‘Head to Toe’ Nonprescription Drug History
Pain—whether acute or chronic, malignant, or nonmalignant—is a subjective experience. The clinician must know the cause of the pain and its natural history before it can be appropriately managed (with or without drugs). Similarly, before a treatment plan can be devised, pain subjectivity must be translated into an objective measure employing a variety of single or multidimensional assessment instruments. When these instruments are inappropriate or cannot be used, the clinician may need to rely upon his physical assessment skills to assist him/her in more fully characterizing the patient’s pain. Whereas these assessments are important within the context of formulating a treatment strategy, an often overlooked criterion for medication selection is a patient’s prior experience with drug therapy; especially a specific opioid or non-opioid medication. Whether use of a specific drug was associated with efficacy, lack thereof, or an adverse effect is an important piece of information that can be used in making therapeutic decisions. Taking a complete and careful medication history is the accepted approach to determining a patient’s past experiences with various drugs.
IThe most important components of the medication history include prescription drugs, nonprescription drugs, drug allergies, and the use of caffeine, alcohol, and tobacco. Whereas the assessment of prescription drugs is fairly straightforward (e.g., drug name, indication, dose, directions for use, duration of use, efficacy, adverse effects, adherence, etc.), it becomes more problematic when a busy clinician has only a few minutes to assess the use of nonprescription drugs which comprise approximately 100,000 products in over 80 categories.
The efficiency and effectiveness of the clinician in conducting the history (and eliciting useful information) is in large measure dependent upon his/her verbal and nonverbal communication skills. As daunting a task as it may seem; there is an efficient way for the busy clinician to assess the self-medication behaviors of the patient. This method borrows from the familiar review of systems (ROS) component of the medical history. Instead of asking questions about complaints involving various organ systems (from head to toe), the clinician asks a series of open-ended questions involving major drug product categories, again going from head to toe. Before starting, be forewarned not to use the term “over-the-counter” drugs as a synonym for nonprescription drugs. Many patients may not be familiar with the term or know its meaning. This fact was borne out nearly two decades ago in a study where only 25% of participants interviewed were able to properly define the term “over-the-counter.”1 It’s probably a fair assumption that many people may still be unfamiliar with the “OTC” term particularly given the changing demographics of the United States. The changes in the ethnic and social landscape, along with literacy issues, pose additional challenges for clinicians and their ability to impact the health and wellbeing of their patients.
When it’s time to interview the patient for nonprescription drug history, tell him/her that you will be asking about major product categories and that you will start with their hair and scalp and work down to their feet. Selected body systems and representative product classifications typically assessed include:
- scalp (medicated shampoos, dandruff or seborrhea products)
- head (simple analgesics for headache)
- ears, eyes and nose (otics, ophthalmics, and nasal drops and/or sprays)
- oral cavity (products for oral lesions, sore throat, teeth/gums)
- skin (acne care products)
- lungs (cough, congestion, or cold products)
- abdomen (antidiarrheals, antacids, laxatives)
- rectum (hemorrhoidal/anal fissure products)
- GU (contraceptives, feminine hygiene products)
- feet (products for athlete’s foot, corn, calluses or bunions)
Importantly, the clinician should also ask about vitamins, supplements, and herbal preparations given their ability to potentially interact with prescription and nonprescription drugs and/or precipitate adverse effects.
In addition to the name of the product or preparation, the clinician should also ascertain the reason for use, doses used, duration of use, whether the drug was effective, and the presence or absence of adverse effects. Many nonprescription products contain multiple ingredients—some of which may be unfamiliar to the clinician. He/she is advised to consult the appropriate primary or tertiary reference sources and/or engage the expertise of colleagues including pharmacists and dietitians.
The aforementioned head to toe approach allows the busy clinician to rapidly and efficiently assess many of the major nonprescription drug categories and thus reliably determine the self-care practices and behaviors of the patient. This information will provide one more piece of the puzzle that, when completed, will form the overall management plan for the pain patient. The ultimate goal, as always, is to ensure that the patient reaps the full benefits from their treatment.