The Pharmacist’s Role in Self-Care Monograph 1 Self-Care ...elearning.pharmacist.com/Portal/Files...Self-Care for Gastronitestinal Disorders Monograph 2 Self-Care for Pain Monograph

The Pharmacist’s Role in Self-Care Monograph 1

Self-Care for Gastronitestinal Disorders Monograph 2

Self-Care for Pain Monograph 3

Self-Care for Fever, Cough, and Cold Monograph 4

Self-Care for Skin nad Mucous Membranes Monograph 5

Herbal and Dietary Supplements Monograph 6

Selection and Use of Home Diagnostic Products Monograph 7

A continuing pharmacy education activity for pharmacists

Supported by an independent educational grant from

Activity PreviewMore than 75% of Americans use over-the-counter (OTC) products to treat common, everyday ailments. These consumers choose from a staggering number of single-entity and combination nonprescription medications, herbal products, and dietary supplements. Pharmacists are the logical health care professionals to assist patients with self-care decisions, because pharmacists are available at the point of purchase and are the only health care professionals who receive in-depth formal education and skill development in nonprescription pharmacotherapy.

This monograph provides an overview of the pharmacist’s role in self-care. Participants are introduced to the evolving OTC marketplace and emerging economic influences on self-care. The “QuEST” process—a framework for identifying a self-treating patient’s chief complaints quickly and accurately, and developing and proposing an appropriate treatment strategy in a time-efficient manner—is described in detail. Important components of effective communication are reviewed, with an emphasis on skillful questioning and active listening. Special self-treatment considerations in children, older adults, pregnant or breastfeeding women, and patients from racial or ethnic minorities are discussed. The monograph concludes with tips on making patients aware of pharmacists’ self-care consulting services.

LeArning ObjectivesAt the completion of this activity, the pharmacist will be able to:1. Define the term “self-care.”2. Discuss patient behavior regarding the selection and use

of OTC products.3. Explain why the pharmacist is an appropriate health care

provider to educate patients about self-care practices.4. Describe the pharmacist’s role in assessing and

counseling self-treating patients.5. Outline strategies for assessing patients and counseling

them about the use of OTC products.

AdvisOry bOArdMagaly rodriguez de bittner, Pharmd, bcPs, cdeAssociate Dean for Academic Affairs and Associate ProfessorDepartment of Pharmacy Practice and ScienceUniversity of Maryland School of PharmacyBaltimore, Maryland

nicholas g. Popovich, PhdProfessor and HeadDepartment of Pharmacy AdministrationUniversity of Illinois–Chicago College of PharmacyChicago, Illinois

AccreditAtiOn infOrMAtiOnThe American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the

accredited provider is 202-000-09-246-H04-P. To obtain 3 hours of CPE credit (0.3 CEU) for this activity, complete the CPE exam and submit it online at www.pharmacist.com/education. A Statement of Credit will be awarded for a passing grade of 70% or better. You have two opportunities to successfully complete the CPE exam. Pharmacists who successfully complete this activity before November 15, 2012, can receive credit.

Your Statement of Credit will be available online immediately upon successful completion of the CPE exam.

deveLOPMentThis home-study CPE activity was developed by the American Pharmacists Association.

suPPOrtThis activity is supported by an independent educational grant from Procter & Gamble.

discLOsuresMagaly Rodriguez de Bittner, PharmD, BCPS, CDE, declares no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria.

Nicholas G. Popovich, PhD, has served as a member of the Dr. Scholl’s Foot Health Council with Schering-Plough and a member of the Nonprescription Medicine Steering Committee with Procter & Gamble.

APhA’s editorial staff declares no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria.

This publication was prepared by Cynthia Knapp Dlugosz, RPh, of CKD Associates, LLC, on behalf of the American Pharmacists Association.

PrOvider: American Pharmacists AssociationtArget Audience: Pharmacists reLeAse dAte: November 15, 2009exPirAtiOn dAte: November 15, 2012

AcPe nuMber: 202-000-09-246-H04-P cPe credit HOurs: 3 hours (0.3 CEU)AcPe Activity tyPe: Knowledge-basedfee: There is no fee associated with this activity.

1Otc Advisor: the Pharmacist’s role in self-care

THE SELF-CARE MOvEMENTSelf-care is defined as the inde-

pendent act of preventing, diagnosing, and treating one’s own illnesses without seeking professional advice. Options for self-care include, but are not necessarily limited to, the following categories:• Nonprescription medications (also

called over-the-counter, or OTC medications).

• Nutritional dietary supplements.• Natural products and homeopathic

remedies.• Home diagnostic tests and monitor-

ing devices (e.g., pregnancy tests, home blood glucose monitors).

• Devices for treatment (e.g., first aid bandages, ice packs, nasal strips, vaporizers).

• Dietary interventions (e.g., chicken soup for a cold).A self-care movement has become

solidly established in the United States. The abundant availability of health-related information—especially from the Internet—has helped patients to become more “self-empowered” to address their own health care issues. Factors that con-tribute to a growing reliance on self-care options include (1) the increasing costs of health care, (2) restricted access to prescribers through health management organizations, (3) the high proportion of underinsured and uninsured persons in the U.S. population, and (4) the bur-geoning number of older Americans. Self-care options also increasingly are used as adjunctive therapy for chronic diseases managed with prescription medications; examples include low-dose aspirin therapy for secondary prevention of cardiovascular disease and fish oil (omega-3 fatty acids) for dyslipidemias.

The decision-making process for self-care requires a number of skills. These include knowing:• When and how to treat oneself.• When and when not to consult a

physician.• When diagnostic tests are

appropriate.• When and when not to use emer-

gency health care services.The degree to which individual pa-

tients actually possess these skills varies considerably. Therefore, despite patients’ expanding knowledge base regarding health care, the guidance of an experi-enced health care professional—acting

as a “learned intermediary” to assist patients with decisions regarding self-treatment of common conditions—can be invaluable. Pharmacists are the logical health care professionals to fill this role, because they are available at the point of purchase and are the only health care professionals who receive in-depth formal education and skill development in nonprescription pharmacotherapy.

THE EvOLvING OTC MARKETPLACE

Nonprescription medications com-prise a huge market in the United States. In 2008—the most recent year for which data are available—retail sales of non-prescription medications were $16.8 billion (excluding Wal-Mart sales). As Table 1 shows, the amount of money spent on products in most categories has risen steadily in recent years.

According to the Consumer Health-care Products Association (CHPA), approximately 1,000 active ingredi-ents are used in more than 100,000 nonprescription products available in the marketplace today. On the plus side, this means that a wide array of options are available for managing an increasing number of self-treatable con-ditions. On the minus side, this bounty of choices can be bewildering—if not downright frustrating—for patients. Many products contain multiple ingredients, and patients may not know which active ingredients are most appropriate for their symptoms. Product line extensions and

reformulations are becoming increasingly common, to the extent that a product may not contain the active ingredient or ingredients usually associated with the brand name. For example, Kaopectate is an antidiarrheal product named for its original active ingredients, kaolin and pectin. Kaopectate was reformulated several times and now contains bismuth subsalicylate as the active ingredient. There is also a stool softener product (containing docusate calcium) that bears the Kaopectate name. Similarly, Claritin Eye is an ophthalmic preparation that contains ketotifen, not loratadine like the original product bearing the name Clari-tin. If patients do not read a product’s Drug Facts label carefully, they could inadvertently purchase an incorrect or inappropriate medication. Patients also might inadvertently take two seemingly different products that contain the same or similar active ingredients (e.g., a nonprescription analgesic and a multi-ingredient cold remedy that contains an analgesic), resulting in excessive dos-ing and potentially harmful therapeutic duplication.

CHPA estimates that more than 700 currently marketed nonprescrip-tion products contain ingredients and strengths that previously were available only by prescription. A number of other prescription-to-nonprescription (Rx-to-OTC) switches are pending. As more and more products become available without a prescription, the need for pa-tient education at the point of purchase will continue to increase. Patients may be

Table 1. Sales of Over-the-Counter Products by Category

Sales (in Millions of Dollars)Category 2005 2006 2007 2008Cough/cold and related products 3,548 3,544 3,643 4,104Internal analgesics 2,261 2,342 2,422 2,449Heartburn (includes antigas) 1,144 1,247 1,263 1,240Laxatives 691 708 761 809First aid 590 605 629 649Smoking cessation products 484 501 503 491Eye care 411 422 441 459Foot care 339 352 355 346External analgesics 318 312 317 319Acne remedies 305 318 328 333Antidiarrheals 168 172 177 173

Source: Consumer Healthcare Products Association. OTC sales by category—2005–2008. Available at: http://www.chpa-info.org/pressroom/Sales_Category.aspx. Accessed September 30, 2009.

2 American Pharmacists Association

tempted to try the “latest, greatest” medi-cation—whether or not it is the most ap-propriate choice for them—and they may not consider or fully understand the risk of drug-drug or drug-disease interactions.

There may be a particular oppor-tunity for pharmacist intervention and services if medications used in the treat-ment of chronic, asymptomatic condi-tions—for example, statins—eventually are approved for nonprescription use. The benefits of pharmacist involvement in the care of patients with hyperlipid-emia have already been demonstrated conclusively. In Project ImPACT: Hyper-lipidemia, ongoing interventions by phar-macists (including point-of-care testing) yielded treatment adherence rates of 94%, with 62% of patients reaching their low-density lipoprotein cholesterol goal. By comparison, without the intervention, only 25% of patients were adherent to therapy, and only 8% reached their lipid management goal. Pharmacists could be instrumental to supporting appropriate use of nonprescription statins, by the patients likely to benefit the most.

A Third Class of Drugs?Pharmacists increasingly are being

called on to serve as gatekeepers for nonprescription products. For example, the Combat Methamphetamine Act of 2005 placed a number of restrictions on nonprescription products containing pseudoephedrine, including the restric-tion that products must be stored behind a counter or in a locked cabinet. Some states have taken a more stringent ap-proach, reclassifying pseudoephedrine-containing products as Schedule v controlled substances that may be sold only by licensed pharmacies. Moving these products behind the pharmacy counter brings patients into contact with pharmacy personnel; these interactions present an opportunity for pharmacists to question patients about their symptoms and ensure that the product most likely to provide relief is selected.

In August 2006, the emergency con-traceptive Plan B (levonorgestrel) became the first dual-status product, approved as a nonprescription option for women at least 18 years of age but available by prescription only (in the same packaging) to girls ages 17 years and younger. (The product since has been made available on a nonprescription basis to consum-ers 17 years of age and older.) The

manufacturer (Duramed Pharmaceuticals) agreed to limit retail distribution of Plan B to outlets with pharmacies, with the ad-ditional stipulation that the product must be kept behind the pharmacy counter. Because the pharmacist may be the first and only health care provider consulted for advice about emergency contra-ception, pharmacists can provide a tremendous service by educating women about the appropriate use of emergency contraception and encouraging them to pursue other needed services (e.g., rou-tine contraceptive planning).

Will these changes lead to a new class of drugs that are available without a prescription, but can be purchased only after intervention by a pharmacist? A behind-the-counter (BTC) class already exists in many other countries, including Canada, Australia, New Zealand, and a number of countries in Europe. When dispensing BTC medications, pharmacists typically must ensure that patients meet certain criteria for therapy. Pharmacists also are required to provide education about the proper use and monitoring of the medication.

Regulatory experts in the United States historically have dismissed the idea of a third class of drugs, because creating such a class would require congressional approval to amend the Food, Drug, and Cosmetic Act. But the sentiment in Washington may be chang-ing along with the nonprescription drug market. In November 2007, the U.S. Food and Drug Administration (FDA) conducted a public meeting to obtain input “as it explores the public health benefits of certain drugs being available without a prescription but only after inter-

vention by a pharmacist.” The meeting solicited input on both general issues and specific logistics of BTC dispensing. A report issued by the U.S. Govern-ment Accountability Office in February 2009—updating a 1995 report titled “Nonprescription Drugs: value of a Pharmacist-Controlled Class Has Yet to Be Demonstrated”—examined arguments

supporting and opposing a BTC drug class in the United States. The report con-cluded that pharmacist-, infrastructure-, and cost-related issues would have to be addressed before a BTC drug class could be established.

In-Store Health ClinicsA relatively new innovation in

health care is the walk-in clinic located in nontraditional settings, especially pharmacies and retail outlets containing pharmacies (e.g., grocery stores, mass merchandise stores). These in-store health clinics (also referred to as retail clinics) usually are staffed by nurse practition-ers; they concentrate on offering fast, convenient, affordable care for common conditions (e.g., strep throat, allergic rhinitis, urinary tract infection). Most clin-ics also offer immunizations and preven-tive screening services (e.g., cholesterol testing, diabetes screening); some offer smoking cessation or weight loss counsel-ing. As of August 2008, nearly one third (28.7%) of the total U.S. population lived

within a 10-minute driving distance of a retail clinic.

The proximity of in-store health clin-ics to pharmacies means that patients can have prescriptions filled on the spot. Frequently, the patients who visit these clinics also have nonprescription product needs. These patients are another natural audience for pharmacist counseling about self-care, particularly if clinic staff refer pa-tients to the pharmacist for assistance with nonprescription medication selection.

Herbal Products and Other Dietary Supplements

Patients who use herbal products and other dietary supplements represent another group that could benefit from pharmacists’ guidance. Data from 2000 showed that the United States led the world in dietary supplement use, with 100.4 million Americans using vitamins and minerals every day and 37.2 mil-lion using herbal remedies regularly. The conditions for which Americans were most likely to use dietary supplements included:• Menopause.• Cough, cold, flu, or sore throat.• Allergy or sinus conditions.• Muscle, joint, or back pain.

Many patients are unaware that the FDA classifies herbal remedies and other dietary supplements as foods, not

Many patients are unaware that the FDA classifies herbal remedies and other dietary supplements as foods, not drugs.


drugs. Thus, patients may not recognize that dietary supplements are excluded from the strict regulations that govern prescription and nonprescription drugs. Dietary supplements generally do not require premarketing approval by the FDA, and manufacturers are not required to submit evidence of product safety or efficacy. The FDA also does not preap-prove structure-function claims for dietary supplements—claims that describe the intended benefits of using a product, such as “calcium builds strong bones” or “fiber maintains bowel regularity.” Consequently, there is a “buyer beware” aspect to purchasing and using dietary supplements; even the FDA Web site states that “it is important to be well informed about products before purchas-ing them [because] it is often difficult to know what information is reliable and what is questionable.” As medication experts, pharmacists can help patients make sense of information that may not be as conclusive or authoritative as information available for conventional medications.

Uninformed use of dietary supple-ments can be particularly dangerous if patients inadvertently select products that interact with prescription or nonprescrip-tion medications they are taking. Data from the most recent Slone Survey of medication use in the U.S. population (an ongoing telephone survey conducted by the Slone Epidemiology Center at Boston University) indicate that 32% of patients using prescription medications also take one or more herbal/natural supplements.

PATIENT SELF-CARE BEHAvIORS

Much of what we know about pa-tients’ self-care behaviors comes from two surveys conducted during the early 2000s:• The Self-Care in the New Millennium

survey, which was conducted by Roper Starch Worldwide for CHPA in January 2001.

• The Attitudes and Beliefs About the Use of Over-the-Counter Medicines: A Dose of Reality survey, which was conducted by Harris Interactive for the National Council on Patient Information and Education in late 2001 and updated in May and June 2003.

The Self-Care in the New Millennium survey included 1,505 adults (≥18 years of age). The overwhelming majority of the participants—96%—reported feeling somewhat confident (38%) or very con-fident (58%) about the health care deci-sions they make for themselves. Nearly three out of four participants (73%) stated that they prefer to try to treat conditions themselves rather than have to go to a doctor; 62% wanted to diagnose and treat more of their ailments at home in the future.

When asked how they had chosen to treat any of a dozen common ailments during the past 6 months, the largest percentage of participants—77%— reported using nonprescription medica-tions. Figure 1 shows the prevalence of nonprescription medication use among participants who reported having experienced each ailment.

When asked where they turn for information about treating minor health concerns, 27% of participants reported relying on family and friends, followed by 20% who said they would consult their physician. Only 7% said they would ask a pharmacist for information—the same percentage that would rely on information from the Internet. However,

the overwhelming majority of partici-pants—84%—agreed that the phar-macist is a good source of information about minor health problems.

The Attitudes and Beliefs About the Use of Over-the-Counter Medicines: A Dose of Reality survey included 1,011 adults (≥18 years of age) as well as 451 pharmacists, nurses, and general prac-tice physicians. Among the consumer participants, 59% reported having taken a nonprescription medication during the past 6 months; 54% had taken a pre-scription medication. More than one third (36%) of participants had used three or more prescription medications during the previous month, and more than one fourth (28%) had used three or more non-prescription medications.

Many of the questions in this survey addressed consumers’ use of nonpre-scription medication labels, knowledge about nonprescription medications, and adherence to dosing instructions. Key findings include the following:• Only 34% of participants reported

reading the label to determine the active ingredient when they purchased a new nonprescription medication.

• Only 22% of participants reported

Figure 1. Use of Nonprescription Medications by Ailment

Source: Roper Starch Worldwide. Self-Care in the New Millennium. American Attitudes Toward Maintaining Personal Health and Treatment. Prepared for the Consumer Healthcare Products Association. 2001. Available at: http://www.chpa-info.org/media/resources/r_4511.pdf. Accessed September 30, 2009.

Headaches(n=630)

Cough/cold/flu/sore throat(n=701)

Skin problems(n=440)

heartburn/indigestion(n=462)

81%

72%

68%

66%

Allergy/sinus(n=583) 58%

Premenstrual(n=116) 53%

Constipation/diarrhea(n=253) 49%

Muscle/joint/back pain(n=731) 49%

Upset stomach/nausea(n=384) 46%


consulting the directions for use be-fore taking a new nonprescription medication for the first time.

• Fewer than 10% of participants re-ported reading the label for usage warnings or information about side effects before taking a nonprescrip-tion medication for the first time.

• The majority of participants (66%) could not correctly identify the active ingredient in the pain reliever they used most frequently.

• One out of three participants had taken more than the recommended dose of a nonprescription medica-tion, believing it would increase effectiveness.

• One out of three participants had taken more than one nonprescription medication when they had multiple symptoms (e.g., a headache and a sore throat).These findings underscore the

concerns expressed by the health care professionals who participated in the survey. Among the 79% of pharmacists, nurses, and general practice physicians who said that inappropriate use of non-prescription medications was a serious problem, the behaviors of greatest con-cern were:• Concurrent use of prescription and

nonprescription medications (cited by 51% of health care professionals).

• Long-term or chronic use of a non prescription medication (44%).

• Using nonprescription medications

for prescription indications (32%).• Concurrent use of two or more non-

prescription products with the same active ingredient (27%).The initial Attitudes and Beliefs About

the Use of Over-the-Counter Medicines: A Dose of Reality survey was conducted before the new Drug Facts label was required to appear on all nonprescrip-tion medications (in May 2002). Older labeling had been criticized for the typi-cally small font size and use of technical and confusing language. The Drug Facts label was intended to rectify these prob-lems with a uniform layout that clearly lists the product’s active ingredients and their purposes, along with uses (indica-tions), warnings, directions, inactive ingredients, and other pertinent informa-tion (Figure 2). There is some evidence that the desired effect was achieved. In response to selected questions from the 2003 updated Attitudes and Beliefs About the Use of Over-the-Counter Medi-cines: A Dose of Reality survey, 44% of participants reported reading the label for the active ingredient when they pur-chased a nonprescription medication for the first time (up from 34% in the initial survey), and 20% reported reading the label for information about possible side effects (compared with fewer than 10% in the initial survey).

ECONOMIC INFLUENCES ON SELF-CARE

From a public health and economic standpoint, self-care has long been the foundation of our health care system. In 1997, the FDA estimated that 60% to 95% of all illnesses are managed initially with self-care, including self-treatment with nonprescription medications. In 1980, economist Simon Rottenberg predicted that if only 2% of self-treating patients in the United States visited primary care practitioners rather than managing the condition on their own, physician office visits would increase 53%.

Appropriate self-treatment with non-prescription medications eliminates the direct and indirect costs—including physi-cians’ fees, travel costs, and time away from work—associated with obtaining a prescription medication. The CHPA Web site offers the following statistics:• The Nielsen Company, on behalf

of CHPA, estimated in 2009 that consumer use of nonprescription heartburn medications saves the U.S. health care system $757 million annually and saves the average con-sumer $174 annually.

• Northwestern University researchers determined in 2004 that the use of certain nonprescription medications in the treatment of upper respiratory infections saves the U.S. health care system and economy $4.75 billion annually. After the antifungal agent micon-

azole was switched from prescription to nonprescription status, the American Pharmacists Association calculated that women could save as much as $80 by using the nonprescription product for pre-viously diagnosed recurring vaginal yeast infections. The nonprescription product could be purchased for less than $20; the total costs for a physician visit and the prescription product were closer to $100. CHPA reported that the switch resulted in a 15% reduction in physician visits from 1990 to 1994 with an associated cost savings of $63.5 million for medical ex-penses and time lost from work.

Nonprescription medications offer a strategy for patients enrolled in Medicare Part D to avoid the coverage gap, or “doughnut hole.” In most plans, patients initially are responsible for a relatively small copayment for prescription drugs (brand name or generic). When the total

Figure 2. Sample Drug Facts Label


retail cost of a patient’s prescription drugs reaches a threshold amount ($2,831 in 2010), the patient must pay the entire cost of any additional prescription drugs until the total retail cost reaches a second threshold ($6,440 in 2010, equivalent to $4,550 in out-of-pocket costs). Nonpre-scription medications do not count toward these totals. If a patient’s condition can be managed adequately with a nonprescrip-tion medication—an increasingly likely possibility as the number of Rx-to-OTC switches increases—spending money on the nonprescription product, rather than a prescription alternative, can help to keep drug expenditures below the $2,831 ceiling.

Individuals who participate in flex-ible spending arrangements (FSAs, also called flexible spending accounts) or health savings accounts (HSAs) are able to pay for many nonprescription medi-cations and some dietary supplements with pretax dollars. (FSAs are voluntary employer-sponsored plans that allow employees to set aside pretax dollars through payroll withholding to pay for certain medical expenses not covered by insurance; HSAs are tax-exempt ac-counts available to eligible individuals covered under a high-deductible health plan.) These plans provide an economic incentive for participants to use low-cost nonprescription drugs instead of expen-sive prescription drugs with high insur-ance copayments. In some instances, patients may not have a choice: insur-ance providers increasingly do not cover prescription drugs when nonprescription versions are available (e.g., loratadine, omeprazole). Paying for nonprescription medications with pretax dollars can help to make these products more affordable. Pharmacists play a role in educating patients about which purchases are eligible and reminding patients enrolled in FSAs to use their FSA debit card for eligible purchases.

Rising health insurance costs and a weakening economy have left an increasing number of persons in the United States without health insurance. According to the U.S. Census Bureau, the number of Americans who lacked health insurance coverage hit a record high of 47 million (15.8% of the popu-lation) in 2006; that number recently was projected to reach a new high of 52 million by 2010. As many as

25 million other persons fall into a category termed “underinsured,” with insurance coverage that is inadequate to meet their health care needs. In all of these cases, patients may self-treat with nonprescription medications primarily out of financial necessity.

THE PHARMACIST AS SELF-CARE ADvISOR

It is clear that self-treatment with non-prescription medications is a desirable and cost-effective health care choice for many patients. It is equally apparent that patients don’t always use nonprescription medications optimally. Simple interven-tions by pharmacists can help to ensure that self-treating patients diagnose the underlying condition correctly, select an appropriate nonprescription therapy, and use nonprescription medications in a manner that minimizes risk.

The potential positive impact of pharmacy self-care counseling was dem-onstrated in a 1996 study conducted by Sclar and colleagues in 23 com-munity pharmacies located throughout Washington state. Student pharmacists in their final professional year of training provided consultation to 745 consumers intending to purchase a nonprescription medication. The consultations averaged 4.6 minutes in length, and resulted in 42.6% of consumers changing their in-tended purchase. Nearly 8% of consum-ers made no purchase after consultation, and 4.3% were referred to a physician. Potential adverse outcomes (drug-disease interaction, drug-drug interaction, addi-tive side effects, or duplication in thera-peutic category) were prevented in 7.1% of the study population.

In some settings, pharmacists may be able to offer self-care consultation services on a fee-for-service basis. Hong and colleagues surveyed 262 patrons of community pharmacies in Arkansas and found that approximately half (51%) were willing to pay for pharmacist advice about proper self-care with nonprescrip-tion medications. This was more than double the percentage of pharmacy patrons who had expressed a willing-ness to pay in surveys conducted 10 years earlier. Most of the respondents indicated that a consultation service should last from 1 to 5 minutes; they also indicated $5 or more as an adequate level of payment.

The QuEST Process for Self-Care Encounters

A consistent and systematic patient care process helps practitioners to be complete and concise when assuming responsibility for a patient’s self-care needs. The acronym “QuEST” is a useful mnemonic for the steps in an efficient self-care encounter. As shown in Table 2, QuEST stands for:• Quickly and accurately assess the

patient.• Establish that the patient is an appro-

priate self-care candidate.• Suggest appropriate self-care strate-

gies to the patient.• Talk with the patient about the

selected self-care strategies.

Quickly and Accurately Assess the Patient

The first step in the QuEST process is to perform a patient assessment as quickly and accurately as possible. Note the deliberate use of the word quickly.

Table 2. The QuEST Process

Quickly and accurately assess the patient• Ask about current complaint (see

Table 3)• Ask about medications and other

products• Ask about coexisting conditions

Establish that the patient is an appropriate self-care candidate• No severe symptoms• No symptoms that persist or return

repeatedly• No self-treating to avoid medical

care

Suggest appropriate self-care strategies to the patient• Medication• Alternative treatments• General care measures

Talk with the patient about the selected self-care strategies• About medication actions,

administration, and adverse effects• About what to expect from treatment• About appropriate follow-up


A complete medical interview usually would comprise:• Chief complaint.• History of present illness.• Past medical history.• Medications, allergies, immunizations.• Family history.• Social history.• Review of systems.In most cases, this amount of data vastly exceeds the information needed for tri-age of the self-treating patient; it also usually would not be feasible to collect this much patient information in a busy pharmacy setting. Therefore, pharmacists should focus on collecting the information that will be of greatest use: (1) details about the patient’s current problem; (2) any concurrent medications, as well as allergies or sensitivities to medications; and (3) coexisting conditions or disease states. With skillful questioning, this infor-mation can be collected in no more than 2 to 3 minutes.

information About the current Prob-lem. The initial part of the patient inter-view should explore the patient’s chief complaint. The acronym “SCHOLAR” is a mnemonic device for the types of in-formation that help to ensure a thorough characterization of the patient’s problem. Table 3 lists the components of SCHOLAR and provides examples of questions that can elicit the various types of information.

SCHOLAR is not an algorithm that must be followed step by step. Pharma-cists should use professional judgment and common sense when asking the SCHOLAR questions. Not all of these questions need to be asked of all pa-tients, and the questions may not need to be asked in the specific order presented.

When questioning patients about their chief complaint, it is important not to confuse the patient’s self-diagnosis with the patient’s symptoms. The patient’s self-diagnosis may not be correct, so pharmacists should always form an inde-pendent assessment based on the infor-mation they collect. Refrain from implying acceptance of the patient’s theory:

Patient: “I don’t know what’s wrong. I think I have the flu, but it’s lasted so long and I’ve tried everything. It’s been going on now for 2 weeks.”Pharmacist: “Well, some people who get the flu do feel sick for quite some time.”

Instead, simply acknowledge the pa-

tient’s theory and then proceed with the interview:

Patient: “I don’t know what’s wrong. I think I have the flu, but it’s lasted so long and I’ve tried everything. It’s been going on now for 2 weeks.”Pharmacist: “Well, some people who get the flu do feel sick for quite some time, but I’m not sure that what you have is the flu. What exactly are your symptoms?”The SCHOLAR components assume

that the pharmacist is interacting directly with the patient. When the pharmacist in-teracts with the patient’s caregiver or rep-resentative (e.g., the parent of a young child, the patient’s husband or wife), the pharmacist should ask additional ques-tions to learn about the patient, such as:• How old is the patient? If the patient

is a child, how much does the pa-

tient weigh?• Is the patient male or female? If the

patient is a female, is she pregnant or breastfeeding?information About Medications.

The second part of the patient interview involves obtaining as complete a list as possible of the prescription medications, nonprescription medications, herbal products, and dietary supplements that the patient is using, as well as the prob-lems or conditions for which the patient is using them. It also is helpful to know about the patient’s use of alcohol, caf-feine, tobacco, and “recreational” drugs, because this information may influence the pharmacist’s evaluation of whether the patient is a suitable candidate for self-treatment (e.g., a cough in a patient who smokes may need to be evaluated by a physician) or the eventual self-

Symptoms• What is bothering you?• What is wrong?• What other problems/symptoms have

you noticed?

Characteristics of the symptoms or problem/Course of the symptoms or problem• What does the pain/problem feel like?• Describe your symptoms/problem to

me.• How are your symptoms changing over

time (better, worse, same)?• How bothersome are your symptoms?• To what extent do your symptoms

interfere with your usual or desired activities (e.g., sleeping, eating, working, walking)?

History of symptoms in past• When have you suffered from the same

symptoms or similar symptoms in the past?

• How has this problem (or these symptoms) affected you in the past?

• What have you done (or what has been done) in the past to alleviate the problem or symptoms? What were the results?

Onset• When did this problem/these

symptoms start?• How often do the symptoms occur?• How did the problem/symptoms start?• What were you doing when you first

noticed the symptoms?• How long have the symptoms been

present?/How long have you had this problem?

Location• Where does it hurt?• Where is the problem located?• In what part of your body are you

experiencing symptoms?

Aggravating factors• What (foods, medications, activities,

positions) make the problem/symptoms worse?

• What else do you feel when you have this problem?

Relieving factors• What (foods, medications, activities,

positions) make the problem/symptoms better?

• What have you done so far to make the problem better/relieve the symptoms, and was it successful?

Table 3. SCHOLAR Mnemonic for Characterizing a Patient’s Current Problem

Source: Adapted from Wheeler SQ, Windt JH. Telephone Triage: Theory, Practice, and Protocol Development. Albany, NY: Delmar Publishers; 1993.


treatment recommendation (e.g., the need to warn a patient about concurrent use of alcohol and pain relievers). The pharmacist should take care to explain why this information is necessary and phrase queries in a nonjudgmental man-ner. For example, “Some medications can interact with alcoholic beverages. To help me determine the best medication for you, please tell me about your usual consumption of beer, wine, or liquor.”

In addition to finding out which medi-cations and products a patient uses regu-larly, pharmacists should inquire whether the patient is allergic to any medications or products. Keep in mind that patients might not differentiate true allergic reac-tions from sensitivities and adverse effects (e.g., stomach upset from aspirin).information About coexisting condi-tions. Information about coexisting conditions is needed to avoid possible drug-disease interactions, as well as to establish that the patient is an appropri-ate candidate for self-treatment. Some of this information will come from the medi-cation history. Examples of questions that help to elicit additional information include:• For what other types of problems or

conditions do you routinely see your doctor?

• What other illnesses have been act-ing up lately?

• What other problems do you have with your health?

establish that the Patient is an Appropriate self-care candidate

The information that pharmacists gather during the assessment step helps them to formulate a presumptive diagno-sis and determine whether the patient is an appropriate candidate for self-care. Patients who are not appropriate self-care candidates need to be referred to a primary care provider. In general, referral is indicated in the following situations:• The patient’s symptoms are too se-

vere to be endured without definitive diagnosis and treatment.

• The symptoms are minor but persis-tent and do not appear to be the result of an easily identifiable cause.

• The symptoms have recurred repeat-edly with no recognizable cause.

• The pharmacist is in doubt about the patient’s medical condition.Pharmacists also must consider symp-

tom-specific exclusions to self-treatment.

As more and more prescription drugs are switched to nonprescription status, it will become increasingly important for pharmacists to know the disease-specific factors that signal the need for referral to a primary care provider.

When advising a patient to consult a primary care provider, the pharmacist should explain the reason for the refer-ral using tact and firmness. Pharmacists should convey the importance of con-sulting a primary care provider without frightening the patient unnecessarily. For example, “Based on what you’ve told me, I’m concerned that a nonprescription product is not the best choice for your symptoms.”

The pharmacist should be precise about where and when the treatment should take place. Does the patient require care within minutes, hours, or days? Should the patient be evaluated in an emergency department, urgent care clinic, or physician’s office? Patients with emergent/urgent or semiurgent symptoms should be given specific instructions, to avoid confusion and decrease possible patient denial:• You must be seen by a physician with-

in 2 hours. Are you able to get to the emergency department within 2 hours, or should we call an ambulance?

• Call your physician’s office as soon as you get home to arrange an ap-pointment. Ask for an appointment this afternoon, or no later than tomor-row morning.

suggest Appropriate self-care strategies to the Patient

If the patient does appear to be a

good candidate for self-treatment, the pharmacist must collaborate with the patient to select an appropriate treatment strategy, based on the pharmacist’s pre-sumptive diagnosis of the patient’s condi-tion. If self-treatment with a nonprescrip-tion product is indicated, the pharmacist may need to ask additional questions at this point to assist with product selection. For example, can the patient swallow a solid dosage form? Must the patient stay alert? If the patient asks about alternative treatments such as an herbal product, the pharmacist should provide information about the relative merits and drawbacks of the product in an unbiased and non-judgmental manner.

talk with the Patient About the selected self-care strategies

Too often, encounters with self-treat-ing patients end with the pharmacist rec-ommending a particular medication and sending the patient off to the appropriate aisle. Before concluding the self-care en-counter, pharmacists should counsel the patient about the topics listed in Table 4. Pointing out specific information on the Drug Facts label and providing patients with supplemental written information can help to ensure that instructions are followed accurately.

As part of the counseling session, pharmacists should explain what the patient should expect during the next few hours or days, both in the normal course of the condition and subsequent to treatment measures. Patients should understand the symptoms or develop-ments that indicate failure of self-treatment or possible complications.

Table 4. Counseling Points for Self-Treating Patients

• The reasons for self-treatment• Description of the medication and/or treatment

- Name- Mechanism of action- Expected effect

• Proper administration of the medication and/or treatment- Dose and dosage schedule- Route of administration- Duration of therapy

• What to expect from treatment• How soon to expect results• Precautions• Anticipated adverse effects and how to manage them• General treatment guidelines• Appropriate follow-up• Other important information (e.g., storage requirements)


Throughout the counseling session, the pharmacist should check for patient understanding by asking the patient to repeat back key information. The phar-macist should provide corrective feed-back as needed. The patient should be encouraged to ask questions throughout the counseling session; at the end of the session, the pharmacist should conclude by asking if the patient has any addi-tional questions or concerns.

Documentation and Follow-UpIdeally, pharmacists should document

all self-care encounters with patients. An example of a self-care consultation form that could serve as a simple documenta-tion system is shown in Figure 3. The self-care consultation form also could provide a useful starting point for evaluations by other clinicians in the event that a patient requires referral to a primary care provid-er. From a purely pragmatic standpoint, documentation of a self-care encounter would be essential if a legal defense of the pharmacist’s recommendations became necessary. Legal experts rec-ommend that pharmacists document all significant encounters with patients as well as interactions with other health care professionals on the patient’s behalf.

Pharmacists ideally would follow up with all patients to:• Determine whether the condition was

managed successfully with the self-treatment recommendations.

• Find out whether the patient sought medical evaluation as recommended.

• Inquire whether any new symptoms had emerged.

• Provide advice about managing any adverse effects.

Follow-up could occur formally (e.g., by setting up a future appointment) or informally (e.g., a telephone call inquir-ing how the patient is doing). However, not all patients will be receptive to follow-up encounters. One strategy is to conclude each self-care encounter by presenting patients with a business card and offering to follow up with them in an appropriate number of days. That way, patients who decline the offer for follow-up still would have the pharmacist’s con-tact information in the event that any new problems or questions were to arise.

COMMUNICATING WITH SELF-TREATING PATIENTS

Good communication skills are the cornerstone of all self-care encounters. During each step of the QuEST process, pharmacists need to gather information from patients and transmit information back to patients. Two important compo-nents of good communication skills are effective questioning and active listening.

Effective QuestioningTo gather information from the patient

efficiently, pharmacists must ask effective questions that facilitate and guide con-versation. Open-ended questions elicit a wide range of responses; they cannot be answered with one-word responses such as “yes” or “no.” In contrast, closed- ended questions limit the number of possible responses; they usually can be answered with a one-word response, such as “yes” or “no.”

Most of the questions asked during a patient interview should be open-ended questions. Open-ended questions allow the pharmacist to gather a large amount of information in a short amount of time and generate hypotheses about the patient’s condition quickly. Open-ended questions usually begin with “who,” “what,” “when,” “where,” or “how.” Although open-ended questions also can begin with “why,” it is possible for such questions to be misinterpreted as criticism:• Why did you wait so long before

seeking treatment?• Why are you using this herbal prod-

uct?Closed-ended questions often begin

with “are,” “is,” “will,” “would,” “do,” “did,” or “does.” Closed-ended ques-tions are useful for clarifying information obtained through open-ended ques-tions. However, pharmacists must take care to phrase closed-ended questions precisely, because patients may answer ambiguous questions without asking for clarification. For example, the question “Do you feel better?” may be interpreted by the patient as “Has your condition improved?” or “Are you feeling back to normal?” Each interpretation would yield substantially different information.

Leading questions are a particular type of closed-ended question that usually should be avoided. Leading questions provide the answer within the

question: “Is the pain severe?” They also may suggest to the patient what you want to hear, or don’t want to hear (e.g., “You didn’t use a heating pad on that, did you?”). Some leading questions can come across as judgmental or conde-scending (“You don’t smoke, do you?”).

The sequence in which questions should be asked during a patient inter-view is presented in Table 5. The inter-view should begin with broad, open-ended questions. The pharmacist might open the encounter with the patient by using a general statement or directive: “How can I help you today?” or “Tell me what brings you to the pharmacy today.” Doing so gives patients an opportunity to share their concerns and their under-standing of the problem. Subsequent open-ended questions would focus more specifically on aspects of the patient’s problem or symptoms: for example, “How would you describe the pain?” or “When did you first notice the rash?”

Open-ended questions also can be used to clarify information provided by the patient (“What do you mean by…” or “Tell me more about…”). It is especially important to qualify a problem before attempting to quantify the prob-lem. For example, patients who complain of “heartburn” or “diarrhea” may or may not be using the precise medical definitions of those terms. Pharmacists should find out more about the nature of a patient’s symptoms (e.g., “How would you describe the pain?” or “What are your stools like?”) before they ask about quantitative and situational aspects (e.g., “How frequently do you experience epi-sodes of heartburn?” or “When did your diarrhea start?”).

Closed-ended questions become helpful as the pharmacist begins to draw conclusions about the nature of the patient’s current problem. Closed-ended questions can help to differentiate among conditions with similar symptoms. For example, both the common cold and allergic rhinitis are characterized by nasal congestion and sneezing, but sore throat usually is associated only with the common cold, and ocular symptoms (e.g., itching, lacrimation) usually are as-sociated only with allergic rhinitis. When open-ended questions reveal that a patient suffers from nasal congestion and sneezing, the pharmacist might follow up with closed-ended questions such as


Figure 3. Sample Nonprescription Consultation Record

© 2007 American Pharmacists Association 11

THE PHARMACIST’S ROLE IN SELF-CARE

Figure 3.

Sample Nonprescription Consultation Form

Self-Care Consultation RecordDate of consultation:

Patient Information (“Who is the product for?”)

Name:

Sex: M F Age: Allergies:

Pregnant: Y N Breastfeeding: Y N

Patient Complaint (“What problem/symptom do you want to treat?”)

Allergy Cough Heartburn Common cold Diarrhea Insomnia Congestion Fever Pain Constipation Headache Skin condition Other:

Notes about patient complaint:

Coexisting Conditions (“What other medical conditions do you have?”)

Current Medications (prescription, nonprescription, herbal, dietary supplements)

Recommendation

No treatment necessary Referred patient to primary care physician/other: Self-treatment

Product:

Notes:

Follow-Up/Contact Information

Follow up on (date):

Name (if different from patient):

Phone: ( ) E-mail:

Pharmacist signature


“Do you have a sore throat?” and “Have your eyes been itching at all?” Closed-ended questions also can be used to clarify information obtained through open-ended questions, especially if the patient provides vague or incomplete information. The “laundry list” question is a useful type of closed-ended question for this purpose:• How would you describe your

pain—sharp, dull, or throbbing?• Is the bleeding dark red or light red?• Would you say that you have a drink

(of beer, wine, or alcohol) about every day, every week, or every month?Unfortunately, closed-ended ques-

tions tend to be overused by clinicians. Observational studies have found that more than 75% of the questions asked by physicians during patient interviews were closed-ended questions. Closed-ended questions hinder the patient interview, because they cut down on the amount

and variety of information supplied by patients and yield minimal new informa-tion. The biggest danger in conducting a patient interview with mostly closed-

ended questions is misinterpretation of the patient’s problem based on incom-plete or inaccurate information. Clini-cians may neglect to ask about important aspects of a problem or fail to explore the problem fully.

Active ListeningAlthough asking effective questions

is important, the pharmacist should not do all of the talking during a self-care encounter. Studies of patient interviews conducted by medical residents have shown that the residents tended to talk three times longer than the patients, but the completeness of the patient history was highly correlated with the amount of time that the patient spent talking.

Listening needs to be an active pro-cess (as opposed to hearing, which is a passive process). Active listening means concentrating on what is being said and blocking potential distractions, including other thoughts that try to intrude. When

the pharmacist listens actively, patients are free to state their problems com-pletely and are assured of receiving the pharmacist’s undivided attention. Active

listening helps to ensure that the pharma-cist’s assessment of the patient’s condi-tion and subsequent recommendations will be based on complete and accurate information.

Active listening also means allowing patients to finish their thoughts and being receptive to patients’ responses to ques-tions. Interrupting or demonstrating either a lack of interest or disapproval may inhibit a patient’s discussion of problems or concerns. Pharmacists should be espe-cially cognizant of their nonverbal cues and behaviors; standing with crossed arms or checking the time while the patient is talking does not convey caring or acceptance.

Summarizing the information provid-ed by a patient and asking whether the summary is correct helps to confirm that the patient’s message is received and interpreted accurately. Empathy is an im-portant aspect of this process. Empathy is a type of understanding—feeling with a person rather than feeling for a person. To demonstrate empathy, pharmacists might paraphrase a patient’s words and reflect on what was said in terms of the patient’s own experience. For example, after listening to a complaint of pain, the pharmacist might say “You have a sharp, stabbing pain in your wrist, is that right?” and end with a statement such as “That must be very uncomfortable.”

Communication ChallengesCommunication challenges may take

the form of disabilities (e.g., patients who are blind or visually impaired, patients who are deaf or hearing impaired) or low literacy skills (general literacy or health literacy). Using targeted com-munication techniques can help to overcome these obstacles. For example, pharmacists should use visual reinforce-ment when communicating with a patient who is deaf or hearing impaired, such as pointing to or circling/highlighting specific information on the Drug Facts label. If the patient reads lips, the phar-macist should position himself or herself directly in front of, and physically close to, the patient. The pharmacist should speak slowly and distinctly in a low-pitched, moderate tone; the tendency to talk loudly or yell should be avoided, because it distorts sound and might em-barrass the patient. Supplemental written information can be offered as a reminder of important points, but it should not

Pharmacists should not assume that patients are able to read and under-stand the information on nonprescription product packages; rather, they should use a variety of educational techniques during self-care encounters, including oral explanations and demonstrations, and pictorial information sheets.

Table 5. Sequence of Questions in the Patient Interview

Start with:• General open-ended questions

- How can I help you today?- Tell me what brings you to the pharmacy today.

• Specific open-ended questions- How would you describe the pain?- When did you first notice the rash?

Proceed to:• Closed-ended questions

- How would you describe your pain—sharp, dull, or throbbing?- Are you allergic to any medications?

Avoid:• Leading questions

- You’re feeling better now, aren’t you?- You don’t smoke, do you?

• Multipart questionsDo you have any trouble sleeping, and how about coughing?


be used as a substitute for pharmacist-patient interaction.

When interacting with a patient who is blind or visually impaired, pharmacists should take special care to identify them-selves to the patient (e.g., by stating “I am the pharmacist”). Pharmacists also should concentrate on conveying empa-thy and interest in the patient’s problem through tone of voice and verbal feed-back, given that blind patients cannot perceive most nonverbal communication. If the need to touch the patient arises (e.g., to examine a suspected sprained ankle), the pharmacist should obtain the patient’s permission first.

The 2003 National Assessment of Adult Literacy, which measured the English literacy of American adults (≥16 years of age) for the first time since 1992, found that up to 22% of adults lack the literacy skills necessary to per-form simple and everyday activities. Because of the stigma associated with reading problems, patients often make excuses (e.g., “I don’t have my read-ing glasses with me”) or try to conceal the fact that they have trouble reading. They also may be less inclined to ask questions or express their concerns. Phar-macists should not assume that patients are able to read and understand the information on nonprescription product packages; rather, they should use a variety of educational techniques dur-ing self-care encounters, including oral explanations and demonstrations, and pictorial information sheets. Pharmacists should conclude self-care encounters by having patients describe how they intend to use a medication, then make construc-tive corrections or fill in information gaps as needed.

SELF-CARE CONSIDERATIONS IN SPECIAL POPULATIONS

Certain groups of patients require special consideration when decisions about self-care are made. These groups include infants and children, older adults, women who are pregnant or breastfeed-ing, and persons from racial or ethnic minority groups.

Pediatric PatientsMany parents (or other caregivers)

use nonprescription medications for the treatment of common childhood illnesses. In a 1994 study by Kogan and col-

leagues, more than half of the mothers surveyed (53.7%) had given a nonpre-scription medication to their 3-year-old child in the past 30 days. A more recent analysis of data from the Slone Survey showed that 56% of children younger than 12 years of age had taken at least one medication product in the 7 days preceding the interview. Nonprescription products accounted for the majority of all products used; acetaminophen, ibupro-fen, pseudoephedrine, and dextromethorphan were among the top six most commonly consumed active ingredients in all age groups.

Unfortunately, pediatric caregivers do not always use nonprescription medications appropriately. In the Attitudes and Beliefs About the Use of Over-the-Counter Medicines: A Dose of Reality survey, only 21% of participants were aware that a child’s weight is the most accurate guide for determining the correct dosage. Only 11% knew that nonprescription medications formulated for infants usually are more concentrated than formulations for older children. In a 1997 study by Simon and Weinkle, only 30 of 100 parents and caregivers (most of whom had at least a high school edu-cation) were able to both determine the correct weight-based dose of acetamino-phen for their child and measure that dose out accurately. In a 2000 study by Li and colleagues, half of the children 10 years of age or younger who presented to one pediatric emergency department (primarily for fever) over a 6-week period were found to have received an incorrect dose of acetaminophen or ibuprofen. Although 28% of the children’s caregiv-ers stated that they had used the package labeling to determine the correct dose, only slightly more than half of those caregiv-ers (56%) actually administered a correct dose. Of concern, 8% of caregivers admitted to guess-ing the correct dose, and 20% stated that the dose should be based on the magnitude of the child’s fever.

Caregivers also continue to rely on household utensils (e.g., teaspoons) for dose administration. In 1996, Madlon-Kay and Mosch gathered information about the dosing of pediatric liquid medications from a convenience sample of 130 persons in the waiting rooms of three clinics near Minneapolis, Minne-

sota. The majority of participants (73%) reported using a household teaspoon to measure liquid medications. Sobhani and colleagues conducted a similar study 10 years later (in 2006) with 96 participants recruited from two health fairs oriented toward infant caregivers in Los Angeles County, California. Although 68% of participants reported using drop-pers and 67% reported using dosing cups to measure liquid medications, 62% also reported using household tea-spoons.

As these data suggest, many prob-lems involving nonprescription drug ther-apy in pediatric patients arise because caregivers:• Determine an incorrect dose from the

Drug Facts label information.• Measure out an incorrect amount.• Fail to use an appropriate dosing

device.Pharmacists can help to avoid these problems by (1) encouraging caregivers to know their child’s weight; (2) determin-ing appropriate weight-based doses; (3) demonstrating the appropriate use of measuring devices; and (4) either emphasizing the importance of using the dosing device that comes with the product or directing parents to an ap-propriate device (e.g., medication cup, dosing spoon, oral syringe). Pharmacists can further help to ensure the appropri-ate dose is administered by placing a mark at the correct spot on the dosing device. Pharmacists should educate care-givers about the well-known inaccuracies of household teaspoons for medication dosing purposes and actively discourage their use.

In general, the FDA recommends against the use of nonprescription medi-cations in children younger than 2 years of age (unless such use is recommended by a primary care provider). Thus, most nonprescription medications do not include dosing information for that age group; caregivers instead are instructed to consult a physician for the appropriate dose. This is true even for products likely

Older adults represent a disproportionately large share of the nonprescription drug market, consuming an estimated 33% of all nonprescription medications.


to be used in infants and young children, such as pediatric acetaminophen prod-ucts. Pharmacists can provide dosing recommendations for drugs with which they are familiar and for which dosing guidelines are readily available. How- ever, because this constitutes off-label use, pharmacists should be especially careful to document the encounter and the method they used to arrive at the recommended dose (e.g., reported weight of child, source of dosing information).

Some pediatric caregivers may wish to mix an oral liquid medication with infant formula, beverages, or food (e.g., applesauce) to facilitate administration to a young child. In these instances, care-givers should be advised to mix the dose of medication with the smallest amount of formula, beverage, or food possible (to ensure that the child consumes the entire dose). The mixing should occur as close to the time of administration as possible.

Older AdultsData from the most recent U.S. Cen-

sus showed that 35 million Americans (approximately 12% of the population) were 65 years of age or older in 2000. That number is expected to double to 72 million by 2030, when adults in this age group will represent nearly 20% of the total U.S. population. The “gray-ing” of the population has a number of important implications for self-care. Older adults represent a disproportionately large share of the nonprescription drug market, consuming an estimated 33% of all nonprescription medications. Unfor-tunately, older adults also are at higher potential risk of serious drug-related prob-lems than younger adults are. When Lam and Bradley investigated the prevalence of self-prescribed use of nonprescription medications and dietary supplements among 45 residents of assisted living facilities in Oregon and Washington, the problems they uncovered included:• Duplicate therapy with different

brands of multivitamins.• Duplicate therapy involving pain and

analgesic products.• Potential interactions between self-

prescribed nonsteroidal anti-inflam-matory drugs (NSAIDs) and prescrip-tion medications.

• Underdosing of cough and cold medications.Only 11% of the residents reported

seeking advice from pharmacists about nonprescription medications and dietary supplements; residents were most likely to consult with family members and friends.

As the data collected by Lam and Bradley suggest, the potential for all types of drug interactions (not just those involving aspirin and other NSAIDs) is of particular concern in older adults. According to the most recent Slone Survey data, 59% of older men and 57% of older women take at least five prescription medications, nonprescrip-tion medications, or dietary supplements per week; 19% of women and 17% of men take 10 or more. Yoon and Schaf-fer reviewed drug use data for 58 older women who reported taking at least one herbal product and one prescription or nonprescription drug; the authors identi-fied a total of 136 actual drug interac-tions with clinical implications, including at least one moderate- or high-risk drug interaction for 43 (74%) of the women. Older adults are particularly likely to be taking anticoagulants (e.g., warfarin) or antiplatelet agents (e.g., aspirin) that may be involved in serious drug interactions. Pharmacists should take special care to obtain as thorough a medication history as possible from older patients and con-sider the possibility of interactions when selecting nonprescription medication therapy.

Older adults also are more likely to have concomitant diseases or conditions (e.g., diabetes, glaucoma, hypertension, thyroid disease) that contraindicate the use of some nonprescription medications. Pharmacists should caution patients to review the Warnings section of the Drug Facts label carefully before self-medicat-ing with any nonprescription drug.

Aging alters the absorption, distribu-tion, metabolism, and elimination of certain drugs, making older persons more susceptible to both the therapeutic effects and adverse effects of many non-prescription medications. For example, older adults generally are more sensitive to the effects of anticholinergic drugs and central nervous system depressants than younger adults are; they may need to take smaller than recommended doses or take the recommended dose less frequently. Pharmacists must consider both the possibility and potential conse-quences of adverse reactions when rec-ommending nonprescription medications

for older adults. Pharmacists also need to consider whether an older adult is requesting a nonprescription medication to treat an adverse reaction from another medication.

Pregnant and Breastfeeding Women

The Drug Facts label of many non-prescription medications directs women to “ask a health professional before use” if they are pregnant or breastfeeding. Most drugs cross the placenta to some extent, and many are able to transfer into breast milk. As a general rule, drug therapy that is not critical to the patient’s well-being should be avoided in women who are pregnant or breastfeeding.

Still, women who are pregnant or breastfeeding may seek nonprescription medications for the self-treatment of com-mon conditions or specifically to man-age conditions commonly associated with pregnancy (e.g., nausea, vomiting, constipation). Pharmacists should recom-mend nondrug measures whenever pos-sible. For example, nausea and vomiting may be alleviated or minimized by eating small meals, frequent snacks, and crackers. Use of an effervescent glucose or buffered carbohydrate solution, or ginger also may be effective. Women who complain of constipation may ben-efit from increasing the amount of fiber in their diet or using fiber supplements (e.g., inulin, methylcellulose, psyllium).

If use of a nonprescription medica-tion appears to be warranted, such use optimally should be undertaken only with the knowledge and agreement of the woman’s primary care provider. When assisting with product selection in these circumstances, pharmacists should obtain current drug safety information from an authoritative reference, such as Drugs in Pregnancy and Lactation (see SelF-Care reSourCeS box). Pharmacists also should keep the following principles in mind:• It is important to determine the tri-

mester of pregnancy when advising pregnant women, because medica-tions considered safe during one trimester may not be considered safe during another.

• Drugs that have been in use for a long time (and thus have a track re-cord of safety or known effects) gen-erally are preferred to newer agents.

• Topical or local dosage forms (e.g., topical decongestants) usually are


a safer choice than oral systemic therapy.Nonprescription medications that

usually are considered to be compatible with breastfeeding are listed in Table 6. Women who are breastfeeding should be advised to take medication just after feeding the infant or just before the in-fant’s lengthy sleep periods.

Patients Belonging to a Racial or Ethnic Minority Group

The United States has become in-creasingly diverse in the last century. In March 2003, the foreign-born popula-tion (i.e., persons who were not born in the United States) numbered 33.5 million—an increase of more than 50% since 1990. Although the non-Hispanic white population remains the largest racial/ethnic group, it is a shrinking ma-jority: the percentage of non-Hispanic whites in the United States is expected to

decrease from 69.4% of the total popula-tion in 2000 to just 50.1% in 2050.

Cultural differences can contribute to communication barriers and misunder-standings about appropriate treatment. Nearly 47 million people in the United States speak a language other than Eng-lish at home; approximately 11 million of those people report speaking English “not well” or “not at all.” Pharmacists are advised not to provide medical informa-tion in another language unless they are fluent in that language and certain of the meaning of their instructions. Pharmacies that serve a large number of non– English-speaking patients might consider having patient information brochures for the most common self-care conditions and nonprescription medications trans-lated into the appropriate languages. Other options include hiring bilingual staff or an interpreter for the pharmacy.

Different cultural groups may use and respond to mainstream American medical care in many different ways. Some patients may choose to blend Western health care with their own cul-ture’s medical practices, which may differ dramatically from accepted biomedical principles. To provide culturally sensitive health care—and to be able to detect potentially harmful cultural practices and lead patients away from them suc-cessfully—the pharmacist must under-stand the patient’s beliefs and attitudes regarding self-treatment and negotiate treatment that is acceptable to both the patient and the pharmacist. Some broad guidelines for interacting with culturally diverse patients are presented in Table 7; additional information can be found in the Handbook of Nonprescription Drugs (Chapter 3, “Multicultural Aspects of Self-Care”) and Essentials of Cultural Compe-tence in Pharmacy Practice (see SelF-Care reSourCeS box).

MAKING PATIENTS AWARE OF SELF-CARE COUNSELING SERvICES

In a survey conducted by the Ameri-can Pharmacists Association early in 2007, more than half (54%) of respon-dents from a nationally representative panel of households indicated that they would be “not too likely” or “not at all likely” to consult with their pharmacist when purchasing a nonprescription medication for the first time. Only 17% of respondents said they would be “very likely” to ask the pharmacist questions.

The survey did not go on to ask re-spondents why they would or would not talk with a pharmacist about nonprescrip-tion medication purchasing decisions. But historically, patients have expressed unwillingness to “bother” a busy phar-macist, or have been unaware that pharmacists were available to assist with self-treatment decisions. Pharmacists who seek to become more involved in self-care counseling may need to begin by making patients aware of this service.

One simple approach to increasing patient awareness is to use signs that inform patients of the pharmacist’s avail-ability. For example, a large poster with the pharmacist’s photograph, name, and title could include a statement such as “I am available to consult with you on a variety of health problems, including heartburn, headache, pain, cold symp-toms, and allergies. Please stop by the pharmacy counter for more information.” Small “shelf-talker” signs could be posi-tioned strategically in the nonprescription medication aisles, with messages such as “Confused about which product is right for you? The pharmacist is available to recommend products for a variety of skin conditions.”

Brochures and Web sites also are effective vehicles for acquainting patients

Table 7. Guidelines for Interacting With Culturally Diverse Patients

• Assess your personal beliefs surrounding persons from different cultures.• Take account of your own biases and prejudices.• Assess communication variables from a cultural perspective (language barriers,

nonverbal communication, use of interpreters, beliefs, and feelings).• Plan care based on communicated needs and cultural background. Adapt care to

meet the cultural needs of the patient.• Modify communication approaches to meet cultural needs (use more than one method

to communicate the stated plan).

Table 6. Nonprescrip-tion Medications That Usually Are Consid-ered Compatible With Breastfeeding

• Acid reducers (antisecretory agents)- Cimetidine- Famotidine- Nizatidine- Ranitidine

• Analgesics- Acetaminophen- Ibuprofen- Naproxen

• Antacids• Antidiarrheals

- Loperamide• Antihistamines

- Brompheniramine- Chlorpheniramine- Diphenhydramine

• Cough preparations- Dextromethorphan

• Cromolyn sodium• Decongestants

- Phenylephrine- Pseudoephedrine

• Laxatives- Bran type- Bulk-forming type- Docusate- Glycerin suppositories- Magnesium hydroxide- Senna


SELF-CARE RESOURCES

reference books

Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: American Pharmacists Association; 2009.

Berger BA. Communication Skills for Pharmacists: Building Relationships, Improving Patient Care. 3rd ed. Washington, DC: American Pharmacists Association; 2009.

Briggs GG, Freeman RK, Yaffee SJ. Drugs in Pregnancy and Lactation. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

Hagel HP, Rovers JP, eds. Managing the Patient-Centered Pharmacy. Washington, DC: American Pharmaceutical Association; 2002.

Halbur Kv, Halbur DA. Essentials of Cultural Competence in Pharmacy Practice. Washington, DC: American Pharmacists Association; 2008.

Knapp Dlugosz C, ed. The Practitioner’s Quick Reference to Nonprescription Drugs. Washington, DC: American Pharmacists Association; 2009.

Pharmacist’s Letter/Prescriber’s Letter Natural Medicines Comprehensive Database. 11th ed. Stockton, CA: Therapeutic Research Faculty; 2009.

Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott, Williams and Wilkins; 2005.

Ulbricht C, Seamon E. Natural Standard Herbal Pharmacotherapy: An Evidence-Based Approach. St. Louis, MO: Mosby/Elsevier; 2009.

web sites

Be MedWise www.bemedwise.org

Consumer Healthcare Products Associationwww.chpa-info.org

National Council on Patient Information and Education www.talkaboutrx.org

with pharmacists’ self-care services. Brochures can be displayed near the pharmacy and used as bag stuffers. Pharmacists who have some control over the pharmacy’s Web site content might consider including an “Ask Your Pharmacist” section with answers to fre-quently asked questions about self-care for various ailments. The site also could contain links to other health information resources.

Special health fairs or presenta-tions can serve to spotlight pharmacists’ self-care services. The pharmacy might

hold seasonal events—for example, ad-dressing self-treatment of common cold in the fall and proper selection and use of sunscreens in early summer. Pharma-cists with an interest in diabetes might conduct a “meter clinic,” inviting patients to bring their meters to the pharmacy for cleaning and inspection.

It is important for all pharmacy em-ployees to understand the pharmacist’s availability for, and interest in providing, self-care counseling. In many pharma-cies, patients are likely to have their initial interaction with pharmacy techni-

cians or cashiers and other support staff. These staff members can direct patients to the pharmacist and reassure patients that they are not “bothering” the pharma-cist with their questions.

CONCLUSIONSelf-care remains the backbone of

the health care system and will further increase in the face of rising health care costs. The growing role of the pharmacist as a provider of medication therapy management services presents abundant opportunities for pharmacists who want to develop a self-care counseling service. Self-care involves much more than the selection of nonprescription medication products; it involves all actions patients take to keep themselves healthy.

Patients benefit when self-care choic-es are made in an informed manner, because they are more likely to use effec-tive remedies and less likely to engage in unsafe self-care practices. Pharmacists are a crucial resource for providing pa-tients with the information they need to make wise decisions about their health. Pharmacists also can screen for condi-tions that require physician evaluation and make appropriate referrals.


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CPE ExAM

1. Approximately how many nonprescription medication products are available in the united states?a. 1,000.b. 10,000.c. 100,000.d. 1 million.

2. Pharmacists who are not familiar with the concept of “product line extensions” might be surprised to discover that claritin eye contains:a. Cetirizine hydrochloride.b. Ketotifen fumarate.c. Loratadine.d. Pheniramine maleate.

3. Pharmacists who dispense drugs in other countries that have a behind-the-counter class of drugs typically must:a. Ensure that patients meet

certain criteria for therapy.b. Educate patients about the

proper use of the medication.c. Help patients understand

how to monitor the effects of therapy.

d. All of the above.

4. for regulatory purposes, the fdA classifies herbal products as:a. Biologics.b. Cosmetics.c. Drugs.d. Foods.

5. Among patients who take prescription medications, what is the approximate proportion of those who are also likely to be taking one or more herbal products or natural supplements?a. One tenth.b. One quarter.c. One third.d. One half.

6. Approximately what percentage of consumers report consulting the directions for use before taking a nonprescription medication for the first time?a. 10%.b. 22%.c. 34%.d. 66%.

7. According to the u.s. census bureau, how many Americans are predicted to be without health insurance by 2010?a. 25 million.b. 47 million.c. 52 million.d. 100 million.

8. in the study by sclar and colleagues—in which student pharmacists provided self-care counseling to community pharmacy patients—what percentage of patients changed their intended purchase after the consultation?a. 4.3%.b. 8%.c. 28.8%.d. 42.6%.

9. which of the following is not a step in the “Quest” process?a. Quickly and accurately assess

the patient.b. Understand the patient’s self-

care needs.c. Suggest appropriate self-care

strategies to the patient.d. Talk with the patient about the

selected self-care strategies.

10. the mnemonic “scHOLAr” helps pharmacists to thoroughly characterize the patient’s:a. Chief complaint.b. Coexisting conditions.c. Medication allergies.d. Medication history.

11. in which of the following situations should a self-treating patient be referred to a primary care provider?a. The patient is older than

65 years of age.b. The patient is taking more than

two prescription medications.c. The patient’s symptoms have

recurred repeatedly with no recognizable cause.


12. which of the following represents an open-ended question?a. What kinds of symptoms are

you having?b. Have you ever had this

problem before?c. Are you feeling better?d. Did you notice any other

symptoms?

13. A closed-ended question might begin with any of the following words, except:a. Are.b. Will.c. Did.d. How.

14. Although a patient interview should consist primarily of open-ended questions, observational studies consistently find that closed-ended questions account for approximately what percentage of the questions?a. 25%.b. 33%.c. 50%.d. 75%.

instructions: the assessment questions printed below allow you to preview the online cPe exam. Please review all of your answers to be sure you have marked the proper letter on the online cPe exam. there is only one correct answer to each question.

15. As part of active listening, pharmacists can demonstrate empathy to patients by:a. Interrupting the patient to clarify

ambiguous information.b. Maintaining constant eye

contact with the patient.c. Paraphrasing a patient’s words

and reflecting on what was said in terms of the patient’s own experience.

d. Standing with crossed arms.

16. Approximately what percentage of American adults lack the literacy skills necessary to perform simple and everyday activities?a. 5%.b. 11%.c. 16%.d. 22%.

17. in general, the fdA recommends against use of nonprescription medications in children younger than:a. 6 months old.b. 12 months old.c. 2 years old. d. 6 years old.

18. Although older adults currently constitute about 12% of the population, they purchase an estimated ________ of all nonprescription medications.a. 6%.b. 25%.c. 33%.d. 47%.

19. which of the following general statements about nonprescription medication use by women who are pregnant or breastfeeding is true?a. It is important to determine the

trimester of pregnancy when advising pregnant women.

b. Newer drugs are preferred to drugs that have been in use for a long time.

c. Oral dosage forms usually are a safer choice than topical dosage forms.


20. Pharmacists can encourage interaction with self-treating patients by:a. Adding a self-care section to

the pharmacy Web site.b. Holding seasonal events keyed

to common self-care concerns.c. Posting signs to inform patients

of the pharmacist’s availability to answer questions.


CPE INSTRUCTIONScompleting a posttest at www.pharmacist.com/education is as easy as 1-2-3…

1. Go to Online cPe Quick List and click on the title of this activity.2. Log in. APhA members enter your user name and password. Not an APhA member? Just click “create one now” to open an account. No fee is required to register3. Successfully complete the CPE exam and evaluation form to gain immediate access to your Statement of Credit.

Live step-by-step assistance is available Monday through Friday, 8:30 am to 5:00 pm ET from APhA Member Services at 800-237-APhA (2742) or e-mail [email protected].

800-237-APhA • pharmacist.com

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