beer or home brew = high blood pressure</strong></p>
<p>Some types of medicines only interact with some types of alcohol.</p>
<p>Examples include some medicines for depression, such as phenelzine, tranylcypromine and moclobemide, the antibiotic linezolid, the Parkinson’s drug selegiline, and the cancer drug procarbazine.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two young women drinking alcohol sitting on bench outside bar" src="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drinking craft beer this summer? This can interact with some drugs to raise your blood pressure.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/two-smiling-women-sitting-on-wooden-bench-1267696/">ELEVATE/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>These so-called <a href="https://www.mydr.com.au/medicine/monoamine-oxidase-inhibitors-maois-for-depression/">monoamine oxidase inhibitors</a> <a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0020/145802/oncol_maoi.pdf">only interact with</a> some types of boutique and artisan beers, beers with visible sediment, Belgian, Korean, European and African beers, and home-made beers and wine.</p>
<p>These types of alcohol contain high levels of tyramine, a naturally occurring substance usually broken down by your body that doesn’t ordinarily cause any harm. </p>
<p>However, monoamine oxidase inhibitors prevent your body from breaking down tyramine. This increases levels in your body and can cause your blood pressure to rise to dangerous levels. </p>
<p><strong>4. Medicines + alcohol = effects even after you stop drinking</strong></p>
<p>Other medicines interact because they affect the way your body breaks down alcohol. </p>
<p>If you drink alcohol while using such medicines you may you feel nauseous, vomit, become flushed in the face and neck, feel breathless or dizzy, your heart may beat faster than usual, or your blood pressure may drop. </p>
<p>This can occur even after you stop treatment, then drink alcohol. For example, if you are taking metronidazole you should avoid alcohol both while using the medicine and for at least 24 hours after you stop taking it. </p>
<p>An example of where alcohol changes the amount of the medicine or related substances in the body is acitretin. This medication is used to treat skin conditions such as severe psoriasis and to prevent skin cancer in people who have had an organ transplant.</p>
<p>When you take acitretin, it changes into another substance – <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2017-CMI-02034-1&d=20221221172310101">etretinate</a> – before it is removed from your body. Alcohol increases the amount of etretinate in your body. </p>
<p>This is especially important as etretinate can cause birth defects. To prevent this, if you are a woman of child-bearing age you should avoid alcohol while using the medicine and for two months after you stop taking it.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-we-dont-know-what-causes-most-birth-defects-78592">Why we don't know what causes most birth defects</a>
</strong>
</em>
</p>
<hr>
<h2>Myths about alcohol and medicines</h2>
<p><strong>Alcohol and birth control</strong></p>
<p>One of the most common myths about medicines and alcohol is that you can’t drink while using <a href="https://youly.com.au/blog/sexual-reproductive-health/does-alcohol-make-the-pill-less-effective/">the contraceptive pill</a>.</p>
<p>It is generally safe to use alcohol with the pill as it <a href="https://www.healthline.com/health/womens-health/birth-control-and-alcohol#:%7E:text=There's%20a%20bit%20of%20good,a%20less%20effective%20birth%20control.">doesn’t directly affect</a> how well birth control works. </p>
<p>But the pill is most effective when taken at the same time each day. If you’re drinking heavily, you’re more likely to forget to do this the next day. </p>
<p>Alcohol can also make some people nauseous and vomit. If you vomit within three hours of taking the pill, it will not work. This increases your risk of pregnancy. </p>
<p>Contraceptive pills can also affect your response to alcohol as the hormones they contain can change the way your body <a href="https://americanaddictioncenters.org/alcoholism-treatment/birth-control">removes alcohol</a>. This means you can get drunk faster, and stay drunk for longer, than you normally would.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding pack of contraceptive pills" src="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=268&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=268&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=268&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=336&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=336&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=336&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Yes you can drink while on the pill. But if you vomit within a few hours of taking it, the pill won’t work.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-hands-opening-birth-control-pills-2139091435">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/always-forgetting-to-take-your-medicines-here-are-4-things-that-could-help-193717">Always forgetting to take your medicines? Here are 4 things that could help</a>
</strong>
</em>
</p>
<hr>
<p><strong>Alcohol and antibiotics</strong></p>
<p>Then there’s the myth about not mixing alcohol with any <a href="https://theconversation.com/mondays-medical-myth-you-cant-mix-antibiotics-with-alcohol-4407">antibiotics</a>. This only applies to <a href="https://www.healthdirect.gov.au/medicines/medicinal-product/aht,21161/metronidazole">metronidazole</a> and <a href="https://www.healthdirect.gov.au/medicines/brand/amt,1011571000168100/linezolid-apo">linezolid</a>. </p>
<p>Otherwise, it is generally safe to use alcohol with antibiotics, as alcohol does not affect how well they work.</p>
<p>But if you can, it is best to avoid alcohol while taking antibiotics. Antibiotics and alcohol have similar side effects, such as an upset stomach, dizziness and drowsiness. Using the two together means you are more likely to have these side effects. Alcohol can also reduce your energy and increase how long it takes for you to recover.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mondays-medical-myth-you-cant-mix-antibiotics-with-alcohol-4407">Monday's medical myth: you can't mix antibiotics with alcohol</a>
</strong>
</em>
</p>
<hr>
<h2>Where can I go for advice?</h2>
<p>If you plan on drinking alcohol these holidays and are concerned about any interaction with your medicines, don’t just stop taking your medicines.</p>
<p>Your pharmacist can advise you on whether it is safe for you to drink based on the medicines you are taking, and if not, provide advice on alternatives.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-let-your-pet-accidentally-get-drunk-this-silly-season-sorry-tiddles-87671">Don't let your pet accidentally get drunk this silly season (sorry Tiddles)</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/196646/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vairea Skincare LLC and a Standards Australia panel member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Jessica Pace does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Drinking alcohol with some medicine means they may not work so well. With others, you risk a life-threatening overdose.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyJessica Pace, Associate Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1949062022-12-13T13:20:32Z2022-12-13T13:20:32ZTiming matters for medications – your circadian rhythm influences how well treatments work and how much they might harm you<figure><img src="https://images.theconversation.com/files/500478/original/file-20221212-110709-c1r8v2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5100%2C3397&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chronotherapeutic drug delivery aims to maximize treatment effectiveness and minimize side effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/clock-and-pills-and-tablets-around-it-royalty-free-illustration/1323067934">Vaselena/iStock via Getty Images Plus</a></span></figcaption></figure><p>All living organisms on Earth are exposed to a 24-hour day-night cycle. This cycle is the reason why people rest during the darkness of night and are active during the light of day. Consequently, all <a href="https://theconversation.com/your-body-has-an-internal-clock-that-dictates-when-you-eat-sleep-and-might-have-a-heart-attack-all-based-on-time-of-day-178601">human body functions</a> also follow this daily rhythm, and the timing of behaviors like exercise or food intake can significantly influence your health. For example, <a href="https://doi.org/10.3177/jnsv.68.S2">eating at night</a> can lead to weight gain over time because while daytime food intake is used for activities, food intake at night leads to increased fat storage because the body expects to be at rest.</p>
<p>When you take your medications is also influenced by your circadian rhythm. <a href="https://doi.org/10.1073/pnas.1408886111">Many drug targets</a> in the body follow a 24-hour cycle. This means that the specific proteins a drug is designed to modify can react differently to the medication over the course of a 24-hour time period. Because how the body responds to a medication can differ depending on whether it is taken during the day or at night, it logically follows that taking medications at specific times could help increase their effectiveness and reduce unwanted side effects.</p>
<p>When doctors prescribe medication for people, they <a href="https://doi.org/10.1126%2Fscience.aax7621">rarely consider</a> the best time to take it. There are two main reasons for that oversight. First, many physicians are not aware that some drugs work better during a specific time of the day. And second, most drugs have not been studied for possible different effects during a 24-hour cycle. As such, patients are directed to take most drugs during the morning or evening primarily to ensure compliance.</p>
<p><a href="https://medschool.cuanschutz.edu/anesthesiology/research-innovation/clinical-research/eckle-lab">My lab</a> <a href="https://scholar.google.com/citations?hl=en&user=QeAbWicAAAAJ&view_op=list_works&sortby=pubdate">and I</a> have been studying chronotherapy, or how time of day affects disease development and treatment effectiveness, for many years. In our <a href="https://doi.org/10.3389%2Ffcvm.2022.982209">recently published research</a>, we found that using a particular sedative at night can increase the risk for heart damage.</p>
<h2>Chronotherapeutic drug delivery</h2>
<p>The concept of chronotherapy isn’t new. For example, <a href="https://doi.org/10.1016/0014-5793(69)80210-3">over 50 years ago</a>, researchers found that the cholesterol drug <a href="https://www.ncbi.nlm.nih.gov/books/NBK532919/">simvastatin</a> is <a href="https://doi.org/10.3390/pharmaceutics8020013">more effective</a> at lowering triglyceride and cholesterol levels when taken at night rather than during the day. This is because the liver enzyme these drugs target is more active at night. As a result, the Food and Drug Administration recommends taking simvastatin in the evening. </p>
<p>Similarly, research in the 1990s showed that taking time of day into account when administering a combination chemotherapy could <a href="https://doi.org/10.1093/jnci/86.21.1608">increase its effectiveness and reduce treatment toxicity</a> for colorectal cancer patients. This is because cancer cells divide at different rates over the course of the day. The rate that the body metabolizes drugs also varies over a 24-hour cycle.</p>
<p>Other examples include the over-the-counter acid reflux medication <a href="https://doi.org/10.1111/j.1365-2036.1995.tb00440.x">omeprazole</a> and <a href="https://doi.org/10.1080/08037051.2022.2142512">blood pressure medications</a> that work best when taken before bedtime or in the evening, respectively.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/uOcpsXMJcJk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Many factors can affect how well a drug will work for each person.</span></figcaption>
</figure>
<p>Taking medications at the wrong time can even cause harm. My colleagues and I wondered whether midazolam, the most common sedative used in surgical procedures worldwide, might <a href="https://doi.org/10.1073/pnas.1201734109">interfere with the internal clock</a> that protects the heart at night. Currently, there are no guidelines regarding when midazolam should be administered.</p>
<p>When we analyzed data from 50 medical institutions for the occurrence of heart damage during surgical procedures from 2014 to 2019, we found that taking midazolam during overnight surgeries may increase the odds of <a href="https://doi.org/10.3389%2Ffcvm.2022.982209">heart damage in healthy patients</a> by over threefold.</p>
<h2>Timing matters</h2>
<p>More research is needed to determine the best times to administer treatments for different diseases. Taking time of day into account might require <a href="https://doi.org/10.1126/science.aax7621">reformulating some medications</a> that last for more than a 24-hour time period in the body.</p>
<p>As of 2019, the FDA has recommendations for <a href="https://doi.org/10.1126/science.aax7621">only four</a> of the 50 currently most prescribed medications to be given at a specific time of day. Considering that the top 10 highest-grossing drugs in the U.S. help only <a href="https://doi.org/10.1038/520609a">between 1 in 25 and 1 in 4</a> of the people who take them, I believe that taking drug timing into account could help make treatments more effective and help more people worldwide.</p><img src="https://counter.theconversation.com/content/194906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tobias Eckle receives funding from the NIH.</span></em></p>There is a best time to take your medications, but your doctor may not know when that is. Researchers are still figuring it out, one drug at a time.Tobias Eckle, Professor of Anesthesiology, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1885602022-08-17T19:25:57Z2022-08-17T19:25:57ZWhy letting Medicare negotiate drug prices won’t be the game-changer for health care Democrats hope it will be<figure><img src="https://images.theconversation.com/files/479678/original/file-20220817-12095-ynmg73.jpg?ixlib=rb-1.1.0&rect=26%2C164%2C4362%2C3347&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug prices have been soaring in recent years. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/prescription-royalty-free-image/155597284?adppopup=true">stevecoleimages/E+ via Getty Inages</a></span></figcaption></figure><p>Democrats hope their new <a href="https://www.nytimes.com/2022/08/16/business/biden-climate-tax-inflation-reduction.html">health care, tax and climate law</a> begins to rein in soaring prescription drug prices. </p>
<p>One of its most touted provisions allows <a href="https://www.medicare.gov/">Medicare</a>, America’s health insurance program for seniors, to negotiate some prescription drug prices for the first time, with some calling it “<a href="https://www.cbsnews.com/news/inflation-reduction-act-lower-drug-costs-medicare-seniors-cbs-news-explain/">game-changing</a>” and a <a href="https://www.biopharmadive.com/news/senate-passage-of-drug-pricing-bill-brings-major-defeat-closer-for-pharma-i/629096/">significant victory over the pharmaceutical industry</a>. Drug manufacturers had stubbornly opposed any governmental regulation of drug prices <a href="https://doi.org/10.1111%2Fj.0887-378X.2004.00311.x">for decades</a> and are <a href="https://news.bloomberglaw.com/health-law-and-business/big-pharma-likely-to-aim-legal-firepower-at-drug-price-measures">likely to challenge the measure in court</a>.</p>
<p>As a <a href="https://public-health.tamu.edu/directory/haeder.html">scholar</a> who has <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">published extensively on the politics of health policy</a>, I’m skeptical that giving Medicare the ability to negotiate prices on a handful of drugs will be as transformative as the law’s backers hope. While a good step, it is unlikely to make a significant difference in how much seniors pay overall for medicine.</p>
<p>Fortunately, there are several other provisions in the law that will do much more to meaningfully help seniors struggling with the high cost of prescription drugs. </p>
<h2>Why US drug prices are so high</h2>
<p>Pharmaceutical innovation over the past few decades <a href="https://theconversation.com/how-much-for-an-amputation-or-checkup-it-takes-a-complex-formula-and-a-committee-of-doctors-to-set-the-price-for-every-possible-health-care-procedure-182109">has been tremendous</a>. The <a href="https://doi.org/10.1038/d41586-020-03626-1">quick response</a> to the COVID-19 pandemic in terms of vaccine development and treatments perfectly exemplifies the incredible benefits that drug developers have brought to the world. </p>
<p>Yet these developments have come at a high price, particularly in the United States, where each person spends more than <a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">US$1,100 a year</a> on drugs – up from $831 in 2013. Indeed, Americans are paying substantially more than residents of <a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">similar countries like Germany, the U.K. and Australia</a> – who pay $825, $285 and $434 per person each year, respectively. </p>
<p>People who need specific high-priced drugs are even more adversely affected. </p>
<p>Dulera, an asthma drug, costs <a href="https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/U.S.%20vs.%20International%20Prescription%20Drug%20Prices_0.pdf">50 times more in the U.S.</a> than the international average. Januvia, for diabetes, and Combigan, a glaucoma drug, cost about <a href="https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/U.S.%20vs.%20International%20Prescription%20Drug%20Prices_0.pdf">10 times more</a>. Americans shell out, on average, <a href="https://www.rand.org/pubs/research_reports/RRA788-1.html">$98.70 for a vial of insulin</a>, compared with the $6.94 Australians pay. </p>
<p>These costs impose a <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">big burden on Americans</a> – <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">1 in 5 of whom</a> skip medications because of the cost. Seniors are <a href="https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-february-2019-prescription-drugs/">particularly affected</a> by these problems.</p>
<p>The reasons for high prices are varied, including the <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">overall complexity of the U.S. health care system</a> and the <a href="https://www.kff.org/other/report/follow-the-pill-understanding-the-u-s/">lack of transparency in the drug supply chain</a>. But as I noted in a 2019 <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">article in The Conversation</a>, the biggest reason Americans pay so much more than people do elsewhere is simple: Pharmaceutical companies face no limits setting prices. </p>
<h2>Changing the game – a little</h2>
<p>The new law, known as the <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">Inflation Reduction Act</a> and signed into law on Aug. 16, 2022, seeks to change that. </p>
<p>The main mechanism to do it is by allowing Medicare to negotiate prices for some of the most expensive drugs. The act gives Medicare the ability to negotiate with drugmakers for 10 drugs starting in 2026 and 20 by 2029. </p>
<p>The law specifies that the medications Medicare is supposed to select must <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">account for most of its spending on drugs</a> and be name brands with no generic equivalents. Research has found that a relatively small number of drugs <a href="https://www.kff.org/medicare/issue-brief/relatively-few-drugs-account-for-a-large-share-of-medicare-prescription-drug-spending/?">are responsible for most spending</a>.</p>
<p>Importantly, pharmaceutical companies may face civil penalties and additional taxes on drug sales if they do not comply with the requirements to establish a “maximum fair price” as laid out in the law. </p>
<p>The provision is expected to <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">save the U.S. government about $102 billion</a> by 2031 by allowing it to pay less on prescription drugs for Americans on Medicare – currently <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Medicare%22,%22sort%22:%22desc%22%7D">63 million people</a>. The annual savings amount to about 5% of what <a href="https://www.kff.org/medicare/issue-brief/relatively-few-drugs-account-for-a-large-share-of-medicare-prescription-drug-spending/">Medicare currently spends on drugs</a>. </p>
<p>There’s also a separate provision that requires pharmaceutical companies, under certain conditions, to provide Medicare with rebates if drug prices outpace inflation. That measure takes effect this year and is expected to <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">yield $71 billion in savings</a> over a decade.</p>
<p>While the government savings are meaningful, I believe seniors themselves are likely to see only a minor drop in costs as a result of this provision, mainly through <a href="https://www.kff.org/medicare/issue-brief/how-would-drug-price-negotiation-affect-medicare-part-d-premiums/">slightly reduced premiums</a> and lower out-of-pocket costs. </p>
<figure class="align-center ">
<img alt="A Black female pharmacist shows Black senior woman some prescription meds." src="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Measures in the law Biden just signed should lower prices for many seniors.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-pharmacist-helping-a-senior-lady-choose-the-royalty-free-image/1352510394?adppopup=true">Marko Geber/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>Where the real savings are</h2>
<p>The provisions that will make a much bigger difference for seniors lie elsewhere. </p>
<p>Importantly, the new law limits seniors’ out-of-pocket expenses for prescription drugs to no more than $2,000 annually. Previously, there were <a href="https://www.healthline.com/health/medicare/medicare-out-of-pocket-maximum#medicare-out-of-pocket-costs">some restrictions but no limit</a>. This will directly help <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">1.4 million seniors</a> who exceeded the $2,000 threshold in 2020. </p>
<p>The law also limits how fast premiums for Medicare Part D, which provides premium-based prescription drug insurance, can rise over the next few years and implements a number of other adjustments. </p>
<p>It also extends the Medicare Part D low-income subsidy to <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">400,000 seniors</a> who previously earned too much to qualify. This program helps people pay for premiums, deductible and copays and has been valued at <a href="https://www.ssa.gov/benefits/medicare/prescriptionhelp.html">$5,100 a year</a>. </p>
<p>The legislation also limits the cost of insulin to no more than $35 per month for Medicare recipients only. This amounts to more than <a href="https://www.kff.org/medicare/issue-brief/insulin-out-of-pocket-costs-in-medicare-part-d/">$1 billion in annual savings for seniors</a>. Almost <a href="https://diabetes.org/about-us/statistics/about-diabetes">16 million American seniors have diabetes</a> and are likely to need insulin at some point in their lives.</p>
<p>Lastly, it also eliminates out-of-pocket costs for seniors for vaccines – a move that would have saved money for <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">4.1 million people in 2020</a>. </p>
<h2>Broader impact</h2>
<p>There are real benefits in the bill President Biden signed into law. The government will save by negotiating prices. Seniors will save through the insulin cap and other provisions. </p>
<p>But I don’t believe Medicare’s ability to negotiate prices will be a <a href="https://www.cbsnews.com/news/inflation-reduction-act-drug-costs-medicare-seniors-cbs-news-explains/">game-changing reform</a>. </p>
<p>Besides affecting prices paid by only a slice of Americans, we do not know how aggressively the federal government will seek savings. This particularly applies to any future administration headed up by a Republican president. </p>
<p>The pharmaceutical industry may still manage to limit the impact of price negotiations, since it will be four years before the changes take effect. The industry has a history of <a href="https://www.amazon.com/American-Sickness-Healthcare-Became-Business/dp/1594206759">skillfully exploiting loopholes</a> and a <a href="https://theconversation.com/prescription-drug-costs-would-have-been-a-major-campaign-issue-so-what-will-happen-now-that-coronavirus-is-center-stage-132493">vast lobbying apparatus</a> to put into that effort. </p>
<p>As for Americans who aren’t covered under Medicare, drug prices <a href="https://rollcall.com/2022/08/10/senates-medicare-drug-pricing-may-ripple-into-private-market">may actually go up</a>. That’s because, if pharmaceutical companies do end up reducing drug prices for seniors, they may shift those costs to everyone else to make up for those lost profits.</p><img src="https://counter.theconversation.com/content/188560/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new law will let Medicare bargain for the first time. But a health policy scholar explains why it’s unlikely to make much of a difference in how much seniors – or anyone else – pays for their meds.Simon F. Haeder, Associate Professor of Public Health, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1641482022-07-19T12:26:00Z2022-07-19T12:26:00ZWhy are drug names so long and complicated? A pharmacist explains the logic behind the nomenclature<figure><img src="https://images.theconversation.com/files/474353/original/file-20220715-18-k6uzvb.jpg?ixlib=rb-1.1.0&rect=178%2C267%2C1886%2C1142&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Having multiple prescriptions is difficult enough to keep track of, let alone ones with complicated names.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-staring-at-stack-of-prescription-bottles-royalty-free-image/523006070">Hill Street Studios/Stone via Getty Images</a></span></figcaption></figure><p>At some point in your life, you’ll likely find yourself with a prescription from your doctor to fill. While it’s important to keep track of all the medications you’re taking, that can be hard to do when the names of so many of these drugs are difficult to pronounce and even harder to remember.</p>
<p><a href="https://usf.discovery.academicanalytics.com/scholar/stack/299489/JASMINE-CUTLER">In my role as a pharmacist</a>, I’ve helped countless patients figure out exactly which medication they were taking for what ailment. Some wonder why they were prescribed the medication in the first place, or need help differentiating between drugs with names that seem like complete gibberish.</p>
<p>But there is a rhyme and a reason to drug names. All prescribed medications follow a standard nomenclature that describes what the drug is made of and how it functions.</p>
<h2>Who names drugs?</h2>
<p>Drugs get both a brand, or proprietary, name and a generic name that is nonproprietary. Each is assigned in a slightly different process.</p>
<p>As long as a drug compound isn’t trademarked, drug companies decide on a proprietary brand name for the medications they sell. Usually the brand name relates to the conditions the drug is intended to treat and is easy for both providers and patients to remember but doesn’t follow a standardized naming guideline. For example, the drug Lopressor helps lower blood pressure. </p>
<p>On the other hand, generic drug names all follow a standard nomenclature that helps medical providers and researchers more easily recognize and classify the drug. Lopressor, for example, has a generic name of metoprolol tartrate. The <a href="https://www.ama-assn.org/about/united-states-adopted-names/usan-council">U.S. Adopted Names Council</a>, composed of representatives from the Food and Drug Administration, American Medical Association, U.S. Pharmacopeia and American Pharmacists Association, works with the <a href="https://www.who.int/teams/health-product-and-policy-standards/inn">World Health Organization</a> to assign <a href="https://dx.doi.org/10.1021%2Facs.jmedchem.1c00181">international nonproprietary names, or INNs</a>, to drug compounds. Similar organizations <a href="https://doi.org/10.1016/B978-0-12-820007-0.00002-7">exist internationally</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pharmacist organizing medicine drawer" src="https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474355/original/file-20220715-495-u2t6el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Generic drugs are named using standard guidelines intended to minimize confusion and aid in classification.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pharmacist-organizing-the-medicine-drawer-royalty-free-image/1352512002">Marko Geber/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<p>A globally recognized naming process makes an otherwise confusing name game more manageable. It helps the medical community easily learn and categorize newly approved medications and reduce prescribing errors by providing a unique, standard name that reflects each active ingredient in the drug.</p>
<p>For example, several Type 2 diabetes medications fall under one class called glucagon-like peptide-1 (GLP-1) receptor agonists. Although all medications in this class have different brand names, each of the generic versions ends in the suffix “-tide.” This helps health providers identify all the drugs that belong to this medication class. A few examples include Byetta (exenatide), Trulicity (dulaglutide) and Victoza (liraglutide).</p>
<h2>How are generic drug names assigned?</h2>
<p>The <a href="https://www.ama-assn.org/about/united-states-adopted-names/procedure-usan-name-selection">naming process</a> starts when a drug company submits an application to the U.S. Adopted Names Council with a proposed generic name. USAN considers a number of factors when evaluating a name, such as whether it relates to how the drug works, how translatable it is to other languages and whether it is easy to say. In general, the name should be simple – fewer than four syllables long – and should not be easily confused with other existing generic drugs. </p>
<p>Once a name is agreed upon by USAN and the drug company, it is then proposed to the <a href="https://www.who.int/teams/health-product-and-policy-standards/inn/inn_expert_group">INN Expert Group</a>. Sponsored by the World Health Organization, the INN Expert Group is composed of global specialists who represent the pharmaceutical, chemical, pharmacological and biochemical sciences. They may either accept the proposed name or suggest an alternative. Once the drug company, USAN and the INN Expert Group come to an agreement about a name, it is placed in the <a href="https://www.who.int/our-work/access-to-medicines-and-health-products/who-drug-information">WHO Drug Information journal</a> for four months for public comments or objections before final adoption. </p>
<h2>What’s in a generic drug name?</h2>
<p>Generic names follow a <a href="https://www.ama-assn.org/about/united-states-adopted-names/united-states-adopted-names-naming-guidelines">prefix-infix-stem system</a>. The prefix helps distinguish a drug from other drugs in the same class. The infix, used more occasionally, further subclassifies the drug. The stem at the very end of the name indicates the drug’s function and marks its place within the name game.</p>
<p><a href="https://druginfo.nlm.nih.gov/drugportal/jsp/drugportal/DrugNameGenericStems.jsp">Stems</a> are composed of one or two syllables that describe a drug’s biological effects as well as its physical and chemical qualities and structure. Drugs with the same stem share features like the conditions they treat and how they work in the body. The WHO publishes a regularly updated <a href="https://www.who.int/publications/i/item/who-emp-rht-tsn-2018-1">stem book</a> to keep everything in line.</p>
<p><iframe id="ENYG9" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ENYG9/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>For example, the stem “-prazole” indicates that the drug is chemically related to a class of compounds called benzimidazoles that have similar functions. As a result, drugs such as lansoprazole (Prevacid), esomeprazole (Nexium) and omeprazole (Prilosec) all treat acid reflux, ulcers and heartburn. The “e” prefix of esomeprazole differentiates it from omeprazole, which has a slightly different chemical structure.</p>
<p>Another common example is drugs that use the stem “stat,” which means enzyme inhibitors. Atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor) all belong to the same class of inhibitors that block a key enzyme in the body’s cholesterol production process. As a result, these cholesterol-reducing “statins” are used to prevent cardiovascular conditions like heart attack and stroke.</p>
<h2>Are there exceptions to the name game?</h2>
<p>Although generic names stay consistent, there have been multiple <a href="https://www.pharmacytimes.com/view/5-notable-drug-name-changes">changes to brand names</a> over the past couple of decades after increases in prescribing and dispensing errors. Some examples include the acid reflux and stomach ulcer drug omeprazole, which was rebranded from Losec to Prilosec because it was frequently confused with the diuretic Lasix. Another example is when the antidepressant Brintellix was changed to Trintellix because it was commonly confused with the blood thinner Brilinta. </p>
<p>Some generic medications may work at <a href="https://theconversation.com/many-medications-affect-more-than-one-target-in-the-body-some-drug-designers-are-embracing-the-side-effects-that-had-been-seen-as-a-drawback-184922">multiple targets in the body</a> and be used for multiple conditions. For example, drugs with the stem “-afil,” such as tadalafil (Cialis), sidenafil (Viagra) and vardenafil (Levitra), belong to a class of drugs that relax smooth muscle and widen the blood vessels. Although commonly prescribed for erectile dysfunction, they can also be used to treat pulmonary arterial hypertension, a specific type of elevated blood pressure that affects the arteries in the heart and lungs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pharmacist showing patient a box of medications" src="https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474354/original/file-20220715-24-38fv83.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pharmacists and other health care professionals can help patients decipher complex drug names.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-pharmacist-helping-a-senior-lady-choose-the-royalty-free-image/1352510394">Marko Geber/DigitalVision via Getty Images</a></span>
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</figure>
<p>In addition, nomenclature guidelines <a href="https://www.who.int/teams/health-product-and-policy-standards/inn/guidance-on-inn">aren’t set in stone</a>, and the U.S. Adopted Names Council anticipates that they will continue to change as newer, more complex substances are discovered, developed and marketed.</p>
<p>For example, a rise in the number of drugs developed with different salts and esters has led to the use of a modified naming process to incorporate the inactive parts of the compound.</p>
<p>As you can guess, it takes health care providers countless months and years to learn and understand this naming process. We are taught the science behind each chemical structure and how it works, which makes it easier to know the rules of the name game. But for those without a background in chemistry and biology, it can be like reading a foreign language.</p>
<p>There are several resources that can help you navigate the drug name game, however. Ask your health care provider or pharmacist if you have questions about how your medication works or what it is used for. They are generally a phone call or visit away.</p><img src="https://counter.theconversation.com/content/164148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Cutler does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Believe it or not, medication names are intended to be easy to remember and descriptive of the function they serve in the body.Jasmine Cutler, Assistant Professor of Pharmacotherapeutics, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1824882022-06-17T12:33:45Z2022-06-17T12:33:45ZHow do drugs know where to go in the body? A pharmaceutical scientist explains why some medications are swallowed while others are injected<figure><img src="https://images.theconversation.com/files/469333/original/file-20220616-24-uw9qbz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While pills come in many shapes and sizes, they all eventually reach your bloodstream and travel throughout your body.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/pop-art-medicine-pill-or-tablet-icon-royalty-free-illustration/1264546155">Vadim Sazhniev/iStock via Getty Images</a></span></figcaption></figure><p>When you take aspirin for a headache, how does the aspirin know to travel to your head and alleviate the pain?</p>
<p>The short answer is, it doesn’t: Molecules can’t transport themselves through the body, and they don’t have control over where they eventually end up. But researchers can chemically modify drug molecules to make sure that they bind strongly to the places we want them and weakly to the places we don’t.</p>
<p>Pharmaceutical products contain more than just the active drug that directly affects the body. Medications also include “inactive ingredients,” or molecules that enhance the stability, absorption, flavor and other qualities that are critical to allowing the drug to do its job. For example, the aspirin you swallow also has ingredients that both prevent the tablet from fracturing during shipping and help it break apart in your body.</p>
<p>As a <a href="https://www.researchgate.net/profile/Thomas-Anchordoquy">pharmaceutical scientist</a>, I’ve been studying <a href="https://www.nibib.nih.gov/science-education/science-topics/drug-delivery-systems-getting-drugs-their-targets-controlled-manner">drug delivery</a> for the past 30 years. That is, developing methods and designing nondrug components that help get a medication where it needs to go in the body. To better understand the thought process behind how different drugs are designed, let’s follow a drug from when it first enters the body to where it eventually ends up.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Shelves of orange pill bottles" src="https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469339/original/file-20220616-20-4bvdhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drugs aren’t sentient, but good design can help them get where doctors and patients want them to go.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rows-of-pill-bottles-on-shelves-in-pharmacy-royalty-free-image/73092126">Andersen Ross/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>How drugs are absorbed in the body</h2>
<p>When you swallow a tablet, it will initially dissolve in your stomach and intestines before the drug molecules are <a href="https://www.britannica.com/science/drug-chemical-agent/Types-of-drugs">absorbed into your bloodstream</a>. Once in the blood, it can circulate throughout the body to access different organs and tissues.</p>
<p>Drug molecules affect the body by <a href="https://open.lib.umn.edu/pharmacology/chapter/introduction-to-drug-receptor-interactions-and-pharmacodynamics/">binding to different receptors</a> on cells that can trigger a particular response. Even though drugs are designed to target specific receptors to produce a desired effect, it is impossible to keep them from continuing to circulate in the blood and binding to nontarget sites that potentially cause unwanted side effects.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uOcpsXMJcJk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Many factors, like your age, genetics and diet, can affect how well your body processes a drug.</span></figcaption>
</figure>
<p>Drug molecules circulating in the blood also degrade over time and eventually leave the body in your urine. A classic example is the strong smell your urine might have after you eat asparagus because of how quickly your kidney clears <a href="https://theconversation.com/that-distinctive-springtime-smell-asparagus-pee-94696">asparagusic acid</a>. Similarly, <a href="https://www.getthegloss.com/article/ask-the-doctor-why-do-vitamins-make-my-pee-yellow">multivitamins</a> typically contain riboflavin, or vitamin B2, which causes your urine to turn bright yellow when it is cleared. Because how efficiently drug molecules can cross the intestinal lining can vary depending on the drug’s chemical properties, some of the drugs you swallow never get absorbed and are removed in your feces.</p>
<p>Because not all of the drug is absorbed, this is why some medications, like those used to treat high blood pressure and allergies, are <a href="https://www.healthymepa.com/2018/07/23/important-take-medications-time/">taken repeatedly</a> to replace eliminated drug molecules and maintain a high enough level of drug in the blood to sustain its effects on the body. </p>
<h2>Getting drugs to the right place</h2>
<p>Compared with pills and tablets, a more efficient way of getting drug into the blood is to inject it directly into a vein. This way, all the drug gets circulated throughout the body and avoids degradation in the stomach. </p>
<p>Many drugs that are given intravenously are “<a href="https://www.fda.gov/about-fda/center-biologics-evaluation-and-research-cber/what-are-biologics-questions-and-answers">biologics” or “biotechnology drugs</a>,” which include substances derived from other organisms. The most common of these are a type of cancer drug called <a href="https://my.clevelandclinic.org/health/treatments/22774-monoclonal-antibody-therapy">monoclonal antibodies</a>, proteins that bind to and kill tumor cells. These drugs are injected directly into a vein because your stomach can’t tell the difference between digesting a therapeutic protein and digesting the proteins in a cheeseburger.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurse checking infusion bag hanging on IV pole" src="https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469317/original/file-20220616-24-tpqvb8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sometimes the most effective way to deliver a drug is through an infusion.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/professional-black-head-nurse-wearing-face-mask-royalty-free-image/1321691597">gorodenkoff/iStock via Getty Images</a></span>
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</figure>
<p>In other cases, drugs that need very high concentrations to be effective, such as <a href="https://health.ucsd.edu/news/features/pages/2017-05-01-intravenous-antibiotics-q-and-a-ritter.aspx">antibiotics for severe infections</a>, can be delivered only through infusion. While increasing drug concentration can help make sure enough molecules are binding to the correct sites to have a therapeutic effect, it also increases binding to nontarget sites and the risk of side effects.</p>
<p>One way to get a high drug concentration in the right location is to apply the drug right where it’s needed, like rubbing an ointment onto a skin rash or using <a href="https://www.webmd.com/allergies/allergy-eye-drops">eyedrops for allergies</a>. While some drug molecules will eventually get absorbed into the bloodstream, they will be <a href="https://doi.org/10.1007/978-1-4471-3625-5_24">diluted enough</a> that the amount of drug that reaches other sites is very low and unlikely to cause side effects. Similarly, an inhaler delivers the drug directly to the lungs and avoids affecting the rest of the body.</p>
<h2>Patient compliance</h2>
<p>Finally, a key aspect in all drug design is to simply get patients to take medications in the right amounts at the right time. </p>
<p>Because remembering to take a drug several times a day is difficult for many people, researchers try to design drug formulations so they need to be <a href="http://dx.doi.org/10.1201/9781315111896-12">taken only once a day or less</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person taking out pills from pill box" src="https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469327/original/file-20220616-15-393l9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Taking medications as instructed can help increase their effectiveness and reduce the risk of side effects.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-woman-took-out-the-pills-from-pill-container-royalty-free-image/1289013876">violetphoto/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Similarly, pills, inhalers or nasal sprays are more convenient than an infusion that requires traveling to a clinic for a trained clinician to inject it into your arm. The less troublesome and expensive it is to administer a drug, the more likely it is that patients will take their medication when they need it. However, sometimes infusions or injections are the only effective way that certain drugs can be administered. </p>
<p>Even with all the science that goes into understanding a disease well enough to develop an effective drug, it is often up to the patient to make it all work as designed.</p><img src="https://counter.theconversation.com/content/182488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom Anchordoquy receives funding from the National Institutes of Health. </span></em></p>From tablets and patches to ointments and infusions, the best way to deliver a drug is the one that gets the right amount to the right place.Tom Anchordoquy, Professor of Pharmaceutical Sciences, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1835852022-05-25T12:54:40Z2022-05-25T12:54:40ZDangerous counterfeit drugs are putting millions of US consumers at risk, according to a new study<figure><img src="https://images.theconversation.com/files/464846/original/file-20220523-20-bgrhbw.jpg?ixlib=rb-1.1.0&rect=52%2C0%2C5000%2C3532&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many counterfeit pharmaceutical drugs are sold online, and the bulk of them are being obtained without a prescription. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/buying-prescription-drugs-online-pharmacy-royalty-free-image/1014737386?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>The Food and Drug Administration took 130 enforcement actions against counterfeit medication rings from 2016 through 2021, according to my new <a href="https://doi.org/10.1177%2F10600280221092482">study published</a> in the journal Annals of Pharmacotherapy. Such actions might involve arrests, confiscation of products or counterfeit rings being dissolved.</p>
<p>These counterfeiting operations involved tens of millions of pills, more than 1,000 kilograms (2,200 pounds) of active ingredient powder that could be turned into pills in the U.S. and hundreds of millions of dollars in sales. Unfortunately, with over <a href="https://doi.org/10.1016/j.japh.2020.04.020">11,000 rogue pharmacy sites</a> selling drugs on the internet, these actions barely scratch the surface.</p>
<p>The FDA’s <a href="https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/criminal-investigations/about-oci">Office of Criminal Investigations</a> conducts and coordinates criminal investigations into manufacturers and individuals violating federal drug laws. The agency maintains a <a href="https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/criminal-investigations/press-releases">database with links to press releases</a> for their enforcement actions. Overall, in 64.6% of cases in that five-year period, the counterfeit products were sold over the internet, and in 84.6% of the enforcement actions taken, the products were obtained without a prescription.</p>
<p>Many of the counterfeit drugs were for controlled substances like opioids such as oxycodone and hydromorphone and stimulants such as those commonly <a href="https://theconversation.com/adhd-in-adults-is-challenging-but-highly-treatable-a-clinical-psychologist-explains-177039">used to treat attention-deficit/hyperactivity disorder</a>, as well as benzodiazepines, which are used for anxiety and sleep. China, India, Turkey, Pakistan and Russia were the most common countries supplying U.S. consumers with counterfeit drugs.</p>
<h2>Why it matters</h2>
<p>The World Health Organization states that approximately <a href="https://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products">11% of medications</a> sold in developing countries are counterfeit, resulting in <a href="https://apps.who.int/iris/handle/10665/331690">144,000 additional deaths</a> annually from imitation antibiotics and anti-malarial drugs alone. My previous study also documented <a href="https://doi.org/10.1016/j.japh.2020.04.020">500 childhood deaths</a> attributed to diethylene glycol – a common additive in antifreeze – being added to knockoff cough suppressants as a sweetener. </p>
<p>In addition, from November 2021 to February 2022, counterfeit versions of drugs used for chronic conditions – such as the <a href="https://www.securingindustry.com/pharmaceuticals/mexico-warns-of-falsified-transplant-medicine/s40/a13949/#.You2wJOZP6B">transplant medication tacrolimus</a>, sold under the brand name Limustin, and the anticoagulant <a href="https://www.securingindustry.com/pharmaceuticals/mexico-warns-of-falsified-clotting-drug-xarelto/s40/a14240/#.YofH76jMI2x">rivaroxaban, or Xeralto</a> – were found on Mexican pharmacy shelves. </p>
<p>In the U.S., the <a href="https://www.fda.gov/drugs/drug-supply-chain-integrity/drug-supply-chain-security-act-dscsa">Drug Quality and Security Act of 2013</a> secures the medication supply through a national electronic track-and-trace system that allows a specific medication to be followed from the manufacturer to the pharmacy. While the medications in licensed U.S. pharmacies are secure, a Kaiser Family Foundation survey found that <a href="https://khn.org/news/faced-with-unaffordable-drug-prices-tens-of-millions-buy-medicine-outside-u-s/">19 million people in America</a> obtained prescription medications that are likely counterfeit through non-U.S. licensed internet pharmacies or while traveling abroad. The National Association of Boards of Pharmacy found that <a href="https://nabp.pharmacy/wp-content/uploads/2016/08/Internet-Drug-Outlet-Report-August-2017.pdf">96% of the 11,688 internet pharmacies</a> they analyzed did not comply with U.S. federal or state laws. Of these, 62% did not reveal their physical location and 87% were affiliated with “rogue networks of internet drug outlets.” </p>
<p>The FDA offers some guidance to help consumers determine whether <a href="https://www.fda.gov/drugs/besaferx-your-source-online-pharmacy-information/know-your-online-pharmacy#">an online product is legitimate</a>.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/6Djftj0bwus?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How counterfeit medications can end up in your medicine cabinet.</span></figcaption>
</figure>
<p><a href="https://nida.nih.gov/drug-topics/opioids/benzodiazepines-opioids#">Opioids, benzodiazepines</a> and <a href="https://adf.org.au/drug-facts/stimulants/#">stimulants</a> are highly addictive and dangerous when taken inappropriately or when used together. While these counterfeit medications may look legitimate, the active ingredients that are supposed to be in these controlled substances are frequently replaced with <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">more dangerous alternatives like fentanyl</a>. <a href="https://www.dea.gov/sites/default/files/2021-12/DEA-OPCK_FactSheet_December%202021.pdf">Four in 10 counterfeit opioid pills</a> containing fentanyl harbor a potentially lethal dosage. </p>
<p>According to the Drug Enforcement Administration, the U.S. confiscated <a href="https://www.justice.gov/usao-id/pr/acting-us-attorney-warns-increasing-danger-counterfeit-prescription-opioids-containing">9.5 million counterfeit pills</a> from April 2020 to April 2021 – more than the previous two years combined. This is a likely driver of the 100,306 drug overdose deaths in the U.S. over that time.</p>
<p><a href="https://doi.org/10.2105/AJPH.2017.303994">Rogue online pharmacies</a> frequently use <a href="https://doi.org/10.1093/bmb/ldw016">social media platforms</a> to reach potential customers. This suggests that more needs to be done by <a href="https://www.nytimes.com/2022/05/19/health/pills-fentanyl-social-media.html">online platforms like social media</a>, online forums and search engines to identify and stop illegitimate sellers of prescription drugs online.</p>
<p>People buying controlled substances over the internet are usually trying to circumvent physician control over the <a href="https://doi.org/10.2196/jmir.2236">medication or the quantities they can receive</a>. However, most people accessing noncontrolled substance counterfeit medications are simply trying to buy them <a href="https://doi.org/10.1161/CIRCULATIONAHA.119.041974">at an affordable price</a>. These trends make clear that the U.S. needs a long-term strategy to lower the cost of prescription medications to diminish demand for counterfeit medications, though there are some <a href="https://www.pharmacytoday.org/article/S1042-0991(17)31664-X/pdf">money-saving strategies</a> that can be used in the short term.</p><img src="https://counter.theconversation.com/content/183585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C. Michael White does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prescription opiods, stimulants such as those used to treat ADHD and the ingredients found in sexual dysfunction drugs like Viagra are some of the drugs that are being marketed to US consumers.C. Michael White, Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1783012022-03-06T18:59:03Z2022-03-06T18:59:03ZLast year, half a million Australians couldn’t afford to fill a script. Here’s how to rein in rising health costs<figure><img src="https://images.theconversation.com/files/449730/original/file-20220303-17-1uwhfd3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/latin-woman-protective-face-masks-sitting-1794695587">Shutterstock</a></span></figcaption></figure><p>Nearly every Australian uses some part of the health system every year, whether it be going to the GP, getting a prescription filled, or seeing a specialist. </p>
<p>Despite having a universal health-care system, we often still pay for these services out of our own pockets.</p>
<p>Sadly, these out-of-pocket payments are unaffordable for many Australians – so they skip the trip to the doctor, or defer going to the chemist. </p>
<p>This is bad for those individuals, but also bad for taxpayers and the economy. It makes people sicker, widens inequities, and puts further strain on the health system down the track.</p>
<p>In the Grattan Institute’s <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments">latest report</a>, we identify what governments should do to make health care more affordable for more Australians.</p>
<h2>Who is missing health care because of cost?</h2>
<p>In 2020-21, <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences-australia-summary-findings/latest-release">more than half a million people</a> deferred or did not fill a prescription because of cost. Nearly half a million decided not to see a specialist because of cost.</p>
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Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
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<p>People with chronic conditions have much higher health-care costs, particularly if they have multiple chronic conditions; they spend between <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments">A$200-600 on average on health care each year</a>.</p>
<p>But they are also less likely to be able to afford their ongoing care because their chronic condition can make it more difficult to keep or get a job.</p>
<p>Many of these people who are forgoing health care due to cost are younger, particularly younger women:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=784&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=784&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=784&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=985&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=985&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450228/original/file-20220306-85660-16z4awf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=985&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Younger people tend to have fewer savings, and can therefore find it harder to afford care. And women are more likely to have chronic health conditions. About <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release">55% of people with two chronic conditions are women</a>, and 60% of people with three or more chronic conditions are women.</p>
<p>Chronic conditions are becoming more common, so more and more Australians will be facing higher health-care costs and are at risk of missing needed care. </p>
<p>Over the past ten years, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">average out-of-pocket payments rose by 50%</a>, and they will continue to rise unless governments act now.</p>
<figure class="align-center ">
<img alt="Pharmacist takes medicine from a cupboard." src="https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/449734/original/file-20220303-4451-q09y2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Out of pocket costs are likely to rise without government action.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/cw2Zn2ZQ9YQ">Unsplash/National Cancer Institute</a></span>
</figcaption>
</figure>
<h2>What can be done?</h2>
<p>The federal government can do much more to reduce out-of-pocket payments and avoid unnecessary costs down the line.</p>
<p><strong>Cost of medicines</strong></p>
<p>While Australia has a world-renowned Pharmaceutical Benefits Scheme (PBS) that helps keep many medications affordable, Australians are still spending nearly A$3 billion on PBS-listed prescriptions each year, including <a href="https://www.pbs.gov.au/info/statistics/expenditure-prescriptions/pbs-expenditure-and-prescriptions-report-30-june-2021">A$1.5 billion on mandatory co-payments</a> and <a href="https://www.pbs.gov.au/info/statistics/under-co-payment/ucp-data-report">A$1.4 billion on PBS-listed prescriptions</a> which cost less than the co-payment.</p>
<p>The federal government should lower the cost of prescriptions for people taking five or more medications for chronic conditions, after their GP conducts a medication review triggered by a computer-generated alert. </p>
<p>We estimate this could reduce inappropriate medication use for about 300,000 patients. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>The government should also extend the duration of prescriptions for some medications to reduce the number of Pharmaceutical Benefits Scheme co-payments people have to make to pharmacies.</p>
<p><strong>Tests and scans</strong></p>
<p>The government should abolish the out-of-pocket burden from diagnostic services, such as blood tests and scans. </p>
<p>Australians spend about <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">A$400 million on these services each year</a> – even though patients aren’t the real users of these tests, doctors are. </p>
<figure class="align-center ">
<img alt="Doctor types on laptop/" src="https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/449735/original/file-20220303-17-1jjr308.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctors are the real users of tests and scans.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/NFvdKIhxYlU">Unsplash/National Cancer Institute</a></span>
</figcaption>
</figure>
<p>With these services now frequently provided by large corporations, the federal government should fund them directly through a commercial tender instead.</p>
<p><strong>Patient enrolment</strong></p>
<p>The government should expand the voluntary patient enrolment scheme to people with two or more chronic conditions. </p>
<p>Patient enrolment is where a patient can enrol in a GP practice and nominate a GP to be their “usual doctor”. It can help make care more affordable for people with chronic conditions by reducing their exposure to out-of-pocket payments. </p>
<p>Greater GP stewardship over a person’s care could reduce inefficiencies in areas such as routine repeat prescriptions and routine renewal of specialist referrals. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-it-costs-you-so-much-to-see-a-specialist-and-what-the-government-should-do-about-it-81998">Why it costs you so much to see a specialist – and what the government should do about it</a>
</strong>
</em>
</p>
<hr>
<p>The government has already committed to this reform for people older than 70. If it was expanded to younger people, we estimate an additional 1.7 million people would be eligible for the program.</p>
<p><strong>Bulk billing</strong></p>
<p>The vast majority of health services people receive outside hospital are “bulk-billed” – meaning the patient pays nothing out of pocket. But bulk-billing rates for specialists and allied health are still far too low – at about <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">46% for specialists and 56% for allied health</a>. </p>
<p>The federal and state governments should expand the number of health-care services provided free of charge, particularly in lower-income areas and areas where bulk-billing rates are especially low.</p>
<p>Our analysis shows that if state and federal governments invest an additional A$710 million a year on these reforms, they could save Australians about A$1 billion in out-of-pockets a year, and enable more people to get the care they need, when they need it. That’s a healthy return on investment.</p><img src="https://counter.theconversation.com/content/178301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is chair of the board of directors of the Eastern Melbourne Primary Health Network. Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p><p class="fine-print"><em><span>Linda Lin is currently on secondment to the Grattan Institute from the Victorian Department of Health.</span></em></p><p class="fine-print"><em><span>Anika Stobart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who need the most health care – the poor and the chronically ill – miss out on care the most. But there are ways to reduce this inequity.Stephen Duckett, Director, Health and Aged Care Program, Grattan InstituteAnika Stobart, Associate, Grattan InstituteLinda Lin, Senior associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1705592021-12-22T21:05:18Z2021-12-22T21:05:18ZDrugs and the sun – your daily medications could put you at greater risk of sunburn<figure><img src="https://images.theconversation.com/files/432801/original/file-20211119-19-1nls6j1.jpg?ixlib=rb-1.1.0&rect=16%2C24%2C5447%2C3506&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>With summer holidays underway, it’s time to think about the sun and your skin. Australia has the <a href="https://www.wcrf.org/dietandcancer/skin-cancer-statistics/">highest rate of skin cancer</a> in the world, so we need to be doing more to protect ourselves from the damaging effects of ultraviolet radiation.</p>
<p>Unfortunately, some medicines can increase your risk of sunburn, because they either enhance UV absorption in your skin or cause you to have a light-activated reaction. </p>
<p>It’s important not to skim over the information provided with your medication, to speak to your pharmacist for on-the-spot advice and to take extra precautions if required.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-cant-get-sunburnt-through-glass-shade-or-in-water-right-5-common-sunburn-myths-busted-150640">I can't get sunburnt through glass, shade or in water, right? 5 common sunburn myths busted</a>
</strong>
</em>
</p>
<hr>
<h2>What happens to your skin</h2>
<p>There are two main ways that medications can increase your risk of sunburn; a <a href="https://www.skincancer.org/risk-factors/photosensitivity/">phototoxic reaction and a photoallergic reaction</a>. </p>
<p>A phototoxic reaction is the most common way for a medication to cause an increase in sun sensitivity. This is where the drug molecule is able to absorb UV light, and then releases it back into the skin. Once the oral medication has been absorbed into the blood stream, or after the topical medication is applied to the skin, a phototoxic reaction can occur anytime within minutes or hours of sun exposure. Typically, only the skin that is exposed to the sun will react.</p>
<p>The second, less common mechanism, is via a photoallergic reaction. This can occur with certain medications that are applied directly to the skin, or that are taken by mouth and then circulated to the skin. </p>
<p>After exposure to the sun, a drug can undergo structural changes. Once these structural changes happen, small proteins in our body can bind to the drug, resulting in our immune system recognising it as a foreign substance. Then antibodies are produced to fight it. </p>
<p>The resulting reaction in many cases resembles eczema or a red rash. This type of reaction can take anywhere between one to three days to occur, and will only occur on the parts of the body that are exposed to the sun.</p>
<p>Importantly, both phototoxic and photoallergic reactions are damage to the skin from UV exposure that can increase the risk of later developing skin cancer.</p>
<p>There are also some types of medicines that can cause heat sensitivity and increase your risk of dehydration. This can occur if a medicine has effects that increase urination, prevent sweating, or reduce blood flow to the skin. Examples of these medications include diuretics, some types of antihistamines and stimulant medications for ADHD.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pharmacist with medications." src="https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432800/original/file-20211119-23-1vn7n38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Your local pharmacist can give you advice on medications and sun sensitivity.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/pharmacist-holding-medicine-box-capsule-260nw-704036482.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/common-skin-rashes-and-what-to-do-about-them-91518">Common skin rashes and what to do about them</a>
</strong>
</em>
</p>
<hr>
<h2>Which medicines can affect your skin?</h2>
<p>There are many medicines that can affect your skin and make you more sensitive to the sun, so it’s important to know which ones to look out for. </p>
<p>The first are the antibiotics. Tetracycline-based drugs are particularly known to cause sensitivity. An example is the drug <a href="https://www.nps.org.au/medicine-finder/apo-doxycycline-tablets">doxycycline</a> which is used to treat infections, acne, and as a malaria prophylactic (or prevention) for those who are going to a tropical location (lots of sun). </p>
<p>Other antibiotics known to cause sun sensitivity are <a href="https://www.nps.org.au/australian-prescriber/articles/fluoroquinolone-antibiotics-and-adverse-events">fluoroquinolones</a>, like ciprofloxacin, and <a href="https://www.nps.org.au/medicine-finder/bactrim-ds-tablets">sulfamethoxazole</a>, which treat a broad range of illnesses such as urinary tract infections, pneumonia or gastroenteritis.</p>
<p>The antifungals griseofulvin and voriconazole are known to cause sun sensitivity. You may be taking these medicines for skin or <a href="https://www.healthline.com/health/fungal-nail-infection">nail fungal infections</a>.</p>
<p>For people who suffer from skin conditions such as acne, psoriasis, or eczema, the oral retinoid medications including acitretin and isotretinoin and the topical cream pimecrolimus will leave you sensitive to the sun.</p>
<p>Non-steroidal anti-inflammatory drugs, like diclofenac, can leave you sun sensitive, especially if applied on the skin, so you need to be sure you adequately protect those areas. The same applies for some opioid-based pain patches, <a href="https://www.nps.org.au/radar/articles/fentanyl-patches-durogesic-for-chronic-pain">like fentanyl</a>. When you remove the patch, the skin underneath will be sensitive to the sun.</p>
<p><a href="https://www.nps.org.au/australian-prescriber/articles/amiodarone">Amiodarone</a> is a drug used to treat irregular heart beats and <a href="https://www.nps.org.au/medicine-finder/azathioprine-an-tablets">azathioprine</a> is an immuno suppressing drug used for people who have inflammatory immune conditions or organ transplants. Both are known to cause sun sensitivity.</p>
<p>Finally, a large number of drugs used in <a href="https://blog.uvahealth.com/2019/07/21/chemo-and-sun-sensitivity-how-to-protect-your-skin/">cancer chemotherapy will sensitise your skin</a>. These include: 5-fluorouracil, 5-aminolevulinic acid, vemurafenib, imatinib, mercaptopurine, and methotrexate.</p>
<p>It is important to note that not all people who use one of these medicines will have a sun sensitivity reaction – but extra precautions should be taken. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman wearing hat putting on sunscreen" src="https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=463&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=463&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432799/original/file-20211119-13-1ezdr9g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=463&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">It is much better to be sun safe than sun sorry.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-bottle-sunblock-outside-on-680463682">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-does-australia-have-so-much-skin-cancer-hint-its-not-because-of-an-ozone-hole-91850">Why does Australia have so much skin cancer? (Hint: it's not because of an ozone hole)</a>
</strong>
</em>
</p>
<hr>
<h2>Protect your skin</h2>
<p>If you are taking a medicine that can make you more sensitive to the sun then always ensure you are <a href="https://www.sunsmart.com.au/">sunsmart</a>.</p>
<p>Remember the five S advice from the <a href="https://www.cancer.org.au/cancer-information/causes-and-prevention/sun-safety/be-sunsmart">Cancer Council</a>: </p>
<ul>
<li>slip on suitable clothing</li>
<li>slop on sunscreen that is rated SPF30 or higher to exposed skin, especially on your face and arms</li>
<li>slap on a hat</li>
<li>seek shade when you can</li>
<li>slide on sunglasses.</li>
</ul>
<p>And if you are concerned a medicine you are taking may be putting you at more risk of sunburn, <a href="https://www.choosingwisely.org.au/resources/consumers-and-carers/5questions">speak to your pharmacist</a>. They can confirm if your medicine does increase your risk of sunburn and discuss options. This could include having your doctor issue a prescription for a different drug. </p>
<p>Never just stop taking a medicine because you are concerned about the risk of sun damage or any other side effects; always discuss it first with your health care provider. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/burnt-is-out-skinscreen-is-in-how-sunscreen-got-a-beauty-makeover-131292">Burnt is out, 'skinscreen' is in. How sunscreen got a beauty makeover</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/170559/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association. Nial is science director of the medicinal cannabis company Canngea Pty Ltd, a board member of the Australian Medicinal Cannabis Association, and a Standards Australia committee member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Elise Schubert is a registered pharmacist at Royal North Shore Hospital, and a PhD Candidate receiving scholarship from the University of Sydney and Canngea Pty Ltd.</span></em></p><p class="fine-print"><em><span>Lisa Kouladjian O'Donnell is a registered consultant pharmacist (independent) and a research fellow in geriatric pharmacotherapy from The University of Sydney. </span></em></p>In Summer, you may need to be extra sun smart if you’re swallowing certain medications or putting them on your skin.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyElise Schubert, Pharmacist and PhD Candidate, University of SydneyLisa Kouladjian O'Donnell, Research Fellow in Geriatric Pharmacotherapy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1401562020-07-09T12:13:52Z2020-07-09T12:13:52ZWhen Trump pushed hydroxychloroquine to treat COVID-19, hundreds of thousands of prescriptions followed despite little evidence that it worked<figure><img src="https://images.theconversation.com/files/346160/original/file-20200707-26-imzchz.jpg?ixlib=rb-1.1.0&rect=0%2C68%2C4587%2C2977&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As public figures and some in the media touted hydroxychloroquine, prescriptions skyrocketed. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/white-pills-spilling-out-of-prescription-bottle-royalty-free-image/1161234835?adppopup=true&uiloc=thumbnail_same_series_adp&uiloc=thumbnail_same_series_adp"> Grace Cary / Moment via Getty Images</a></span></figcaption></figure><p>In late March and early April, <a href="https://www.huffpost.com/entry/trump-fauci-coronavirus-hloroquine-azithromycin_n_5e768e4fc5b6eab77949660d">President Trump repeatedly proclaimed that hydroxychloroquine</a> could prevent or treat COVID-19. Within days, the number of prescriptions for the drug skyrocketed even though evidence it could safely prevent or treat the disease was at the time very weak. </p>
<p>A casual remark by a president who is not in any way a medical expert somehow led thousands of U.S. physicians to write prescriptions for a drug that had never before been used to treat a viral illness. What could be happening here? </p>
<p>As a <a href="https://health.ucdavis.edu/team/internalmedicine/373/richard-kravitz---health-policy---internal-medicine-sacramento">general internist</a> at the University of California, Davis health center, I have seen thousands of patients in both inpatient and outpatient settings. As a researcher, I have focused on how <a href="https://scholar.google.com/citations?user=u8ZMXTMAAAAJ&hl=en&oi=ao">patients influence what physicians do</a>, and consequently, I often find myself asking how the larger world influences what patients think. </p>
<p>Through my research, I’ve found that the process of prescribing medication is more complicated than most people realize. In the real world, it’s a mix of the current state of medical knowledge and a negotiation between what the patient wants or asks for and the habits and beliefs of the physician. It is a human experience, and can be influenced by things like advertising, media and even politics. </p>
<p>I think the hydroxychloroquine situation perfectly illustrates how much the outside world shapes patients’ views of their own health care. It also shows how, particularly when the science is uncertain, patients’ views strongly affect what their doctors do.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">President Trump has repeatedly and consistently touted the effectiveness of hydroxychloroquine despite shaky scientific evidence at best, even going so far as to announce that he was taking it as a preventative measure against the coronavirus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Trump/3357c55019e6411687156a1db305332c/22/0">AP Photo/Evan Vucci</a></span>
</figcaption>
</figure>
<h2>The hydroxychloroquine boom</h2>
<p>On March 21 President Trump touted hydroxychloroquine – and its biochemical cousin, chloroquine – as <a href="https://thehill.com/homenews/administration/488796-trump-steps-up-effort-to-tout-malaria-drug-as-coronavirus-game">potential “game changers”</a> in the battle against COVID-19. Two months later, he announced on national television that he had been <a href="https://thehill.com/homenews/administration/498375-trump-says-hes-been-taking-hydroxychloroquine">taking the drug himself</a> as a preventative treatment.</p>
<p>During the 10-week period between Feb. 17 and April 27 doctors wrote approximately <a href="https://dx.doi.org/10.1001/jama.2020.9184">483,000 more prescriptions for hydroxychloroquine</a> than in the same time period in 2019. The week after President Trump mentioned the drug during a press conference, prescriptions were up more than <a href="https://dx.doi.org/10.1001/jama.2020.9184">200% compared to the previous year</a>. The vast majority of excess prescriptions were written between March 14 and April 4, but as news spread about shortages of the drug and the lack of evidence to support its use, prescribing returned quickly to normal. </p>
<p>Research now shows that this once-promising drug likely <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">isn’t effective for preventing or treating COVID 19</a>, but the damage was already done. Hundreds of thousands of Americans unnecessarily took medicine that <a href="https://www.who.int/publications/m/item/targeted-update-safety-and-efficacy-of-hydroxychloroquine-or-chloroquine-for-treatment-of-covid-19">can have dangerous side effects</a>. Additionally, many people with an actual medical need to take hydroxychloroquine – like those living with lupus and related autoimmune diseases – found themselves <a href="https://www.washingtonpost.com/business/2020/03/20/hospitals-doctors-are-wiping-out-supplies-an-unproven-coronavirus-treatment/">unable to obtain the drugs they needed</a>.</p>
<p>What explains the sharp rise, and equally precipitous fall, of hydroxychloroquine prescriptions?</p>
<h2>Amplification of shaky science</h2>
<p>The hydroxychloroquine story is in part connected to the way information about prescription drugs in the United States is produced and disseminated. This process greatly influences what the public thinks about drugs. </p>
<p>First, the clinical research supporting the use of hydroxychloroquine for COVID-19 was <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">shaky from the start</a>. The initial studies were very small, and likely because of the pressure from the pandemic, the research was <a href="https://theconversation.com/coronavirus-research-done-too-fast-is-testing-publishing-safeguards-bad-science-is-getting-through-134653">rushed through the usual safeguards like peer review</a>.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p>
<p>Second, influential individuals and organizations played on the public’s perceptions. President Trump was certainly a factor, but media outlets – notably <a href="https://www.foxnews.com/opinion/sean-hannity-gov-cuomo-stop-denying-new-yorkers-hydroxychloroquine">Fox News</a> and <a href="https://nypost.com/2020/04/02/hydroxychloroquine-most-effective-coronavirus-treatment-poll/">the New York Post</a> oversold the apparent benefits and downplayed the ample uncertainty surrounding the treatment at the time. Even The New York Times may have inadvertently contributed to the <a href="https://www.nytimes.com/2020/04/01/health/hydroxychloroquine-coronavirus-malaria.html">initial prescribing stampede</a> by covering the science before it was peer–reviewed, even though they clearly stated the shortcomings of the research.</p>
<p>The truth is that researchers, academic institutions, medical journals and the media all face powerful incentives to portray the latest research findings as more earthshaking than they actually are. Under normal circumstances, numerous mechanisms exist to blunt some of the worst overhyping and many sources of medical information do their best to be accurate in what they report. But in the midst of a pandemic, the urgency of the moment can overwhelm these defenses and good intentions. Bad science can be spread far and wide by normally credible sources.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Why were doctors prescribing hydroxychloroquine to patients when the science was still so shaky?</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-talking-to-patient-royalty-free-image/532726150?adppopup=true">LWA-Dann Tardif / Stone via Getty Images</a></span>
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</figure>
<h2>From public interest to actual prescriptions</h2>
<p>It would be one thing if patients could get unproven medications like hydroxychloroquine for COVID-19 on their own. But physicians are supposed to be the guardians at the gate of medicine. Why were doctors writing prescriptions for a drug to fight COVID-19 without evidence that it worked?</p>
<p>Some physicians were likely overeager early adopters. Additionally, some hospitals – including my own at the University of California, Davis – made hydroxychloroquine available to COVID-19-positive inpatients during the early days of the epidemic. However, early adopters constitute a low percentage of all prescribers - generally <a href="https://www.jstor.org/stable/3768086">less than 10% according to one study</a> – and cumulative U.S. hospitalizations through April 25 totaled <a href="https://gis.cdc.gov/grasp/covidnet/COVID19_3.html">no more than 150,000</a>. With almost a half million extra prescriptions filled over that time, these explanations cannot fully explain the surge.</p>
<p>Substantial research, including my own, shows that when patients ask for drugs by name, <a href="https://dx.doi.org/10.1001/jama.293.16.1995">doctors will frequently prescribe them</a>. A reasonable hypothesis is that many of the excess hydroxychloroquine prescriptions filled in the weeks after President Trump’s remarks resulted from patients asking about or explicitly requesting hydroxychloroquine from their primary care physicians.</p>
<p>Over a decade ago, my colleagues and I ran an experiment where we sent actors pretending to have symptoms of depression to see physicians. Some of the actors explicitly asked for drugs while others did not. The results were striking. Patients requesting antidepressants were more than <a href="https://dx.doi.org/10.1001/jama.293.16.1995">twice as likely to receive them</a>, regardless of whether their symptoms warranted the drugs or not.</p>
<p>These results should not be overinterpreted - we would not have found the same results in a study where patients with broken bones asked for chemotherapy, for example. But much of medical practice occurs in the gray zone of limited evidence. It is these gray areas where <a href="https://doi.org/10.1136/bmj.324.7332.278">media and advertising most influence patients</a>, who in turn influence physicians. With research on treatments for COVID-19 coming out at an incredible rate, the health effects of the virus still largely a mystery and people’s lives on the line, the gray zone for COVID-19 treatments is massive.</p>
<p>In the case of hydroxychloroquine, the combination of shaky science, loud public proponents like the president and the influence patients have on physicians likely resulted in close to half a million prescriptions before the public health benefits and risks were adequately understood.</p>
<p>Research on hydroxychloroquine has accumulated, and now most experts agree that <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">it likely isn’t effective</a> as a COVID-19 treatment – with some studies even suggesting that it <a href="http://dx.doi.org/10.1016/j.medj.2020.06.001">may be harmful</a>. But new drugs and treatments to fight this deadly virus are going to continue to emerge in the coming months and years. The media, politicians, doctors and patients must all maintain a critical stance and acknowledge the influence they have on each other.</p>
<p>Waiting for solid evidence in the form of randomized studies takes patience. But the alternative is to wander into a therapeutic fog where potential harms lurk alongside potential benefits. This is never a good idea, and it is especially dangerous now.</p><img src="https://counter.theconversation.com/content/140156/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard L. Kravitz received funding from the National Institutes of Health.</span></em></p>When news reports tout a drug, people get interested, even if the benefits are unproven. Patient hopes, requests and demands can easily turn into real prescriptions in their doctor’s office.Richard L. Kravitz, Professor of Health Policy and Internal Medicine, University of California, DavisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1349742020-03-30T17:32:20Z2020-03-30T17:32:20ZCanada’s coronavirus aid package guards against drug shortages with compulsory licensing<figure><img src="https://images.theconversation.com/files/323716/original/file-20200327-146671-lhxwq.jpg?ixlib=rb-1.1.0&rect=74%2C91%2C1842%2C1184&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The COVID-19 Emergency Response Act enables compulsory drug licensing to help avoid medication shortages.</span> <span class="attribution"><span class="source">(Pixabay)</span></span></figcaption></figure><p>Canada’s <a href="https://www.parl.ca/DocumentViewer/en/43-1/bill/C-13/third-reading">COVID-19 Emergency Response Act</a>, which provides emergency assistance to cope with the expected dramatic economic downturn due to the COVID-19 pandemic, contains an important clause that may get overlooked. The act effectively brings back compulsory licensing for drugs if supply is interrupted because of the effects of COVID-19. </p>
<p>There have already been stories about <a href="https://edmontonjournal.com/opinion/letters/wednesdays-letters-sellers-share-blame-for-toilet-paper-shortage/">toilet paper shortages</a> in parts of Canada. Far worse would be a shortage of medicines. That has already been reported in Australia where people are being accused of <a href="https://www.theguardian.com/world/2020/mar/19/paracetamol-and-ventolin-limited-to-one-per-customer-as-australia-combats-coronavirus-hoarding">hoarding Ventolin asthma puffers and acetaminophen</a>. Here in Canada, <a href="https://www.pharmacists.ca/news-events/news/canadian-pharmacists-association-warns-against-stockpiling-medication-in-response-to-covid-19/">pharmacists are already warning people</a> not to stock up on drugs as that may trigger shortages.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323718/original/file-20200327-146724-1dayeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stockpiling left toilet paper in short supply on March 19, 2020 at a Walmart in Laval, Que.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<p>Compulsory licensing helps prevent drug shortages. Simply put, compulsory licensing means that generic companies can get a licence to produce and market a drug even if the drug is still covered by a patent. In return the patent holder gets a royalty. Under the COVID-19 Emergency Response Act, the government can issue the licence almost immediately without having to first enter into negotiations with drug companies. The act doesn’t set out the amount of the royalty.</p>
<h2>Controlling high drug prices</h2>
<p>In 1969, in response to high drug prices in Canada due to the effects of the patent system, <a href="https://www.jstor.org/stable/45131117">Canada introduced legislation allowing compulsory licensing to import</a>. This meant generic companies could import and sell their own versions of drugs in Canada. Compulsory licensing proved to be an effective way to control drug spending.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323717/original/file-20200327-146678-wzinzc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stockpiling medications has led to shortage of Ventolin puffers for asthma in Australia.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>A <a href="http://epe.lac-bac.gc.ca/100/200/301/pco-bcp/commissions-ef/eastman1985-eng/eastman1985-eng.htm">1984 report</a> found that compulsory licensing had reduced the country’s annual drug bill by $211 million to a total of $1.6 billion, while at the same time brand-name drug companies lost only 3.1 per cent of the market. In fact, according to the report, since compulsory licensing started growth in the pharmaceutical industry was more buoyant in Canada than in the United States.</p>
<p>Despite its success, compulsory licensing was anathema to multinational pharmaceutical companies, especially those in the United States. Companies there influenced the American government to make the <a href="https://doi.org/10.2190/ucwg-ybr3-x3l0-nwyt">termination of compulsory licensing</a> one of the key conditions for successful negotiation of the 1987 Free Trade Agreement between Canada and the U.S. Brian Mulroney’s Conservative government complied with the U.S. demand and significantly weakened compulsory licensing, and then <a href="https://doi.org/10.1016/S0168-8510(96)00886-X">completely eliminated it following the completion of the NAFTA negotiations</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=767&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=767&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=767&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=964&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=964&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323721/original/file-20200328-146699-ayvsl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=964&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An RCMP constable stands guard on Parliament Hill in Ottawa in October 2001 while hazardous materials personnel investigate a possible anthrax contamination.</span>
<span class="attribution"><span class="source">CP ARCHIVE PHOTO/Fred Chartrand</span></span>
</figcaption>
</figure>
<p>That was effectively the end of compulsory licensing as a means of dealing with both drug prices and shortages. Canadians briefly heard about compulsory licensing again <a href="https://www.npr.org/2011/02/15/93170200/timeline-how-the-anthrax-terror-unfolded">in the fall of 2001 when there was a scare about packages of anthrax being sent in the mail</a> to various people in the U.S. Ciprofloxacin was considered the best antibiotic for treating anthrax, but Bayer, the multinational that sold it, said that it couldn’t guarantee a sufficient supply if large numbers of people needed treatment. In return, <a href="https://www.theglobeandmail.com/news/national/patent-war-looming-over-drug-for-anthrax/article4155009/">Health Minister Alan Rock threatened to issue a compulsory licence</a>, but never followed through on the threat as the scare never materialized.</p>
<p>Compulsory licensing also played a role in the fall 2001 meeting of the World Trade Organization. Faced with the growing AIDS crisis and the then-unaffordable prices for HIV medicines, developing countries pushed the WTO to adopt a resolution allowing for the use of compulsory licensing to lower costs. The Doha Declaration applied to all countries, but <a href="http://www.who.int/medicines/areas/policy/WT_L_540_e.pdf?ua=1">Canada and a number of other developed countries pledged not to use compulsory licensing to import lower-priced drugs</a>.</p>
<h2>Rethinking future use</h2>
<p>That’s where compulsory licensing in Canada stood until last week. </p>
<p>Any compulsory licence issued under the COVID-19 Emergency Response Act is only good for one year, and no new licences will be issued after Sept. 30, 2020. The federal government should rethink those positions. </p>
<p><a href="https://www.canadadrugshortage.com/">Drug shortages in Canada have been around for a decade now</a> and they won’t go away once the COVID-19 emergency is over. Public drug spending <a href="https://www.cihi.ca/sites/default/files/document/pdex-report-2019-en-web.pdf">increased 6.8 per cent in 2018</a>, 1.5 percentage points higher than in the previous year. As we move to a national pharmacare plan we will need more ways to control drug prices and compulsory licensing could be one of those tools.</p>
<p>Let’s make compulsory licensing permanent.</p><img src="https://counter.theconversation.com/content/134974/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2017-2020, Joel Lexchin received payment for being on a panel at the American Diabetes Association, for talks at the Toronto Reference Library, for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p>Toilet paper shortages were bad enough. A shortage of drugs during the COVID-19 pandemic would be worse. A provision in the Canadian government’s relief package aims to prevent that from happening.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1276822020-02-20T12:18:35Z2020-02-20T12:18:35ZBoomers have a drug problem, but not the kind you might think<figure><img src="https://images.theconversation.com/files/314302/original/file-20200209-27552-16fh1on.jpg?ixlib=rb-1.1.0&rect=38%2C153%2C5092%2C3046&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some boomers are on multiple medications. Combinations of those drugs could have serious side effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-couple-in-front-of-lake-royalty-free-image/108354581?adppopup=true">Getty Images / Sporrer/Rupp</a></span></figcaption></figure><p><a href="https://www.census.gov/library/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html">Baby boomers</a> – that’s anyone born in the U.S. between 1946 and 1964 – are 20% of the population, more than 70 million Americans. Decades ago, many in that generation experimented with drugs that were both recreational and illegal. Although boomers may not be using those same drugs today, many are taking medications, often several of them. And even if those drugs are legal, there are still risks of interactions and side effects. </p>
<p>The taking of multiple medications is called <a href="https://doi.org/10.1186/s12877-017-0621-2">polypharmacy</a>, typically four or more at the same time. That includes prescriptions from doctors, over-the-counter medicines, supplements and herbs. Sometimes, polypharmacy can be dangerous.</p>
<p><a href="https://med.virginia.edu/faculty/faculty-listing/la2e/">I am a geriatrician</a>, one of <a href="https://health.usnews.com/health-news/patient-advice/articles/2015/04/21/doctor-shortage-who-will-take-care-of-the-elderly">only 7,500 in the U.S.</a> That’s not nearly enough to accommodate the <a href="https://www.census.gov/library/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html">surging number of elderly boomers</a> who will need medical care over the next two to three decades – or help in dealing with the potential problems of multiple drug use. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314322/original/file-20200209-27529-1yob4sw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Make sure your doctor is regularly reviewing your medication list.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-woman-taking-medicine-from-pill-organizer-royalty-free-image/505700181?adppopup=true">Getty Images / dszc</a></span>
</figcaption>
</figure>
<h2>Reactions to medications can change over time</h2>
<p>We geriatricians know that polypharmacy isn’t always bad; multiple medications may be necessary. If you’ve had a heart attack, you might be on four medications or more – <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/beta-blockers/art-20044522">beta-blockers</a>, <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/ace-inhibitors/art-20047480">ACE inhibitors</a>, statins and aspirin, for instance. And that’s appropriate. </p>
<p>But about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864987/">half of older adults</a> take at least one medication that’s not necessary or no longer needed. Doctors need to periodically reevaluate to make sure each medication is still right for the patient and still the correct dose. During treatment, the patient’s weight may fluctuate, either up or down. Even if it stays the same, body composition might change; that occurs as people age. As a result, one may react differently to a drug. That can happen even with a medication a person has been on for years. </p>
<p><a href="https://doi.org/10.1517/14740338.2013.827660">Polypharmacy often means</a> higher health care costs and more drug interactions. Patients are more likely to miss medications or stop taking them altogether. Sometimes, physical activity diminshes; falls, cognitive impairment, malnourishment and urinary incontinence increase; there may be less ability to do daily tasks. Those on five or more medications have <a href="https://doi.org/10.1517/14740338.2013.827660">a much higher incidence </a> of having an ADE – an adverse drug event – compared to those using fewer meds. Making matters worse, the symptoms of polypharmacy <a href="https://doi.org/10.15256/joc.2011.1.4">are sometimes masked</a> and taken as signs of aging.</p>
<h2>Check the list</h2>
<p><a href="https://doi.org/10.1186/s12875-017-0642-0">Studies have suggested solutions</a>, with better coordination among care providers being one. Making the pharmacist an integral part of routine care is another. The increasing use of electronic patient records helps. So do smartphone apps, sometimes an easier way for patients and providers to connect. But so far, there’s no magic pill, and as researchers and clinicians investigate improvements, much of the burden remains on patients and their families. </p>
<p>There are steps you can take to stay safe, however. Regularly clean out the medicine cabinet and get rid of expired medicines or those you’re no longer taking. Either throw them away or ask your doctor or pharmacist about the best way to dispose of them. When seeing the doctor, bring in the meds you take and review each one in detail. Make certain you need to continue taking them all and verify the right dose.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314321/original/file-20200209-27519-1rijghf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Make sure you regularly check the expiration dates on your medications.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/medicine-pills-and-bottles-royalty-free-image/157310213?adppopup=true">Getty Images / dszc</a></span>
</figcaption>
</figure>
<p>You can also check the PIMs list, also known as the <a href="https://doi.org/10.1111/jgs.15767">Beer’s List</a>. Published by the <a href="https://www.choosingwisely.org/societies/american-geriatrics-society">American Geriatric Society</a>, it’s an index of medications potentially harmful to the elderly. Some are linked to increased risks of side effects, and not a few are sold over-the-counter without prescription. </p>
<p>That includes medicines containing antihistamines like diphenhydramine, or Benadryl. In the elderly population, Benadryl carries an increased risk of dizziness, confusion and urinary retention. Medicines that are part of the NSAID family (nonsteroidal anti-inflammatory drugs) are also on the list. In some elderly patients, they can cause high blood pressure or kidney failure. Commonly used medicines in the NSAID family are those containing ibuprofen or naproxen. </p>
<p>Just because a medicine is on the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15767">Beer’s List</a> doesn’t mean your doctor was wrong to prescribe it, or that you should stop using it. Instead, use the medication with caution and discuss with your doctor to make sure you need it. Determine with your doctor the lowest useful dose, monitor for side effects, and speak up if you have any. </p>
<p><a href="https://www.choosingwisely.org/societies/american-geriatrics-society">As a geriatrician</a>, I see patients in an outpatient setting, either as their primary care provider or as a specialist consultant. We review medications at every visit: the list, the dose and how often the patient is taking it. A true and accurate medication list is the critical first step in geriatric care. </p>
<p>This is especially important during care transitions, such as when a patient is coming out of the hospital or nursing home. Particularly at that time, we find out if the patient is using the medication as prescribed, or taking it more frequently or less or not at all. Which leads to my final piece of advice: If you’ve strayed with your meds, one way or another, know that we doctors don’t judge or punish patients. Just tell us the truth. That’s all we want to hear. Then we can move forward together to find the best regimen for you. </p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/127682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laurie Archbald-Pannone is affiliated with American Geriatrics Society.</span></em></p>As the boomers age, many will have medication issues. That can be compounded by the number of drugs they take, both prescription and over-the-counter.Laurie Archbald-Pannone, Associate Professor Medicine, Geriatrics, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1258092019-10-31T18:54:14Z2019-10-31T18:54:14ZWhat time of day should I take my medicine?<figure><img src="https://images.theconversation.com/files/299592/original/file-20191030-17868-1jqgbz6.jpg?ixlib=rb-1.1.0&rect=3%2C1%2C1019%2C680&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Does it matter if you take your medicine morning, noon or night? That depends on a number of factors.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/various-pills-capsules-organizer-clock-on-1254773287?src=lTNi4XfRk7QXoxYjmhO84g-1-31&studio=1">from Kat Ka/www.shutterstock.com</a></span></figcaption></figure><p>Whether you need to take a drug at a specific time of day depends on the medication and the condition you are treating. For some medicines, it doesn’t matter what time you take it. And for others, the pharmacist may recommend you take it at the same time each day. </p>
<p>But we estimate that for around 30% of all medicines, the time of day you take it <em>does</em> matter. And a <a href="https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz754/5602478">recent study</a> shows blood pressure medications are more effective if you take them at night.</p>
<p>So, how do you know if the timing of your medication is critical?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-should-you-do-with-your-unused-medicine-81406">Health Check: what should you do with your unused medicine?</a>
</strong>
</em>
</p>
<hr>
<h2>When timing doesn’t matter</h2>
<p>In most cases, it’s not important when you take your medicine. For instance, you can take non-drowsy antihistamines for hay fever, or analgesics for pain when you need them. It doesn’t matter if it is morning, noon or night.</p>
<p>What is more important is the time interval between each dose. For instance, paracetamol needs to be taken at least four hours apart, any closer and you run the risk of taking a toxic dose.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-has-a-paracetamol-poisoning-problem-this-is-what-we-should-be-doing-to-reduce-harm-122532">Australia has a paracetamol poisoning problem. This is what we should be doing to reduce harm</a>
</strong>
</em>
</p>
<hr>
<p>Even when a medication <em>doesn’t need</em> to be taken at a particular time, the pharmacist may still recommend you take it at the same time every day anyway.</p>
<p>This daily pattern helps remind you to take it. An example is taking the oral contraceptive at the same time each day, simply out of habit.</p>
<p>For the <a href="https://www.nps.org.au/medicine-finder/microlut-tablets">mini pill</a>, taking it at the same time is actually necessary. But the actual time of day can be whatever works best for you.</p>
<h2>When does it matter?</h2>
<p>It may seem fairly obvious to take some medicines at particular times. For example, it makes sense to taking sleeping medications, such as <a href="https://www.healthdirect.gov.au/temazepam">temazepam</a>, at night before you go to bed.</p>
<p>Some antidepressants, such as <a href="https://www.nps.org.au/medicine-finder/endep-tablets">amitryptyline</a> or <a href="https://www.nps.org.au/medicine-finder/avanza-tablets">mirtazapine</a>, have drowsy side effects. So it also makes sense to take them at night.</p>
<p>For other medicines, taking them in the morning is more logical. This is true for diuretics, such as <a href="https://www.nps.org.au/medicine-finder/lasix-tablets">furosemide</a>, which helps you get rid of excess fluid via your urine; you don’t want to be getting up in the night for this.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299119/original/file-20191029-183151-s0hjfe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When a medicine needs to be taken at a specific time, this will be indicated on the box.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>For other medications, it’s not obvious why they have to be taken at a particular time of day. To understand why, we have to understand our circadian rhythm, our own internal body clock. Some systems in our body work at different times of day within that rhythm.</p>
<p>For instance, the enzymes controlling cholesterol production in your liver are most active at night. So there may be some benefit to taking lipid (cholesterol) lowering drugs, such as <a href="https://www.nps.org.au/medicine-finder/zocor-tablets">simvastatin</a>, at night.</p>
<p>Finally, sometimes it’s important to take medications only on particular days. <a href="https://www.nps.org.au/medicine-finder/dbl-methotrexate-tablets">Methotrexate</a> is a medicine used for rheumatoid arthritis and severe psoriasis, and the timing of this medication is critical. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-rheumatoid-arthritis-the-condition-tennis-champion-caroline-wozniacki-lives-with-119537">What is rheumatoid arthritis, the condition tennis champion Caroline Wozniacki lives with?</a>
</strong>
</em>
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<p>You should only take it on the same day once a week, and when taken this way it is quite safe. But if you mistakenly take it daily, as happened recently with <a href="https://www.meridianlawyers.com.au/insights/medication-misadventure-methotrexate-reminder-pharmacists-exercise-independent-judgment-safety-prescribed-medicine/">a patient in Victoria</a>, then it can cause serious illness or even <a href="https://www.smh.com.au/healthcare/worrying-rise-in-accidental-overdose-of-prescription-drug-methotrexate-20160606-gpcaz3.html">death</a>.</p>
<h2>What about blood pressure medicines?</h2>
<p>One of the ways the body regulates blood pressure is through a pathway of hormones known as the <a href="http://pharma.bayer.com/en/innovation-partnering/research-and-development-areas/cardiovascular/the-raas-system/#targetText=The%20renin%2Dangiotensin%2Daldosterone%20system%20(RAAS)%20is%20a,release%20an%20enzyme%20called%20renin">renin, angiotensin and aldosterone system</a>.</p>
<p>This system responds to various signals, like low blood pressure or stressful events, and controls blood volume and the constriction of blood vessels to regulate your blood pressure.</p>
<p>Importantly, this system is more active while you’re asleep at night. And a <a href="https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz754/5602478">recent study</a>, which found blood pressure medication is more effective at night,
may change the way we use medicines to treat high blood pressure.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-do-my-blood-pressure-numbers-mean-29212">Health Check: what do my blood pressure numbers mean?</a>
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<p>Two types of drugs typically prescribed to lower blood pressure are <a href="http://www.bloodpressureuk.org/BloodPressureandyou/Medicines/Medicinetypes/ACEInhibitors">angiotensin converting enzyme (ACE) inhibitors</a>, such as <a href="https://www.nps.org.au/medicine-finder/apo-perindopril-arginine-tablets">perindopril</a>, and <a href="http://www.bloodpressureuk.org/BloodPressureandyou/Medicines/Medicinetypes/ARBs">angiotensin receptor blockers</a> (known as ARBs), such as <a href="https://www.nps.org.au/medicine-finder/irbesartan-an-tablets">irbesartan</a>. These drugs dilate blood vessels (make them wider) to reduce your blood pressure.</p>
<p>Until now, doctors and pharmacists have often advised patients to take these medications in the morning, assuming it’s good to have a hit of the drugs when you’re up and about.</p>
<p>But this study found taking blood pressure medications at night produced a significant reduction (45%) in heart disease, including fewer strokes, heart attacks and heart failure compared to taking them in the morning.</p>
<p>Taking them at night also meant people’s blood pressure was better controlled and their kidneys were healthier.</p>
<p>So if you take one of these drugs to control your blood pressure and aren’t sure what you should do, talk to your pharmacist or doctor. While evidence is building to support taking them at night, this might not be appropriate for you.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-is-it-ok-to-chew-or-crush-your-medicine-39630">Health Check: is it OK to chew or crush your medicine?</a>
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<img src="https://counter.theconversation.com/content/125809/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association. Nial is also a director of the medicinal cannabis company Canngea Pty Ltd and a Standards Australia committee member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Andrew Bartlett is a member of the Australian College of Pharmacy</span></em></p>For most medicines, it doesn’t matter when you take them. But others work best at particular times.Nial Wheate, Associate Professor | Program Director, Undergraduate Pharmacy, University of SydneyAndrew Bartlett, Associate Lecturer Pharmacy Practice, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1241692019-10-02T20:03:40Z2019-10-02T20:03:40ZHere’s what happened when codeine was made prescription only. No, the sky didn’t fall in<figure><img src="https://images.theconversation.com/files/295175/original/file-20191002-101447-15o2pee.jpg?ixlib=rb-1.1.0&rect=0%2C13%2C998%2C652&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When people went to their GP asking for painkillers, they weren't prescribed higher doses of codeine or stronger opioids, as some feared.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/british-gp-talking-senior-woman-surgery-98521166?src=CyaCbhqZljZiIOusQJyLog-1-11">from www.shutterstock.com</a></span></figcaption></figure><p>Fears switching the painkiller codeine to a prescription only medicine would lead to more people misusing stronger painkillers are unfounded, according to research published today.</p>
<p>Our research, in the journal <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.14798">Addiction</a>, found the 2018 switch resulted in a 50% drop in codeine overdoses and sales. There was also no increase in overdoses with stronger opioids or high strength codeine, as some had feared.</p>
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Read more:
<a href="https://theconversation.com/trust-me-im-an-expert-the-science-of-pain-91907">Trust Me I'm An Expert: The science of pain</a>
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<h2>Remind me again, how did we get here?</h2>
<p>Australia has a love affair with codeine. It has historically been our <a href="https://www.ncbi.nlm.nih.gov/pubmed/26781123">most used opioid</a>, and 2013 data showed we <a href="https://www.ncbi.nlm.nih.gov/pubmed/26690771">took more codeine</a> as a country than the USA, despite having roughly 7% the population.</p>
<p>However, from <a href="https://www.tga.gov.au/codeine-info-hub">February 2018</a>, you could only buy codeine in Australia with a prescription. Before then, you could buy low strength codeine (up to 15mg per tablet) in combination with paracetamol, ibuprofen and aspirin over-the-counter (OTC) at pharmacies. Higher strength codeine has always required a prescription.</p>
<p>The 2018 change was not an overnight decision. Codeine has been on the government’s radar for <a href="https://ris.pmc.gov.au/sites/default/files/posts/2017/02/codeine_re-scheduling_ris.pdf">over a decade</a>; the Therapeutic Goods Administration (TGA) set up a codeine working party in 2008 in response to increasing misuse. Codeine is an opioid analgesic, meaning people can become dependent on it, and there is a risk of harm from overdose.</p>
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Read more:
<a href="https://theconversation.com/why-making-codeine-products-prescription-only-is-a-good-idea-34745">Why making codeine products prescription-only is a good idea</a>
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<p>There was also an <a href="https://ris.pmc.gov.au/sites/default/files/posts/2017/02/codeine_re-scheduling_ris.pdf">earlier attempt at reducing harm</a> when in 2010, all codeine painkillers were moved behind the counter at pharmacies. Before that, the lower strength products could be picked up off the pharmacy shelf without consulting a pharmacist.</p>
<p>Unfortunately, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27177599">our previous study</a> showed this move to stocking codeine behind the counter had little impact. Other studies also showed that <a href="https://www.mja.com.au/journal/2015/203/7/trends-and-characteristics-accidental-and-intentional-codeine-overdose-deaths">deaths from codeine continued to increase</a>. </p>
<p>The <a href="https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/21028a.pdf.aspx?inline=true">2016 National Drug Strategy Household Survey</a> reported codeine available from behind the counter at a pharmacy was the most misused legal opioid in Australia and misuse was particularly common in adolescents. </p>
<p>This left the TGA with little choice but to bring Australia in line with most other countries that restrict codeine to prescription only. The TGA announced the change in <a href="https://www.tga.gov.au/scheduling-decision-final/scheduling-delegates-final-decision-codeine-december-2016">December 2016</a> following a lengthy consultation, and the change took effect on February 1, 2018.</p>
<h2>Not everyone was happy</h2>
<p>The announcement <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12568">divided community and health-care professional groups</a>. <a href="https://www.pulseitmagazine.com.au/news/australian-ehealth/2770-rescheduling-otc-codeine-could-cost-316m-a-year-guild">Pharmacy organisations</a> opposed the change, whereas <a href="https://www1.racgp.org.au/newsgp/professional/gps-criticise-pharmacy-guild-on-codeine-rescheduli">GPs were in favour</a>. </p>
<p>There were also fears the change would lead to a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29699742">massive burden on GPs</a> as patients came to request codeine.</p>
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Read more:
<a href="https://theconversation.com/three-claims-used-to-justify-pulling-codeine-from-sale-without-a-prescription-and-why-theyre-wrong-87257">Three claims used to justify pulling codeine from sale without a prescription, and why they're wrong</a>
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<p>Some people were concerned the move would drive people to use <a href="https://www.abc.net.au/news/2018-05-11/panadeine-shortage-pushing-patients-onto-stronger-painkillers/9741946">higher strength codeine</a>. This was because people wanting codeine would need to see their doctor, so they might request the stronger products that had always been prescription only. <a href="https://www.tga.gov.au/scheduling-submission/public-submissions-scheduling-matters-referred-acms17-march-2016-codeine">There was also concern</a> the change would push people towards even stronger painkillers, like oxycodone and morphine. </p>
<h2>What happened next?</h2>
<p>In our work at the <a href="https://www.poisonsinfo.nsw.gov.au/">NSW Poisons Information Centre</a> we get hundreds of calls about opioid overdoses every month. So we were keen to evaluate whether the change in codeine availability affected the number of overdoses. We, like others, were also worried there might also be unintended consequences of the change in its availability.</p>
<p>In the year after the change, we saw a 51% drop in codeine poisonings overall. This mainly affected low strength preparations (the category no longer available without prescription), where poisonings dropped by 79%. </p>
<p>There was no increase in poisonings with high strength codeine or other opioids. Similarly, sales data showed overall use of codeine dropped by almost 50%, with use of low strength codeine most affected, dropping by 87%. Again, there was no increase in use of high strength codeine.</p>
<h2>Your genetics are also important</h2>
<p>Concerns over misuse and addiction were not the sole reason behind the change in codeine availability. A person’s response to codeine is <a href="https://theconversation.com/weekly-dose-codeine-doesnt-work-for-some-people-and-works-too-well-for-others-58067">determined by their genes</a>, specifically a gene that codes for the enzyme CYP2D6. This enzyme activates codeine by converting it to morphine in the body. </p>
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Read more:
<a href="https://theconversation.com/weekly-dose-codeine-doesnt-work-for-some-people-and-works-too-well-for-others-58067">Weekly Dose: codeine doesn't work for some people, and works too well for others</a>
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<p>So, depending on their DNA, some people don’t get any effect from codeine, some get a “normal” effect, while others find it toxic at what is normally considered a safe dose. </p>
<p>The latter is the most dangerous scenario, and has resulted in <a href="https://www.ncbi.nlm.nih.gov/pubmed/28520350">several deaths</a>. This has included a <a href="https://www.ncbi.nlm.nih.gov/pubmed/17872605">newborn baby</a> who died after their mother had a normal dose of codeine for pain after childbirth. The mother was later found to have the gene that results in excessive codeine activation, and a lethal dose of morphine was transmitted to her baby in her breast milk. </p>
<p>Even if the misuse problems disappeared overnight, people who advocated codeine be available only by prescription argued that a medicine with such a variable effect should only be available after seeing a doctor.</p>
<h2>How about unintended consequences of the codeine switch?</h2>
<p>Future research needs to look into possible unintended consequences of the change in codeine availability.</p>
<p>For instance, people may have switched to simple analgesics, like paracetamol and ibuprofen. These don’t have the same potential to be abused, are generally safer, and are <a href="https://www.ncbi.nlm.nih.gov/pubmed/21257263">more effective</a> than low-strength codeine products. Yet they can still be toxic when overdosed.</p>
<p>Our research didn’t look at whether the codeine switch led to more people using paracetamol or ibuprofen, or were harmed by them.</p>
<h2>Limiting availability works</h2>
<p>Prescription drug misuse and overdoses are problems that are very much <a href="https://www.nps.org.au/australian-prescriber/articles/pharmaceutical-drug-misuse-in-australia">driven by drug availability</a>. And when the availability of other medicines in Australia and internationally have been restricted, we’ve seen the benefits, namely reductions in misuse and poisoning.</p>
<p>This has happened with the opioid painkillers <a href="https://www.ncbi.nlm.nih.gov/pubmed/20407028">tramadol</a>, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2484293">hydrocodone</a> and <a href="https://www.mja.com.au/journal/2013/199/4/trials-and-tribulations-removal-dextropropoxyphene-australian-register">dextropropoxyphene</a>; and the benzodiazepine <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2530900">alprazolam</a>.</p>
<p>Our study shows a good example of how effective simple strategies can be in tackling opioid misuse. Codeine is just one small piece of the puzzle, and we would like to see further investment and a systematic strategy to address causes of the <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02018?OpenDocument">rise in fatal poisonings</a> from prescription drugs in the past decade.</p>
<p>We would like to see a National Centre for Poisoning Research set up, which would bring together and support existing and new researchers. This would focus on preventing and managing poisoning, to provide a national response to this clinical and public health problem.</p><img src="https://counter.theconversation.com/content/124169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Cairns receives funding from the NHMRC for suicide prevention research. She has previously been an associate investigator on an untied educational grant from Seqirus to study tapentadol misuse (this funder had no role in the current study).</span></em></p><p class="fine-print"><em><span>Nicholas Buckley has received funding from the NHMRC to support research into poisoning prevention.</span></em></p>When codeine became a prescription only drug in 2018, the number of overdoses dropped, our new research shows. But restricting sales of codeine is only one way to reduce harm from opioids.Rose Cairns, Lecturer in Pharmacy, University of SydneyNicholas Buckley, Professor of Clinical Pharmacology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1237682019-09-24T05:02:47Z2019-09-24T05:02:47ZDo new cancer drugs work? Too often we don’t really know (and neither does your doctor)<figure><img src="https://images.theconversation.com/files/293510/original/file-20190923-23822-1kn8g6y.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4294%2C3027&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The effectiveness of a drug may be evaluated based on its potential to shrink tumours – but this doesn't necessarily equate to improved survival rates.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>It’s hard to find anyone who hasn’t been touched by cancer. People who haven’t had cancer themselves will likely have a close friend or family member who has been diagnosed with the disease. </p>
<p>If the cancer has already spread, the diagnosis may feel like a death sentence. News that a new drug is available can be a big relief. </p>
<p>But imagine a cancer patient asks their doctor: “Can this drug help me stay alive longer?” And in all honesty the doctor answers: “I don’t know. There’s one study that says the drug works, but it didn’t show whether patients lived longer, or even if they felt any better.”</p>
<p>This might sound like an unlikely scenario, but it’s precisely what a team of <a href="https://www.bmj.com/content/366/bmj.l5221">UK researchers</a> found to be the case when it comes to many new cancer drugs. </p>
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Read more:
<a href="https://theconversation.com/we-dont-need-to-change-how-we-subsidise-breakthrough-cancer-treatments-87185">We don't need to change how we subsidise 'breakthrough' cancer treatments</a>
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<h2>A look at the research</h2>
<p>A study published last week in the <a href="https://www.bmj.com/content/366/bmj.l5221">British Medical Journal</a> reviewed 39 clinical trials supporting approval of all new cancer drugs in Europe from 2014 to 2016.</p>
<p>The researchers found more than half of these trials had serious flaws likely to exaggerate treatment benefits. Only one-quarter measured survival as a key outcome, and fewer than half reported on patients’ quality of life.</p>
<p>Of 32 new cancer drugs examined in the study, only nine had at least one study without seriously flawed methods. </p>
<p>The researchers evaluated methods in two ways. First, they used a standard “risk of bias” scale that measures shortcomings shown to lead to biased results, such as if doctors knew which drug patients were taking, or if too many people dropped out of the trial early. </p>
<p>Second, they looked at whether the European Medicines Agency (EMA) had identified serious flaws, such as a study being stopped early, or if the drug was compared to substandard treatment. The EMA identified serious flaws in trials for ten of the 32 drugs. These flaws were rarely mentioned in the trials’ published reports.</p>
<h2>From clinical trials to treatment – faster isn’t always better</h2>
<p>Before a medicine is approved for marketing, the manufacturer must carry out studies to show it’s effective. Regulators such as the EMA, the US Food and Drug Administration (FDA) or Australia’s Therapeutic Goods Administration (TGA) then judge whether to allow it to be marketed to doctors. </p>
<p>National regulators mainly examine the same clinical trials, so the findings from this research are relevant internationally, including in Australia.</p>
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Read more:
<a href="https://theconversation.com/spot-the-snake-oil-telling-good-cancer-research-from-bad-36344">Spot the snake oil: telling good cancer research from bad</a>
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<p>There’s strong public pressure on regulators to approve new cancer drugs more quickly, based on less evidence, especially for poorly treated cancers. The aim is to get treatments to patients more quickly by allowing medicines to be marketed <a href="https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.59">at an earlier stage</a>. The downside of faster approval, however, is more uncertainty about treatment effects. </p>
<p>One of the arguments for earlier approvals is the required studies can be carried out later on, and sick patients can be given an increased chance of survival before it’s too late. However, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2733561">a US study</a> concluded that post-approval studies found a survival advantage for only 19 of 93 new cancer drugs approved from 1992 to 2017.</p>
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<img alt="" src="https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293512/original/file-20190923-23822-zn3gbl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">If the evidence for a new cancer drug is flawed, this leaves patients vulnerable to false hope.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<h2>So how is effectiveness measured currently?</h2>
<p>Approval of new cancer drugs is often based on short-term health outcomes, referred to as “surrogate outcomes”, such as shrinking or slower growth of tumours. The hope is these surrogate outcomes predict longer-term benefits. For many cancers, however, they have been found to do a poor job of <a href="https://www.sciencedirect.com/science/article/pii/S095980491831476X?via%3Dihub">predicting improved survival</a>. </p>
<p><a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2729389">A study of cancer trials</a> for more than 100 medicines found on average, clinical trials that measure whether patients stay alive for longer take an extra year to complete, compared to trials based on the most commonly used surrogate outcome, called “progression free survival”. This <a href="https://ascopubs.org/doi/10.1200/JCO.2011.38.7571">measure</a> describes the amount of time a person lives with a cancer without tumours getting larger or spreading further. It’s often poorly correlated with overall survival.</p>
<p>A year may seem like a long wait for someone with a grim diagnosis. But there are policies to help patients access experimental treatments, such as participating in clinical trials or compassionate access programmes. If that year means certainty about survival benefits, it’s worth waiting for. </p>
<h2>Approving drugs without enough evidence can cause harm</h2>
<p>In an <a href="https://www.bmj.com/content/366/bmj.l5399">editorial</a> accompanying this study, we argue that exaggeration and uncertainty about treatment benefits cause direct harm to patients, if they risk severe or life-threatening harm without likely benefit, or if they forgo more effective and safer treatments. </p>
<p>For example, the drug <a href="https://english.prescrire.org/en/81/168/57219/0/NewsDetails.aspx">panobinostat</a>, which is used for multiple myeloma patients who have not responded to other treatments, has not been shown to help patients live longer, and can lead to serious infections and bleeding.</p>
<p>Inaccurate information can also encourage false hope and create a distraction from needed palliative care. </p>
<p>And importantly, the ideal of shared informed decision-making based on patients’ values and preferences falls apart if neither the doctor nor the patient has accurate evidence to inform decisions.</p>
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Read more:
<a href="https://theconversation.com/if-we-dont-talk-about-value-cancer-drugs-will-become-terminal-for-health-systems-44072">If we don't talk about value, cancer drugs will become terminal for health systems</a>
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<p>In countries with public health insurance, such as Australia’s Pharmaceutical Benefits Scheme (PBS), patients’ access to new cancer drugs depends not just on market approval but also on payment decisions. The PBS often refuses the pay for new cancer drugs because of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13350">uncertain clinical evidence</a>. In the cases of the drugs in this research, some are available on the PBS, while others are not.</p>
<p>New cancer drugs are often very expensive. On average in the US, a course of treatment with a new cancer drug costs more than US$100,000 (A$148,000).</p>
<p>Cancer patients need treatments that help them to live longer, or at the very least to have a better quality of life during the time that they have left. In this light, we need stronger evidence standards, to be sure there are real health benefits when new cancer drugs are approved for use. </p>
<p><em>The article has been updated to reflect Agnes Vitry’s current role at the University of South Australia.</em></p><img src="https://counter.theconversation.com/content/123768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Mintzes receives funding from the National Health and Medical Research Council (NHMRC) for a research project on post-market regulatory safety advisories on medicines. She is also a member of Health Action International (HAI-Europe), a network of health and consumer organisations that promotes access to essential medicines and quality use of medicines. </span></em></p><p class="fine-print"><em><span>Agnes Vitry is affiliated with Cancer Voices, SA.</span></em></p>National drug regulators use evidence from clinical trials to decide whether new cancer drugs will be approved for use. But these studies are often flawed.Barbara Mintzes, Senior Lecturer, Faculty of Pharmacy, University of SydneyAgnes Vitry, Senior lecturer, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1002992018-07-23T23:00:34Z2018-07-23T23:00:34ZDebunking the myths about a Canadian pharmacare program<figure><img src="https://images.theconversation.com/files/228916/original/file-20180723-189326-1prj54y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A national pharmacare program may one day be a reality in Canada. Myths abound about how it would work and what the consequences would be for Canadians and pharmaceutical companies.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Recently in Canada, there has been increasing public discussion of universal public drug insurance, or pharmacare. </p>
<p>The federal government’s <a href="https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/implementation-national-pharmacare/biographies.html">Advisory Council on the Implementation of National Pharmacare</a> is consulting with Canadians this summer on a program that would see prescription drugs covered through expanded publicly funded systems.</p>
<p>Premiers <a href="https://www.cbc.ca/news/politics/premiers-health-friday-1.4754762">discussed pharmacare</a> at their recent annual meeting, calling for a “voluntary” program designed and delivered by provinces, with federal funding and an ability for provinces to opt out. </p>
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<img alt="" src="https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228743/original/file-20180723-189341-zq8th3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Eric Hoskins, head of the federal advisory council on how to implement a national pharmacare program, and Linda Silas, president of the Canadian Federation of Nurses Unions, at a news conference after a meeting with Canadian premiers in New Brunswick on July 20, 2018.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
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<p>Nonetheless, a number of myths have found their way into the public debate over the benefits and costs of pharmacare. Addressing these myths and misconceptions will help Canadians come to a reasoned opinion about whether the time is right to adopt a national pharmacare program.</p>
<h2>Myth 1</h2>
<p><em>Pharmacare will reduce choice of drugs to the detriment of patients.</em></p>
<p>All public and many private drug plans have a list of drugs eligible for coverage. Some argue that pharmacare will mean a reduced choice of drugs, and this will be harmful to patients.</p>
<p>First, not all pharmacare programs aim to cover the majority of prescriptions, at least not initially. There <a href="http://www.cmaj.ca/content/189/8/E295.full">are proposals</a> to start universal public coverage in Canada with a small list of <a href="http://cmajopen.ca/content/5/1/E137.full">essential medicines</a>. Other prescriptions would continue to be paid for by existing public and private plans or directly by patients.</p>
<p>This was how <a href="https://utorontopress.com/ca/ideas-and-the-pace-of-change-3">Australia implemented universal pharmaceutical benefits in 1950</a>, and they expanded to a comprehensive list of medicines within a few years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228747/original/file-20180723-189313-1xtwt48.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacist Denis Boissinot checks a bottle on a shelf at his pharmacy in 2012 in Québec City. Under some national pharmacare proposals, only a small list of essential medicines would immediately be covered, to be expanded later.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jacques Boissinot</span></span>
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<p>Pharmacare could also be adopted with a list meant to cover most prescriptions. Even if this is the case, when it comes to drugs, <a href="https://onlinelibrary-wiley-com.libaccess.lib.mcmaster.ca/doi/abs/10.1002/hec.1415">more is not necessarily better</a>. More <em>new</em> drugs, in particular, are not necessarily better: The level of effectiveness required for a new drug to receive marketing approval from Health Canada is actually <a href="https://utorontopress.com/ca/private-profits-versus-public-policy-4">fairly low</a>. </p>
<p>In Canada today, public medicine lists are smaller than private because they are <a href="https://www.cadth.ca/about-cadth">evidence-based</a>. Drugs have to pass a high bar in an additional review process in order to be listed.</p>
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Read more:
<a href="https://theconversation.com/no-raising-drug-prices-in-canada-will-not-help-the-u-s-96608">No, raising drug prices in Canada will not help the U.S.</a>
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<p>This review focuses on how clinically effective a drug is, and also considers its value for money. This means public formularies do better at listing drugs that offer real benefits to patients, and they don’t waste resources on drugs that provide little benefit or have increased risks.</p>
<p>Finally, a private drug plan is not a guarantee of unlimited drug choice. Some private plans are already finding they need to raise premiums or co-payments, or reduce benefits, in response to increasing drug costs. </p>
<h2>Myth 2</h2>
<p><em>Canadian drug prices are not excessive; we already get a reasonable deal on pharmaceuticals.</em></p>
<p>It is sometimes argued that Canadian drug prices are not excessive and already offer value for money. After all, Canada has a <a href="http://pmprb-cepmb.gc.ca/home">Patented Medicines Prices Review Board</a> (the PMPRB) with the explicit mandate to ensure that the prices of patented (brand-name or innovative) medicines are not excessive. </p>
<p>In 2016, the PMPRB began modernizing its guidelines for regulating drug prices. It acknowledged “<a href="http://www.pmprb-cepmb.gc.ca/CMFiles/Consultations/DiscussionPaper/PMPRB_DiscussionPaper_June2016_E.pdf">the coupling of high Canadian patented drug prices and record low investment in R&D has many questioning the effectiveness of the PMPRB</a>.” It noted that while Canada’s prices are at the median of the seven OECD countries the PMPRB uses as comparisons, this group of countries includes the highest drug prices in the world: Canada currently has the third-highest prices. Canada also spends more per capita on drugs than any OECD country other than the United States.</p>
<p>When comparing drug prices internationally, we should understand that the PMPRB uses “list” prices, similar to the “sticker” prices on new cars. Like new cars, the price of drugs is negotiated between sellers and purchasers and is not transparent. </p>
<p>Drug manufacturers offer purchasers confidential discounts in exchange for listing their drugs. Larger purchasers (such as governments purchasing for an entire country) can negotiate better prices. </p>
<p>Confidential price negotiations likely widen the gap between drug prices in Canada and countries like the United Kingdom and Australia, because smaller provincial drug plans have less negotiating power and the discounts they get only apply to people who are covered by public plans.</p>
<h2>Myth 3</h2>
<p><em>Pharmacare will result in less pharmaceutical industry investment (particularly in research and development) in Canada.</em></p>
<p>Some argue since pharmacare would result in more regulation and lower drug prices, it would <a href="https://www.fraserinstitute.org/studies/implications-of-the-proposed-changes-to-canadas-pharmaceutical-pricing-regulations">cause the pharmaceutical industry to decrease investment</a>. They argue this would hurt the Canadian economy and patients’ access to innovative drugs. </p>
<p>The <a href="http://www.pmprb-cepmb.gc.ca/CMFiles/Consultations/DiscussionPaper/PMPRB_DiscussionPaper_June2016_E.pdf">PMPRB</a> points out that pharmaceutical R&D investment in Canada is already comparatively low (five per cent of sales versus 20 per cent in the U.K., which has much lower prices). It notes that R&D investment is driven by location of head offices, trial infrastructure and scientific clusters, not prices or insurance. This is supported by <a href="https://utorontopress.com/ca/private-profits-versus-public-policy-4">published academic research</a>.</p>
<p>There is also a lack of evidence that pharmaceutical manufacturers choose not to market drugs in Canada because of regulation or pricing policies. </p>
<p>For example, <a href="http://www.longwoods.com/content/24626">researchers</a> recently asked whether manufacturers forgo marketing applications for <a href="https://www.orpha.net/consor/cgi-bin/Education_AboutOrphanDrugs.php?lng=EN">so-called orphan drugs for rare diseases</a> in Canada. Many countries have orphan drug-specific regulatory incentives to recognize the challenges of bringing new drugs for very small populations to market, but Canada does not. </p>
<p>We might expect that this lack of incentives would make manufacturers reluctant to market these drugs in Canada, but the researchers have found this isn’t the case.</p>
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Read more:
<a href="https://theconversation.com/pharmacare-and-the-chaotic-world-of-canadian-drug-prices-93343">Pharmacare and the chaotic world of Canadian drug prices</a>
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<p>As Canadians consider possibilities for pharmacare reform in the coming months, they should have access to the best available evidence about how it might work in our country. </p>
<p>Hopefully, a key outcome of the advisory council will be to make this evidence accessible to Canadians.</p><img src="https://counter.theconversation.com/content/100299/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine Boothe receives funding from the Social Sciences and Humanities Research Council of Canada</span></em></p>As Canadians consider possibilities for pharmacare reform in the coming months, they should have access to the best available evidence about how it might work in our country.Katherine Boothe, Associate Professor, Political Science, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/941052018-03-29T01:33:21Z2018-03-29T01:33:21ZIs psychiatry ready for medical MDMA?<p>Within five years, science will likely have answered a controversial question: can methylenedioxymethamphetamine (MDMA) treat psychiatric disorders? </p>
<p>After some <a href="https://www.ncbi.nlm.nih.gov/pubmed/20643699">studies</a> showing a positive effect, MDMA-assisted psychotherapy is entering <a href="https://www.maps.org/news/media/6786-press-release-fda-grants-breakthrough-therapy-designation-for-mdma-assisted-psychotherapy-for-ptsd,-agrees-on-special-protocol-assessment-for-phase-3-trials">final clinical trials</a> as a treatment for post-traumatic stress disorder (PTSD). If these trials show positive results, MDMA will go from an illegal drug to a prescription medicine in the United States by 2021, potentially prompting movement in this space in Australia and Europe.</p>
<p>MDMA would move from the fringes to mainstream psychiatry, becoming recognised as a mainstream treatment option. What remains less clear is how psychiatry will deal with questions arising from this new treatment approach. </p>
<h2>MDMA in medicine: a brief history</h2>
<p>German pharmaceutical company <a href="https://upload.wikimedia.org/wikipedia/commons/1/12/Merck_MDMA_Synthesis_Patent.pdf">Merck</a> patented MDMA in 1912. However, it appears not to have been used in humans <a href="https://www.ncbi.nlm.nih.gov/pubmed/17152992">until later that century</a>.</p>
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Read more:
<a href="https://theconversation.com/shroom-to-grow-australias-missing-psychedelic-science-17344">Shroom to grow: Australia's missing psychedelic science </a>
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<p>Better known as a street drug in the rave scene of the 1980s and ’90s, MDMA was used in the 1970s by a small band of <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=grinspoon+mdma">US psychiatrists and therapists</a>. This group believed it enhanced the therapeutic bond and improved treatment for ailments ranging from marital distress to, potentially, <a href="http://inch.com/%7Ejholland/julie/jhchapter.htm">schizophrenia</a>. </p>
<p>Following rebranding as “ecstasy”, large-scale recreational use of MDMA led to its 1985 listing as an illegal drug in the USA (Australia followed in 1986). The <a href="http://www.cognitiveliberty.org/dll/mdma_scheduling_history.htm">MDMA-therapy community</a> unsuccessfully protested against this designation. </p>
<p>Advocates for MDMA-assisted psychotherapy have been playing the long game ever since, undertaking a painstaking process of research and advocacy, which has culminated in the upcoming trials. </p>
<h2>MDMA versus ecstasy</h2>
<p>Advocates for MDMA-assisted psychotherapy have been at pains to distinguish the street drug ecstasy from MDMA the medicine. Ecstasy can contain a range of substances as well as varying doses of MDMA. </p>
<p>This is unsurprising given early <a href="https://www.ncbi.nlm.nih.gov/pubmed/1379014">evidence</a> that high repeated MDMA doses – more relevant for recreational than therapeutic use – damage serotonergic neurons in animals. </p>
<p>Catastrophic predictions of a lost generation of ecstasy users, however, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24830185">failed to materialise</a>. Indeed, numerous people have received MDMA doses similar to those proposed for therapy in <a href="https://www.ncbi.nlm.nih.gov/pubmed/28443695">laboratory studies</a>. This shows that MDMA can be safely administered under controlled conditions to well-screened healthy adults. </p>
<p>It remains unknown whether the same is true of groups excluded from most studies. This includes children and older people, and those with psychiatric or physical illnesses. Studies to date do, however, suggest acceptable safety in <a href="https://www.ncbi.nlm.nih.gov/pubmed/20643699">adults with PTSD</a>. </p>
<h2>Pharmacologically enhanced treatment</h2>
<p>One aspect of MDMA therapy attracting less attention is that it involves a fundamental shift in psychiatric medication. All currently approved psychiatric medications treat symptoms rather than the disease itself. Relapse is common after stopping treatment.</p>
<p>MDMA-assisted psychotherapy, by comparison, involves limited MDMA doses over two or three sessions of eight to ten hours. The aim is to “fast-track” psychotherapy to produce long-lasting changes. </p>
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Read more:
<a href="https://theconversation.com/human-testing-of-illicit-drugs-the-highs-and-lows-8155">Human testing of illicit drugs – the highs and lows</a>
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<p>Possible mechanisms of such an effect are unclear. One suggestion is that the effects of MDMA, such as feelings of empathy, openness and reduced fear, might allow people to reprocess traumatic memories during <a href="http://www.maps.org/news-letters/v23n1/v23n1_p10-14.pdf">psychotherapy</a>. </p>
<p>Other medications are also being considered as adjuncts for psychotherapy. These include potent psychoactives like LSD and psilocybin, or drugs thought to enhance psychotherapy via mechanisms other than psychoactive effects (e.g. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27314661">d-cycloserine</a>). </p>
<p>It is possible, however, that a broader range of pharmaceuticals could be used in this way. Thus, a potential benefit of MDMA’s approval could be to spur further research in this area. </p>
<h2>The challenges of regulation</h2>
<p>The potential approval of MDMA for prescription gives rise to pressing questions about regulation. For instance, should prescribing be limited to physicians with specific qualifications? What training should be required for those conducting the psychotherapy? How should the drug be handled and stored by pharmacists? </p>
<p>The combination of a drug-affected patient with non-drug-affected therapists could make patients vulnerable during psychotherapy. This suggests a need for stringent training and oversight of MDMA-assisted therapy. </p>
<p>Approval of MDMA will also lead to off-label prescribing, with doctors prescribing the drug for conditions other than PTSD. This could include a range of conditions, such as depression and substance use disorders, and various patient groups. </p>
<p>A particular issue is prescribing to children/adolescents. To date no controlled studies have assessed the safety of MDMA in young people. Planned studies in adolescents with PTSD will thus be important. </p>
<h2>Is anything ‘penicillin for the soul’?</h2>
<p>The slow progression of MDMA-assisted psychotherapy from the subcultural margins towards approval has been driven by the belief of those advocating for it.</p>
<p>Without this motivated community, MDMA would likely not have been developed as a medication, as it is off patent. The downside of this robust advocacy base is that it can lead to rather extreme claims (e.g. <a href="http://www.azquotes.com/quote/769126">“penicillin for the soul”</a>) and experimenter bias. </p>
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Read more:
<a href="https://theconversation.com/weekly-dose-ecstasy-the-party-drug-that-could-be-used-to-treat-ptsd-55149">Weekly Dose: ecstasy, the party drug that could be used to treat PTSD</a>
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<p>In addition to well-designed studies that control for experimenter bias, there is a need for researchers and clinicians outside the MDMA-advocacy community to be involved in the ongoing development of this research direction. </p>
<p>If MDMA is to become a part of mainstream psychiatry’s armamentarium, many questions will need to be answered. The next few years will be critical to see if MDMA joins the ranks of failed psychiatric treatments, or offers new hope to people suffering from PTSD.</p><img src="https://counter.theconversation.com/content/94105/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gillinder Bedi receives funding from the US National Institute of Drug Abuse. </span></em></p>Current trials suggest MDMA could used to treat psychiatric disorders as a prescription medicine by 2021. But there remain a number of unresolved patient / doctor issues to be considered.Gillinder Bedi, Assistant Professor of Clinical Psychology (in Psychiatry) University of Melbourne and Orygen National Centre of Excellent in Youth Mental Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/902222018-01-17T03:44:19Z2018-01-17T03:44:19ZWhich medicines don’t go well with flying?<figure><img src="https://images.theconversation.com/files/202210/original/file-20180116-53314-45d63n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some medications increase our risk of blood clots. And so does flying. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Every day, <a href="http://www.iata.org/pressroom/pr/Pages/2012-12-06-01.aspx">more than 10 million people</a> take a flight somewhere in the world. While flying is relatively safe, the unique environmental conditions can put passengers at risk if they’re taking certain medications.</p>
<p>These include any hormone-based drugs, like the contraceptive pill and some fertility medicines, and drugs used to prevent heart attack and stroke. Antihistamines should also not be used to help passengers sleep during a flight.</p>
<h2>What makes flying different from other forms of travel?</h2>
<p>While flying is <a href="https://theconversation.com/whats-most-likely-to-kill-you-measuring-how-deadly-our-daily-activities-are-72505">one of the safest forms of travel</a>, there are specific risks that come with air travel, regardless of the length of the flight. </p>
<p>Passenger planes are typically pressurised to the same atmospheric conditions that are found at 10,000 feet altitude. <a href="https://www.ncbi.nlm.nih.gov/pubmed/6823572">At that level</a>, <a href="https://www.higherpeak.com/altitudechart.html">the effective oxygen level is only 14.3%</a>, which is much lower than the 20.9% found at ground level.</p>
<p>An additional risk is reduced blood flow from a lack of movement and sitting in cramped conditions, unless of course you’re fortunate enough to be in business or first class. And finally, dehydration is also a common side effect of flying due to the lack of humidity in the air.</p>
<p>When these conditions are combined, it results in an increased risk of <a href="https://www.healthdirect.gov.au/deep-vein-thrombosis">deep vein thrombosis</a>, which is also known as DVT. This is a type of blood clot that occurs in the veins deep in the body and occurs most often in the legs. The development of a blood clot can result in blocked blood flow to the lungs, heart, or brain, which in turn can cause a heart attack or stroke.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-deep-vein-thrombosis-11140">Explainer: what is deep vein thrombosis?</a>
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<h2>Contraceptive pill and other hormone-based medicines</h2>
<p>Given the inherent risk of a blood clot when flying, a passenger should use with caution any medication that can further increase the risk of a clot.</p>
<p>Some brands of contraceptive for women (tablet or implant formulation) are <a href="http://www.theaustralian.com.au/national-affairs/health/new-bloodclot-alerts-added-to-diane35-eds-product-information/news-story/eaa0b596541a760e9c6cf89b37900c42">known to increase the chances of a blood clot</a>, although the overall increase in risk is small. While it’s thought the major risk comes from the hormone <a href="http://www.healthywomen.org/condition/estrogen">estrogen</a>, <a href="http://www.cochrane.org/CD010813/FERTILREG_contraceptive-pills-and-venous-thrombosis">a review of all the medical evidence in 2014</a> showed there’s a risk of blood clot from all contraceptive medicines.</p>
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<a href="https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202211/original/file-20180116-53295-5o0izo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">It’s important you talk to your doctor about flying if you take hormonal medicines.</span>
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<p>Likewise, <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hormone-replacement-therapy-hrt-and-menopause">hormone replacement therapy</a>, particularly those that include estrogen, or some fertility medicines, such as <a href="https://www.babycenter.com/0_fertility-drug-gonadotropins_6188.bc">gonadotrophins</a>, can increase the risk of a blood clot.</p>
<p>If you take one of these medicines, it does not mean you cannot fly, nor that you should necessarily stop taking the drug. Many millions of women fly while taking these medicines and suffer no ill effects.</p>
<p>But the risk is also increased if you have an underlying health condition that includes type II diabetes, heart disease, and prior heart attacks or strokes. As such, passengers who also take medications to help prevent heart attacks and strokes should consult their doctor or pharmacist before flying.</p>
<p>If you’re at increased risk of a blood clot, then an anti-platelet medication may be suitable for you. These medicines act by stopping the blood cells from sticking together and include prescription medicines such as <a href="http://www.melbournehaematology.com.au/fact-sheets/warfarin.html">warfarin</a> and <a href="https://www.nps.org.au/australian-prescriber/articles/clopidogrel">clopidogrel</a>, and over-the-counter medicines such as <a href="https://www.healthdirect.gov.au/medicines/brand/amt,34661000168102/aspirin-low-dose-pharmacy-action">low dose aspirin</a>.</p>
<h2>Antihistamines</h2>
<p>Many passengers can have trouble sleeping when flying, especially on long-haul flights. Parents flying with young children can also be concerned about them not sleeping or being unsettled and annoying other passengers.</p>
<p>In these instances, many will turn to <a href="https://www.healthdirect.gov.au/antihistamines">sedating antihistamines</a>, like <a href="https://www.healthdirect.gov.au/medicines/brand/amt,22661000168108/phenergan">promethazine</a> to try to induce sleep. But this is a bad option.</p>
<p>The Australian Medical Association specifically recommends <a href="http://www.smh.com.au/national/australian-medical-association-warns-against-sedating-children-on-long-journeys-20150405-1mesd0.html">parents do not do this</a>, as sometimes it can have the reverse effect and make children less sleepy and more active. These types of <a href="http://www.medsafe.govt.nz/profs/PUArticles/Mar2013ChildrenAndSedatingAntihistamines.htm">antihistamines are also known to depress breathing</a>, and in the low oxygen environment of the aircraft this can be especially dangerous.</p>
<p>If you feel you or another family member will need sedation when flying, don’t use an antihistamine. Consult your doctor or pharmacist for a more suitable medication. Examples include prescription sleeping tablets, such as <a href="https://sleepfoundation.org/sleep-topics/melatonin-and-sleep">melatonin</a>, or natural remedies, such as <a href="https://www.webmd.com/vitamins-supplements/ingredientmono-870-valerian.aspx?activeingredientid=870">valerian</a>.</p>
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Read more:
<a href="https://theconversation.com/prepare-for-a-healthy-holiday-with-this-a-to-e-guide-69552">Prepare for a healthy holiday with this A-to-E guide</a>
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<h2>What to do before and during your flight</h2>
<p>Before you fly, if you’re taking any form of medication, it’s recommended you meet with your doctor or pharmacist to discuss the suitability of your medicines. They may advise you there’s little risk for you, or if there is a risk, they may recommend a different medicine for the trip or recommend a new medicine to reduce the risk of blood clots.</p>
<p>During your flight, don’t take antihistamines, and reduce your chance of a blood clot by drinking lots of water, stretching in your seat, and moving about the cabin as much as is appropriate.</p>
<p>Finally, the effects of alcohol can be increased when flying – so drink in moderation, and try to avoid tea, coffee, and other caffeinated drinks as these can have dehydrating effects and make it harder to sleep.</p><img src="https://counter.theconversation.com/content/90222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is affiliated with the Royal Australian Chemical Institute.</span></em></p>Commonly recommended sleeping tablets aren’t appropriate for plane travel. Here’s why.Nial Wheate, Associate Professor | Program Director, Undergraduate Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814062017-12-19T02:06:29Z2017-12-19T02:06:29ZHealth Check: what should you do with your unused medicine?<figure><img src="https://images.theconversation.com/files/182524/original/file-20170818-28163-kegiiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We're a nation of medication hoarders, and that can be dangerous.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/407440897?src=seA2MF_Uu1vxhri2d0wgqQ-1-5&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>If you were to look in your kitchen or bathroom cabinet, the chances are you’d find some unused medicine.</p>
<p>Maybe you recovered from surgery more quickly than you expected, and didn’t take all the strong painkillers your doctor prescribed. Or perhaps you took a medicine so long ago that it’s expired, the cardboard packaging is disintegrating, and you can’t be certain what it was for in the first place.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-do-we-need-to-follow-medication-use-by-dates-4329">Explainer: do we need to follow medication use-by dates?</a>
</strong>
</em>
</p>
<hr>
<p>But stockpiling medicines at home can be risky, not just for you but for your family and pets. And disposing of them in the garbage or down the toilet carries risks too.</p>
<p>Our new research, published in the <a href="http://www.publish.csiro.au/AH/AH16296">Australian Health Review</a>, shows that both practices are common. And few people know how to safely dispose of unwanted or expired medicines.</p>
<h2>How big is the problem?</h2>
<p>Pharmacists dispensed <a href="http://www.pbs.gov.au/statistics/expenditure-prescriptions/2015-2016/expenditure-prescriptions-report-2015-16.pdf">208 million</a> government-subsidised prescriptions in the 2015-16 financial year. And in a <a href="http://www.wsmi.org/wp-content/uploads/2015/06/CONSUMER-BEHAVIOUR-FACT-BOOK_MARCH-2015.pdf">2015 national survey</a>, eight out of ten adults said they had used at least one non-prescription medicine in the previous month.</p>
<p>Our research showed that almost two out of three people (60%) surveyed said they had unwanted medicines at home, and one-third (33%) of these medicines had expired.</p>
<p>Medicine can be unused or left over <a href="https://link.springer.com/article/10.1007/s11096-014-9981-2">for a number of reasons</a>. Perhaps we decide not to take what our doctor prescribed, or we feel better so we think we no longer need it, or the doctor changes our medicine and prescribes something else.</p>
<p>Keeping medicines to use for reoccurring conditions, like migraines, is appropriate. But <a href="https://link.springer.com/article/10.1007%2Fs11096-016-0287-4">keeping antibiotics</a> to use for a different infection can lead to treatment failure if those antibiotics do not target the new infection. When we use antibiotics incorrectly, bacteria can also change to become <a href="https://www.nps.org.au/medical-info/consumer-info/antibiotic-resistance-the-facts">more resistant</a> to treatment.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
</strong>
</em>
</p>
<hr>
<p>Stockpiling medicines at home can also be a safety problem. <a href="https://www.poisonsinfo.nsw.gov.au/site/files/ul/data_text12/4638177-kids_and_poisons_2014.pdf">Children</a> or pets can accidentally eat or drink them, older people can become confused about which ones to take, and medicines can lose their effectiveness or become toxic after their expiry date.</p>
<p>Then there are <a href="https://acic.govcms.gov.au/sites/g/files/net1491/f/2017/06/illicit_drug_data_report_2015-16_full_report.pdf?v=1498019727">security issues</a> such as theft. This is particularly relevant for opioid medicines (strong pain relievers like codeine) prescribed after surgery, <a href="http://www.couriermail.com.au/news/queensland/queensland-doctor-shoppers-pop-their-prescription-pills-on-black-market/news-story/2e3eae8eceb2d7aac67ab77442e53414">which can be sold on the black market</a>.</p>
<p>One <a href="http://jamanetwork.com/journals/jamasurgery/fullarticle/2644905">recent US study</a> found that most opioids prescribed after surgery were unused, and not stored or disposed of safely.</p>
<h2>A nation of hoarders</h2>
<p>To find out what people do with their unused medicines, <a href="http://www.returnmed.com.au/wp-content/uploads/2017/08/NatRUM-Project-Final-Report-Griffith-University.pdf">we surveyed</a> more than 4,300 Australians. </p>
<p>Most people (75%) said they kept medicines in case they needed them in the future. Other reasons included not wanting to waste money, not knowing how to dispose of them, intending to give them to family and friends, or forgetting the medicines were there.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182527/original/file-20170818-28132-7djuh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People often save their unused medicines because they think they might need them again, or don’t know how to dispose of them.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/655320097?src=ZP4kaKa0hurJRvbk2cT5Ig-1-16&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>People reported commonly storing their medicines in kitchens, bedrooms and/or bathrooms. When the same medicines are stored in multiple locations, people could accidentally take higher doses than recommended. This is because <a href="https://theconversation.com/prescribing-generic-drugs-will-reduce-patient-confusion-and-medication-errors-77093">multiple brands</a> of the same medicine can lead to confusion and the risk of duplicating a dose.</p>
<p>Many people were surprised at how many of their medicines were expired and some reported using expired medicines. This can delay treatment if they are less effective, and sterile treatments such as eye drops could be harmful if they have become contaminated.</p>
<p>When people said they had previously disposed of unwanted medicines, the most common reasons for this were that medicines had expired, were no longer needed, or treatment had changed.</p>
<h2>In the garbage and down the toilet</h2>
<p>In the 12 months to 2012, the Australian Bureau of Statistics estimated that <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4602.0.55.002Main+Features30Mar+2012">more than one million Australian households</a> discarded unwanted medicines with their usual garbage.</p>
<p>Our survey also found evidence for this, with most respondents (65%) having disposed of unwanted medicines this way. About a quarter (23%) said they had poured unwanted medicines down the drain or toilet.</p>
<p>Either of these disposal methods can cause problems. For instance, there is the risk of <a href="http://www.sciencedirect.com/science/article/pii/S0160412008002237?via=ihub">identity theft</a> from personal information on medicine labels disposed of in the garbage.</p>
<p>Then there are potential risks from medications that end up in <a href="http://www.sciencedirect.com/science/article/pii/S0269749105005129?via=ihub">surface</a> and <a href="http://pubs.acs.org/doi/pdf/10.1021/es801845a">drinking water</a>. This is because sewerage systems are not equipped to remove medicines and their metabolites (by-products) effectively. So these can be discharged into waterways and subsequently into drinking water supplies. Medicines disposed in the garbage end up in landfill and may leach out more slowly into water systems.</p>
<p><a href="http://www.abc.net.au/news/2015-07-07/common-drugs-found-lurking-in-sydney-harbour-water/6599670">Once in waterways</a>, medicines and their metabolites can affect <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314909/">plant, marine and animal life</a>. For instance, hormone-containing medicines can have feminising effects on fish near wastewater treatment works, and antibiotic-resistant bacteria have been found in waste water, surface water and drinking water. </p>
<p>Antibiotics in surface and groundwater have also been found to put <a href="http://www.sciencedirect.com/science/article/pii/S0147651316304080?via%3Dihub">algae, daphnids (small crustaceans) and fish</a> at risk.</p>
<p>Medications in our drinking water can <a href="https://link.springer.com/article/10.1208%2Fs12248-015-9729-5">potentially affect humans</a> too, but this requires further research.</p>
<h2>How to dispose of medicines safely</h2>
<p>In 1998, the Australian government <a href="http://www.returnmed.com.au/about-us/">introduced the Return Unwanted Medicines Project as a free scheme</a> and now <a href="http://www.returnmed.com.au/3-steps-to-a-safer-home/">encourage people to</a>:</p>
<ul>
<li><em>read</em> the labels on their stored medicines to see if they had expired or were really needed</li>
<li><em>remove</em> them from where they’re stored (and place in a bag or container),</li>
<li><em>return</em> them to their local pharmacy for safe disposal.</li>
</ul>
<p>Last year the scheme collected and safely disposed of <a href="http://www.returnmed.com.au/collections/">more than 700 tonnes</a> of medicines, preventing them from ending up in waterways or landfill. About one in five (22%) people in our survey said they had returned unwanted medicines to a pharmacy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181907/original/file-20170814-28487-50tfm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Full to the brim. This is how pharmacists collect your unwanted medicines, part of a national scheme few have heard of.</span>
</figcaption>
</figure>
<p>Once you hand in your unused or expired medicines, pharmacy staff put them in special bins. The bins are then transported to one of three national incineration sites where they are disposed of by high-temperature incineration. </p>
<p>Yet, our study found more than 80% of people hadn’t heard of the scheme; this was for both consumers and health-care workers. However once they knew about it, 92% said they would use it.</p>
<p>All health professionals, not just pharmacists, can remind people to return their unwanted medicines so they can be disposed of safely.</p>
<p>We all have a role to play to minimise the risks associated with unwanted medicines.</p><img src="https://counter.theconversation.com/content/81406/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This project was funded by The National Return & Disposal of Unwanted Medicines Limited and the Australian Government Department of Health. The researchers were independent from the funder. The financial assistance provided must not be taken as endorsement of the contents of this report.</span></em></p>If you look into your kitchen or bathroom cabinet, chances are you’d find some unused medicine, much of it expired. Here’s what to do with it.Amanda Wheeler, Professor, Griffith UniversityEmilie Bettington, Research fellow, Griffith UniversityFiona Kelly, Pharmacy Lecturer, Griffith UniversityJean Spinks, Research Fellow, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/770932017-05-09T14:16:03Z2017-05-09T14:16:03ZPrescribing generic drugs will reduce patient confusion and medication errors<figure><img src="https://images.theconversation.com/files/168498/original/file-20170509-20757-1w3h710.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If doctors prescribe generic drugs rather than their brand name equivalents, most times patients benefit.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/559764574?src=cvIlBVQ8z139t7FZlLOmNg-1-81&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p><em>In last night’s federal budget, Treasurer Scott Morrison announced an <a href="http://www.abc.net.au/news/2017-05-01/budget-to-push-generic-medicines-to-save-dollars/8486736">anticipated</a> range of measures to encourage doctors to prescribe generic medicines rather than their more expensive brand name equivalents. So unless specified by the doctor, patients will receive a prescription with the generic medication name on it.</em></p>
<p><em>This is part of A$1.8 billion in measures announced to reduce the drugs bill over five years. But beyond saving costs, the push towards generics may also reduce confusion among patients and medication errors.</em> </p>
<hr>
<p>“Are you taking aspirin at the moment?” I ask Iris, a pensioner in her 80s.</p>
<p>“No dear, I haven’t taken that for years,” she says, as she empties a large brown paper bag filled with medication boxes, new, old and empty.</p>
<p>I see a new bottle of aspirin emerge from the bag and ask if she is taking them.</p>
<p>“Oh yes, I always take my <em>Astrix</em> tablets.”</p>
<p>It’s not just elderly people who can be confused about which medication they’re taking. <a href="https://theconversation.com/cant-pronounce-the-name-of-your-medicine-heres-why-15416">Drug names are long, complex</a> and there are usually multiple brands for the same product.</p>
<p>For any medication, there are likely to be <a href="https://www.mja.com.au/journal/2011/195/11/what-s-name-brand-name-confusion-and-generic-medicines">up to 15 different</a> brands available. People are likely to use these brand names to describe the drug, like Iris did with her Astrix tablets.</p>
<p>In Australia in 2010 only <a href="http://www.publish.csiro.au/AH/AH12009">19.5% of scripts</a> issued by GPs used the generic term for a drug, compared with 83% in the United Kingdom.</p>
<p>Encouraging doctors to prescribe generics goes beyond economic value. It has the potential to lead to a simplification of the language around medications, less influence on our purchasing decision by pharmaceutical marketing, and fewer medication errors by both doctors and consumers.</p>
<p>When we visit the GP, unless a specific reason exists, we should receive a script written with the generic term.</p>
<h2>What is a generic term for a medication?</h2>
<p>The generic term for a medication is the name of the <a href="https://www.tga.gov.au/book/prominence-active-ingredients-medicine-labels">active ingredient</a> it contains. This is the ingredient that actually does the work of controlling your asthma or reducing your risk of heart disease.</p>
<p>There is only one generic name for each medication. But several different brands may be available. The brand name is usually the largest writing on the packet. Nurofen, for instance, is the brand name for the generic medication ibuprofen.</p>
<p>Generic medications are available for older drugs, and are commonly offered by your pharmacist as a cheaper alternative to the original branded medication. These drugs are tested to contain exactly the same active ingredients, <a href="https://www.tga.gov.au/publication/australian-regulatory-guidelines-prescription-medicines-argpm">so they produce the same effects</a>. </p>
<p>However, there are a few rare exceptions, such as in <a href="http://www.sciencedirect.com/science/article/pii/S1059131106000033">some epilepsy medications</a>, where drug levels may differ slightly between brands. So in such cases, doctors can choose to prescribe the branded version for its specific clinical benefits.</p>
<hr>
<p><em><a href="https://theconversation.com/explainer-how-do-generic-medicines-compare-with-brand-leaders-1386">Explainer: how to generic medicines compare with brand leaders?</a></em></p>
<hr>
<p>Which medicine name your doctor writes on you prescription - brand name or generic - can <a href="https://www.mja.com.au/journal/2011/195/11/what-s-name-brand-name-confusion-and-generic-medicines">often be a lottery</a>. </p>
<p>If your doctor writes a prescription for a brand name, your pharmacist may offer to substitute this for an equivalent generic drug. So, people often leave the pharmacy with a medication name or package that bears no resemblance to the prescription.</p>
<h2>Potentially confusing for patients</h2>
<p>The main problem with all these multiple names is the potential for confusion, especially for those most likely to use multiple medications - <a href="http://journals.lww.com/americantherapeutics/Abstract/publishahead/Error_in_Drugs_Consumption_Among_Older_Patients_.98899.aspx">the elderly</a>.</p>
<p>As a result, patients are at risk of not understanding which medications they are taking or why they are taking them. This often leads to doubling-up of a certain drug (taking two brands of the same medication), or forgetting to take them because the name on the package doesn’t match the script.</p>
<p>This problem of some patients’ poor medication literacy significantly affects doctors, nurses and pharmacists, who need to know which medications people are using. While our own GP may have your list of medications, often we visit multiple doctors who won’t have access to these list (different GPs while on holidays, emergency departments or specialists). If patients doesn’t know their medications, neither will doctors.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168541/original/file-20170509-11023-o7zd95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many elderly patients are confused about the names of their medications.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>An advisory group for Australian pharmaceuticals, well aware of the dangers this confusion can cause, and as far back as 2005, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/5B47B202BBFAFE02CA257BF0001C6AAC/$File/guiding.pdf">promoted the use</a> of prescribing and labelling with generic terms. The US Institute for Safe Medication Practices estimates that <a href="https://www.ismp.org/newsletters/acutecare/articles/20070809.asp">25% of medication errors</a> result from name confusion.</p>
<h2>Why do doctors use brand names when prescribing?</h2>
<p>In a busy clinic running half an hour behind, the generic name of a medication is often the last thing on the doctor’s mind. There are thousands of medications and even the most diligent doctor can’t remember them all. </p>
<p>Pharmaceutical companies have marketed brand name medication to both doctors and (in some countries) consumers, so they are far more memorable and palatable – for instance Viagra, rather than the generic term sildenafil.</p>
<p>But when doctors rely on using brand names in conversation and prescribing, this can cause confusion. Doctors using branded prescribing can lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307571/">serious medication errors</a>. This may be due not knowing the active ingredients in those medications, or mixing up brand names, which are becoming increasingly difficult to recognise when written in doctor’s handwriting.</p>
<p>So, to avoid confusion, medication errors and allowing for patient control over purchasing decisions, we <a href="http://onlinelibrary.wiley.com/doi/10.1111/imj.12805/full">recommend</a> doctors use generic terms when prescribing unless a specific reason exists.</p>
<h2>How does this affect me?</h2>
<p>Everyone uses medications. The key issue here is autonomy. A script that contains the generic term for a medication allows that person to decide exactly what type of medication they wish to purchase, rather than that be influenced by what brand the doctor writes on the script.</p>
<p>When language excludes (for instance, by being complex or relying on jargon) or confuses, it restricts our autonomy. At present, the language of medications may have two, three or ten words for each drug, and the words we use are often influenced by pharmaceutical marketing and what a doctor prescribes. </p>
<p>The greatest effect of this budget announcement may be the chance to simplify this language to a singular generic drug term, to reduce confusion and allow us to be more involved with our medication decisions.</p><img src="https://counter.theconversation.com/content/77093/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Grant does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A push towards prescribing generic medications rather than their branded equivalents, as flagged in the budget, may have benefits beyond simple cost savings.Matthew Grant, Research Fellow, Palliative Medicine Physician, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.