A Prescription for Adolescent Medicine Misuse
Mary Poppins did it with a spoonful of sugar, but it turns out that to “make the medicine go down” can be a tricky business indeed when you’re dealing with millions of reluctant little sick chicks who need to take it.
It can be a serious problem for adults too, of course, especially for the elderly, who tend to amass prescriptions from multiple sources--prescriptions that sometimes interact with each other and cause physical and psychological problems.
But the problem with children and teen-agers has largely gone unnoticed, even though it too can often be dangerous, occasionally fatal. According to Louis W. Sullivan, secretary of the Department of Health and Human Services, of the estimated 13 million youngsters who need to take prescribed medicine in any two-week period, nearly half--about 46%--are taking their medicine the wrong way.
Researchers came up with this number after reviewing dozens of studies. In addition, they found that adolescents were the most likely to make mistakes, although the problem exists at all ages, and that “the tendency toward not following treatment guidelines holds true even when the medicine is for serious illnesses such as cancer and kidney transplants.”
They also found that almost 5% of all pediatric hospital admissions were related to reactions to or improper use of medicines and that nearly half were serious or fatal.
Sullivan, along with Frank Young, commissioner of the Food and Drug Administration, and Paul Rogers, chairman of the board of the National Council on Patient Information and Education, last week issued guidelines for parents, doctors and children to help solve what they are calling “America’s ‘other’ drug problem.”
A report prepared by the council, a nonprofit organization supported principally by the prescription-drug industry, identified some specific ways medications are misused, with some suggested methods of countering them.
Young, in remarks accompanying the release of the report, noted that the over-the-counter drug problem is also knotty but that manufacturers of those medicines--mostly for colds, fevers, rashes and stomach upsets--are currently working with the FDA to make directions clearer and measurements more exact.
An article in the FDA magazine, the FDA Consumer, cited a study conducted at the universities of Michigan and Rochester in which 3,900 medication decisions made by 500 mothers over a nine-month period were judged by a panel. The panel found that the parents did only slightly more good than harm in dosing their sick kids.
One would think that prescription drugs would be more carefully administered, but parents are apparently no more likely to read a doctor’s directions than they are those on the back of a box of cough drops, and instructions from physicians and pharmacists are not notably adequate.
The report found that medicating mistakes centered on four major categories:
* Stopping a medicine too soon. Grown-ups do this too. The minute they feel better, they stop taking the medicine. The minute the kids feel better, the parents stop giving the medicine. This can be a serious mistake with serious consequences.
Take antibiotics, for example. The child feels better, and the infection appears to have cleared up. However, if the medicine is stopped too soon, not only is the child vulnerable to re-infection, but the organisms that have survived the first onslaught of the antibiotic will, in the best Darwinian tradition, likely have built up a resistance to the medicine so that the next infection will be much harder to stamp out.
The specialists also cited anti-epileptic medicines, which may need to be taken even during seizure-free periods to prevent a recurrence of the attacks.
* Not taking enough of a medicine. Doses may be skipped or forgotten. Medicines that must stay in the blood at a specific level in order to be effective--medications for people with asthma, for instance--will not work properly if they are not given promptly and precisely around the clock. This may mean waking the child up for medicine at least once a night. Any parent whose asthmatic child is sleeping peacefully at last simply doesn’t want to wake him or her. (One study cited in the report found that among patients required to take the asthma medicine theophylline every eight hours, compliance was poor--there was only 25% adherence. Compliance was much better when once-a-day doses were provided.)
The report also noted that liquid medicines cause special problems. If they are not shaken, for example, the active ingredient may not get into the spoon. What’s more, the measurements may be inexact.
* Refusing to take a medicine. Studies found a variety of reasons for this--including objection to the taste and bothersome side effects.
As another factor, the report cited “a covert expression of parental resistance” that led to refusal of the medicine.
* Taking too much of a medicine. The if-a-little-is-good-more-is-better school of dosing is a serious medical problem among adults as well as kids more frequently with over-the-counter medications than with prescription drugs.
Parents, the report found, also may be overly casual in giving children small portions of over-the-counter medicines prepared for adults. Children are not just smaller versions of adults, and sometimes adult medicines (cough and cold preparations, for example) are suspended in alcohol, which can be particularly dangerous to children. Children may react in vastly different ways than adults do to certain medicines.
Parents come in for the most criticism in the report--in not seeing to it that their children take the medicines properly, regularly and religiously--but physicians, pharmacists and care-givers also are faulted for failing to talk to the children themselves and explain adequately the importance of taking medicines the right way. “The parents can hear, but they should be talking directly to the kids,” noted Robert M. Bachman, executive director of the council.
Sidney Wolfe, a physician and director of the Public Citizen Health Research Group, said a better approach would have been the printed inserts that were scheduled to be required in many prescription drug packages in the early 1980s until the regulation was killed by the Reagan Administration. The council, formed shortly after that action, “is an inferior replacement for a guaranteed automatic flow of information to the patient,” Wolfe said.
Bachman said the council’s report did not deal specifically with the problems involved in testing drugs for pediatric use. “It is a complicated problem,” he said. On the one hand, especially in drugs specifically targeted for diseases of children, it seems essential that there be full and appropriate testing. However, the ethical considerations involved in using children in research protocols makes such testing an especially difficult and expensive proposition.
The FDA is wrestling with regulations that would permit testing of drugs to treat pediatric AIDS on children without waiting for thorough tests to be completed in adults. AIDS researchers have expressed concern that lives are being lost because of the delays caused by the current rules.
