Friday, August 11, 2006

Online drugs

Ran into an article this morning from BBC news. It tells the story of a 64-year old woman who self-diagnosed herself with chronic fatigue syndrome (I feel like I've been having those symptoms this week).

She went to the internet and purchased a medication -- without a prescription -- and is now losing her eyesight because of cateracts and glaucoma (side effects of this prescription med without physician oversight).
Writing in the Lancet, the researchers said: "The expansion of the internet is relentless and, from the perspective of patients seeking information, in the main positive.

"However, the online availability of controlled and uncontrolled drug therapies needs to be carefully monitored."

Mr Fraser added: "If you look online it is extremely easy to get hold of anything you like. Obviously, you do not need a prescription.

"If you are going to access medicines on the internet you are gambling with your own health."

He said doctors needed to be more aware of the issue and to make sure that they asked patients whether they were taking any medicines purchased over the counter or online.
I think all that is good stuff except for the last paragraph. I am definitely aware of the issue. However, it's going to be next to impossible for me to "police" this as they are asking.

People can tell me if I'm wrong, but, if my patient doesn't think that I'm adequately treating a certain condition, I think my patient would be reluctant to tell me if she/he purchased a medication on the internet -- just out of embarrassment. This doesn't only apply to prescription med purchases on the internet, but also herbal and alternative treatments.

I think I have set up an environment where I think my patient would be able to open up and tell me about this, but putting the burden on docs to police this information is not fair. Communication is a two-way street and is essential for ideal medical care.


Anonymous said...

Often patients are unwilling to mention these kinds of medicines. On the other hand, I think there's a way one can ask if they're taking other medications: the old line our school taught was, "Are you taking any other over the counters, herbal medications, or anything else we haven't discussed yet?" When I have time to use it, it often gets results, like, 4000mg of ibuprofen for the last week. :)

Dr. A said...

One of the things that I do or my staff does is ask the patient to put in a bag all the bottles of pills that they are taking no matter what it is. Sometimes this works, sometimes this doesn't.

Dinah said...

Never asked anyone about stuff they get specifically over the internet, but I do routinely ask people about vitamins/alternatives/herbals...amazing what you find out when you ask. Then again, I ask folks in their 80's if they've ever used street drugs...never gotten a yes, but plenty of people in their 60's have been smoking pot daily for the last 30 years.

If you wear the tie, skip the suspenders, call them by their last name, and have a gentle and accepting demeanor, you can ask people pretty much anything without offending them. I doubt, however, that people are honest on those checklist forms that are handed out by staff to speed up the H&P.

Maybe have each patient assigned a logo when they order their online narcotics?


Dr. A said...

Maybe they are buying logos on the internet without telling me. Hmmm... Interesting.

Anonymous said...

I agree that you can't police people.

One reason people might hesitate to tell you what they are taking is the fear of losing you as their doctor. It's like a child's fear to admit a wrongdoing to his/her parent . . . The difference is that a parent will rarely abandon a child, but there is no guarantee that your doctor will keep you as a patient.

Dr. A said...

Good point. Doctors terminate the dr/pt relationship (DPR) for all kinds of reasons these days. I understand the hesitation a patient has on believing the DPR may be jeopardized.

Mother Jones RN said...

Many patients tell me things they are afraid to tell a doctor, including things about their medications. Many patients view a nurse as an "angel of mercy," while viewing doctors as powerful authority figures. It’s all a matter of perception. I think difficultpt has a very good point. People are afraid to admit to their doctor that they are buying medications over the Internet.

Dr. A said...

Actually, the best history (aka information) I ever got was when I was a medical student -- mainly because the resident always gave me ALL DAY to workup the patient and eventually you will get all the information on a patient. There were times I "scooped" the resident by obtaining some little pearl of information that the resident couldn't get. Of course, I got the lecture never to make the resident look bad -- particularly in front of the chief resident -- apparently, this is poor forum. Oh well...

Wrkinprogress said...

Maybe it would help to explain why you need to know if they're taking supplements, herbs, or internet prescriptions. Most people have no clue that these things could affect their other medications in a negative way.

Dinah, what do you say to people who tell you they've been smoking pot for 30 years?!? lol I guess that is going to be an interesting feature of senior citizens in the years to come, with the first of the baby boomers hitting 60 this year!

Cathy said...

You know what Dr. A. and this may seem brass but I guess thats my mood today.

People have to take responsiblity for themselves. It shouldn't be your job to try and force out of someone what they may be taking, I wouldn't do it. I guess maybe one option would be to put up a sign in the exam rooms,telling people to be sure and tell the Dr. (all) medications you are taking. That might get a few of them to tell you.

To be honest, if they are doing this and even tell you they are, whats to say they won't continue? Especially if they think it is helping. You may be better off not to have that knowledge in the long run. Does that make sense? You can't be responsible for something you have absolutely no knowledge of.

You know 5 years down the road they could get cancer from those drugs or something. I could just hear some of them saying "Yes, my doc has known for 5 years that I was taking this."

Count on me today for the pessimistic view!

NeoNurseChic said...

I agree that communication is a two-way street, but I also feel that it is VERY important to ask a patient about herbals/vitamins/supplements and over the counter meds when getting a med history. I like how Alice put it about asking about "anything else we haven't discussed yet" as an additional... So many people out there don't believe that herbs or vitamins can be dangerous and don't remember to tell their doctor about the use of these. It isn't even a matter of not taking the responsibility for communication - these could be excellent patients - but it is about misinformation and naivete about the actions, contraindications, risks and possible dangers of meds that you can obtain without a prescription (including herbs, etc...)

Yes, it's a 2 way street, but some people don't even know where to begin. Of course I know to name the drugs I'm prescribed, but what if I forget to mention the aspirin a day I decided to start taking on my own? (Being a hypothetical, 80 year old lady there) Or the St. Johns Wort? I know you can think of instances where not knowing that a patient is taking these things can be very, very dangerous. It's important to expand the question to more than just prescribed medications to also include any herbs, vitamins, supplements, or over the counter meds a patient may be regularly taking...and now apparently, anything they take that they ordered off the 'net, too.. LOL there going to be a pay increase for asking all these questions? That's a lot more writing! :)

Anonymous said...

I agree with Cathy - it's not a physician's responsibility to squeeze a patient for information. You can ask the questions ... you can warn that the meds you're prescribing could cause problems with other things, if they haven't been candid with you, but really, that's all you can do - other than make sure there's lots of room for them to feel safe to brings things up on their own.

I think embarrassment is a big reason that a lot of people stay mum when asked "are you taking anything else?" ... and for the exact reason you mentioned.

Now, I've never bought meds over the internet in any way, but if I take something on my own that I know is a "no no" ... I'm not likely to be candid about it unless I'm asked, but if I'm asked, I will be honest.

Also - I relate to what Mother Jones said - there are definitely things I can tell the nurses that I'd have a hard time telling a doctor. The "authority figure" statement is right on.

Great post, Dr. Anon!

HP said...

A hard line to take maybe but if you're going to buy unprescribed drugs over the internet, then you have to wear the consequences. The implications of taking such drugs without medical supervision is plain scary.

I know people who take unprescribed steroids (prednisone) sourced from overseas. I truly understand their frustration in that they have as yet medically undiagnosed symptoms and are getting nowhere with a diagnosis and I can comprehend the fact that the steroids makes them feel better (being on this drug myself) but that in itself doesn't prove anything - because, in the case of this drug, it makes anything feel better! Not only are the longterm implications of steroids are considerable, taking steroids will only make diagnosis more difficult because it masks so much.

I think you're right when you say most people would not confess to taking a drug such as this to their doctor for fear of jeopardising the doctor-patient relationship. I definitely think the doctor should always ask and probe a little, particularly for those patients like my mother who wouldn't even consider a herbal supplement a drug and therefore not mention it, but ultimately everyone has to take some responsibility for their own actions.

It's me, T.J. said...

People have been self-medicating for thousands of years.

It's a given.

I think that the "sack of stuff" and proper terminology and phrasing is the best solution.

A lot of people do not think that herbs, aspirin, nose drops, decongestants, etc., are "actual medications". The main reason is because it doesn't have a prescription associated with it.

And then there are the elderly who don't recall every thing that they may have dragged out of their medicine cabinets the past week.

I think it would behoove all involved in medicine today to try to glean as much information as possible.

I'm not looking at it from the policing point of view so much as the liability aspect.

If there were some adverse reactions/complications or dire misdiagnosis, whose ___ would be in the sling?

The patient's?


Dr. A said...

Warning! Rant Alert! I really didn't want to go there, but since TJ is giving me the softball, I guess I'll take a swing and see what happens.

Personal responsibility has already mentioned in these comments. At least here in the United States, the victim mentality rules. It's always someone else's fault. When it's someone else's fault, then you must get back at them and sue.

I can just see it now, "Dr. A. The reason Mrs. Z got glaucoma is not because she bought prescription drugs on the internet. It's because YOU did not adequately address her chronic fatigue syndrome. If YOU did that, then none of this would have happened. We are seeking $50 million in pain and suffering."

What? You think I'm nuts? (Well, I am.) But, why do all McDonalds coffee cups have a warning that the coffee is hot? Why do doctors order extra tests that in their gut, they know are not needed? It's all about liability.

So, in answering TJ, some attorney somewhere would take on this case and try to show that all of medicine is responsible for this patient's glaucoma -- not the patient herself. Whew! I have to go now and calm down somewhere.

HP said...

Breathe, Dr. A., breathe!!!!

The system is silly and it's not just related to the medical world.

Here, some man got a huge compensation payout (in the millions) because he dived into water, without checking the depth first, and hit a sandbar. This payout, and others like it, make insurance premiums for councils, lifesaving organisations. sports organisations etc etc. so high that activities have to be restricted or stopped.

Now, while I feel sorry for the guy and his injury, is it really anyone's fault but his own? Can the council/lifesaving organisation be held negligent for not having signposted every change in water depth on the beach? For not having signs about checking the water depth before entering the water? Obviously some people think so.

That rant is catching!

NeoNurseChic said...

This is exactly why I have my typed up medical history that I update as's got my current info on the first page with meds I'm taking, doses, etc...including anything OTC or the B vitamin supplement I take daily. I also have all of my doctors' names and phone numbers on this history because I think it's important for my own life that all of this be on there. I take personal responsibility VERY seriously.

OTOH, I've been seriously screwed over by a couple of docs in the past that have prescribed things I should not have been on. I cannot personally look up every single detail of every single med that I'm prescribed to make sure that it doesn't have anticholinergic properties or any other thing that I can't have. I was really upset when my neurologist prescribed a major anticholinergic TCA for me almost right after I had the major anticholinergic reactions. My psychiatrist was the one that told me to stop taking it and informed me about the properties. So even though I try to be very informed and everything else that I do, there are still times when I've run into dangerous situations. It's very frustrating...

HP - I did not realize that people bought steroids over the 'net to treat medically unexplained symptoms. That really upsets me. A lot of the cluster headache sufferers I know also do not truly realize the damage that these steroids can do because they "feel" fine. A lot of the bad effects of these steroids are not felt until it's too late, though! Having been one that's gotten avascular necrosis from the steroids, I really do feel very sad to hear that people are buying them on the internet. What will they do if they get something like AVN and end up disabled? Do they even realize that they could get AVN from taking steroids? It's actually not that unlikely a scenario... That whole thing just really bothers me!

Dr.A - if you want to relax for a second, go out and look at the sky...then get back to me at this post on my blog. The sky is absolutely gorgeous here tonight!! Also, I have all kinds of comforting junk food that I just got tonight on a study break. I'm willing to share. LOL

Take care,
Carrie :)

Dr. A said...

Interesting observation foofoo5. I would think that an anesthesiolgist may have a more difficult time getting accurate information because the consequence is possibly postponing of a patient's surgery.

I agree that the possibilities and the "what ifs" are endless. I do admit that if they don't think it's important to reveal what they're taking, then I failed in communicating how important it is that I know what they're taking.

But, if I specifically ask as you suggest, and they do not tell me, is it my responsibility to keep asking the same question differently until I get the info I want? It's just so confusing and frustrating sometimes.

Carrie, Thanks for the invite. I'll be over in a little bit.

Dreaming again said...

In light of this conversation ...if someone finds the magical internet cure for lupus or myasthenia gravis ...point me in that direction.

*ducking and running*

HP said...


When people experience symptoms that interfere severely with their lives, alongside medical tests that are suggestive of, let's say, adrenal failure, you can understand the desperation that might consider someone to take this action when no one else seems to be acting upon it - but that's the flip side to Dr. A's question I guess. Some people have to battle with less than efficient health systems and less than effective doctors (sorry, Dr. A!) Having said that, I'm in no way condoning self-prescribing. My sister lost two hips to AVN, possibly associated to steroid, so the fact that people can buy steroids (and other drugs) without prescription really concerns me.

In the same way your comment about being prescribed drugs contraindicated for your condition reflects the other side of the coin. The doctor has an equal responsibility to make sure he/she is aware of all the medications the patient is taking. I too have have been prescribed drugs I should never have been.

What it really comes down to in the end is team work. I feel certain my doctor would refuse to treat me further if I self-medicated and rightly so. Similarly. if you can't confide what you're taking to your doctor or get to the position where you feel you need to self-medicate, it's time to get a new doctor.

Anonymous said...

Interesting that so many think a patient would reveal to a nurse before a doctor because of authority positions.

I'm just the opposite. My doctor's nurse gets to learn my weight, temp, and bp. Other than that, I don't give her the time of day. I've got a confidential relationship with my doctor, not his nurse. I go to see my doctor for help and guidance, not his nurse.

Not to imply that there's anything wrong with her, just that my personal private information isn't any of her business. If it's something I feel uncomfortable about why would I tell the nurse? She's not my healthcare partner - my doctor is.

Dr. A said...

Hello incaseiforget and thanks for stopping by. Getting back to my good 'ol med school days -- The reason I was able to get some interesting information and the reason MJRN states nurses can get some interesting information -- is that those two groups have a precious commodity that I no longer have as a practicing doc -- and that's time.

On rotations as a med student, there were times that I spent most of the day with the same patient. And, nurses for between 8-16 hours a day, sometimes spends most of this time on the same floor and/or with a certain patient. A general rapport and comfort zone is built up during this time.

In the hospital, pretty much everybody from docs, to nurses, to med students, to physical therapists, to lab personnel, to other hospital staff -- wear lab coats. So, pretty much without name tags, it's difficult for a sick patient to keep track of who is who.

(I've lost my point again, let me try to find it).

My point is that sometimes it's not about who the authority figure is in a certain setting. Sometimes it's the person who establishes the patient rapport (ie - patient trust) who is able to help the most by obtaining key information. We're all on the same health care team and we work together, hopefully, in the best interest of the patient.

ipanema said...

It is such a danger self-diagnosing and easy access to some medicines online isn't helping. That's the sad thought - monitoring. Whoever is in charge isn't working hard enough to protect people from harming themselves.

I think there should only be certain meds that can be purchased online and that a monitoring board be put up. I hope this helps. We know for a fact that people can cheat online in whatever they do.

Thanks for this good post Dr. A. By the way, one can feel your 'chronic fatigue syndrome' through your posts (you sound serious/lethargic in your recent posts). Relax, find time for yourself. Hope you're well.

Cathy said...

Dr. A. I hope that even though you are on call that you are finding some time to rest this weekend.

We are going to have to doctor you if you don't take better care of yourself.

Sarebear said...

What about the Archer's Coconut Macaroon cookies I take, once a day, for my IBS? Hee.

My dad saw a newspaper article on this working, so he mentioned it. I say, hey, if a cookie a day keeps the %$#ts away, go for it. Plus, even if it's psychological, I'll take THAT, too. In the END (hee), it's the results, that matter. At least, with this cookie prescription.

I may be humorous here, but hey, I suppose I ought to discuss ANYTHING I'm doing to improve my conditions, with my doc. But this one would be kinda embarassing . . .


Sarebear said...

Oh, I must say (my anxieties are making me, again) that I'm not this gullible person who goes for things like this . . . I'm actually very intelligent. But I guess it goes to show to what wierd things (although in this case, a sweet one, it can't hurt, esp. since I'm exercising . . .) people will turn, when there's no relief.

Cause, IBS sucks. Rather interferes with life to a large degree, although I must say, it's minor compared to Carrie's headaches (not that we have to compare severity of ailments, butt I also know that well my anxieties are making me again lol.)

Anyhoo. I'm not an herbal remedy person either, although I DO have a bottle of enteric-coated peppermint pills sitting around, that I haven't ever tried yet, for the IBS . . . . spent many hours scouring information, and the ONLY interaction problem the peppermint has is with a prescription IBS med, which I think is for the other side of IBS than I have, and has too many side effects for me to want to take anyway.

Unlike the caraway seed oil/extract whatever, which could potentially abort a fetus, that is sometimes used to help IBS . . .

It's a minefield!!!! Anyway, I'm not an herbal supplement person either, and I guess I'd rather take a cookie than admit that I was one of "those" people who try herbal supplements . . . and so the bottle stays untried.

None of you know how much I am NOT one of "these" people that go after odd and/or herbal remedies, and so I guess I wanted to say that I wasn't, except maybe I am, but . . . suffering leads to (why is Yoda going thru my head right now!!) all sorts of places, even for intelligent people.

Anyone want a macaroon?

Flashtrigger said...

Asking is one thing. What a patient doesn't want to tell you is another. Asking a doctor to be held responsible for patients in this manner is like asking a bartender to be held responsible for his patrons. It's not logical, and it's not fair to the professional. While I try to tell my doctor everything "pretinent" I have omitted things before...and as stupid as that can be, a physician can't be a mindreader and shouldn't be expected to even try.(No offense to you at all, I just don't like when doctors are held unduly responsible for such things.)

Dr. A said...

Angry Angel, good points. I know good screening doesn't take place. I've seen it myself -- or not seen it as the case may be. That's something that frustrates me (don't worry, no rant alert this time).

To Everyone: Thanks for your concern about me. As a weekend update, call has been ok. Busy, as usual, and I've been trying to catch some winks here and there. ipanema is right, the energy level has been low. I also have my Alzheimer's talk this week. I'm working on that this weekend and will blog about it soon.

NeoNurseChic said...

Speaking of ordering meds online and things like that, I guess there is one further story that I must share. My neurologist makes me tell this story every time he has a new doctor in the room for my appt. The last time, it was this new adorable headache fellow up from Baltimore.... ;)

So anyways...last year this rage went through the clusterheadache community to try Kudzu for CH. You could order it online and you'd take it 3 times a day. Honestly, in the week and a half that I took it, I had a great headache week. Almost no CH's...migraine was better...kinda like a month or so ago with the methotrexate. There were no contraindications for this med, and I did ask my neuro if I could try it before ordering it, and he said he didn't see why not. There truly was no evidence as to why not...

Until...I was doing my clinical rotation in the ER one night 3-11, and I went home after to my apartment across the street. I remember laying in bed listening to Conan O'Brien do his monologue when I thought my nose was running. My initial instinct was to put my hand up to my face and I pulled my hand away and it had blood on it. I'd had sinus surgery a month and a half prior, so nosebleeds were actually something I'd struggled with quite a bit. I'd even gone to the ER before for a bad nosebleed since the surgery. But it had been awhile and for 2 weeks there had been no nosebleeds. The only change was that I'd started taking the Kudzu...and it was literally a month and a half after the first surgery.

So I thought to myself, "Crap...not another stupid bleed." And as I sat up, my nose gushed like a faucet turned on full blast. In seconds, blood was everywhere. I hopped out of bed and grabbed my box of tissues - went all the way through those trying to just put pressure and then went to the bathroom and held a washcloth against my nose. Had to rinse that out 3 times....blood was everywhere. I picked up the phone, dialed the ER and got my best friend James to come over. I was afraid that I wouldn't make it to the ER myself. He cleaned up some of the blood in the apartment and we got me into the ER.

As I was back in a room, the bleeding kept going on and on. I filled an entire large yellow bin full of 4x4s saturated in blood. And at this point, I was coughing out golf-ball sized clots. My friend Jim was sitting with me and rubbing my back to try to relax me because the clots were scaring me half to death - as was the sight of all that blood (and I've seen a lot of blood doesn't bother me). The ER doc was great when he said he needed to examine me, and knew that pulling away the 4x4s against my nose would cause another gush of blood...He said it was okay and really kept me very calm while I started coughing out more blood. This was like the nosebleed from hell.

Then ENT came down and the resident kept trying to suction blood out of my nose so he could see where the bleed was coming from. He was using his little scope thing and all of this was making me really wish to be knocked out. He was doing fine with it all, but imagine just going through all of that and then being suctioned multiple times and having a camera jammed up your nose and down your throat...all without any kind of pain medication or sedation. Finally he thought he saw the vessels and he packed my nose.

I had emergency surgery that night to cauterize off NO specific vessels causing that bleed. My ENT told me later that the inside of my nose looked like mush. Blood was oozing from everywhere. So they consulted hematology who ran a bunch of lab tests. Other than having a high Factor VIII (which was irrelevant in a bleeder...), they said I was fine.

But wouldn't you know that hematologist ripped me a new one. He really was rude to me...telling me that what I'd taken was like going out and eating a weed. They took away my meds and wouldn't consult neurology as now I had the worst headache ever. Instead they were trying to treat it with IV morphine, an it kept getting worse. Well...that's because I'd been well-controlled on lamictal, the Kudzu and a few other things and they stopped all of them! It's any wonder that I didn't have a seizure. But this doctor was truly mad at me that I'd taken this herb.

Since then, there have been no reports of any kind of adverse effect to Kudzu except mine. My neurologist said he did a search on the internet and only came across a story that a friend of mine had written about MY reaction to Kudzu. LOL My neuro really wanted me to try it again because of the relief it brought, and I'd considered it but then once we found out that some of my other hematology panels really ARE out of whack, he said he wants hematology's "blessing" first...

I highly doubt that hematology is going to give any blessing for me to take what they consider to be a weed. But it sure as hell did help the headache. ;)

And Sarebear - no comparing pain or conditions....I don't allow that in my world. :)

Doc Shazam said...

Since when is taking a history considered policing? all you are doing is gathering information.

Why should asking about Rx meds be any less comfortable than asking about sex or illegal drug use? It's part of the package of being a doctor. It's your job to ask.

Anonymous said...

Good grief... haven't they learned yet that nobody can control another person and that if a person is convinced they have something no matter what anyone else thinks they are going to do what they want... they are treating people as if they don't have will's of htere own give me a break... sometimes i think docs are glorified babysiters for the stupid *rolls eyes*

like there really going to tell you ha

Dr. A said...

Hi That Girl! Thanks for stopping by. Hope you're able to link this post/discussion.

Shazam: The issue is not me taking a history. If you review the post and comments, the real issue is when I ask and the patient does not tell me for whatever reason.

Am I obligated to keep asking until I get the answer I want? Some people make me, as the doctor, ultimately responsible for all prescription meds my patient takes whether they obtain it from me or the internet.

So, if my patient doesn't tell me after I ask, what obligations do I have to press the issue, or is the patient ultimately responsible for potential problems from choosing to get prescription drugs or herbal medicines from the internet or anywhere else?

Dr. A said...

Here is the post That Girl is referring to. I was quite surprised when I read it. I encourage you to check it out and comment as you see fit.

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