Thursday, March 24, 2011

Following Instructions

“Take one to two pain pills by mouth every 4 to six hours”

To me that is clear.  I was reminded recently that it isn’t to all patients. 
A patient complained of lack of relief from her pain medicines after surgery.  Her description of the pain didn’t suggest any complications so I ask how she was taking them.  I was looking for a way to safely use NSAIDS or tylenol as a boost rather than giving her something stronger.
“I take one pain pill and then wait an hour to take another one.”
I prompted her to tell me when she took the next dose.
“I wait four hours and then take one pain pill, but I wait for six hours to take the next one.”

I had mentioned to her and her caregiver that due to her small size she should begin with just one, then wait for 30 minutes to an hour to see if she needed the second one.  They were doing that, but the other part wasn’t clear.
“Take one to two pain pills by mouth every 4 to six hours”
1.  Take one pain pill every 4 hours.
2.  Take two pain pills every 4 hours.
3.  Take one pain pill every 6 hours.
4.  Take two pain pills every 6 hours.
Oh, but there are really more options aren’t there:
1.  Take one and half pain pill every 4 hours.
2.  Take one pain pill every 5 hours.
So she was taking the medicine in a correct way, but it wasn’t the optimal one for her.  We had a short discussion which seemed to help.
There is much discussion about patients and compliance in taking medicine.  It starts with the physicians, nurse, and pharmacists.  I have to write good instructions.  Sometimes this is difficult to do and keep them short enough to go on the label.
With pain medicines it is nice for patients to know there is a range of effective, safe dosages. 

U.S. Pharmacopeia has proposed labeling standards which can be viewed here. Comments on the proposed standards may be submitted to through March 31, 2011.  One of the changes is:
Give explicit instructions—Instructions should clearly separate the dose itself from the timing of each dose and use numeric characters (e.g., “Take 2 tablets in the morning and 2 tablets in the evening” rather than “Take two tablets twice daily”). …
Ambiguous directions such as ‘‘take as directed’’ should be avoided unless clear and unambiguous supplemental instructions and counseling are provided (e.g., directions for use that will not fit on the prescription container label)


Elaine Schattner, MD said...

Hi Ramona,
Again, you've raised an important issue. Quite often doctors don't realize that their patients don't understand the instructions given. "Non-compliant" patients may have misunderstood what they were told. The hard part, from the doctor's perspective, is to be clear without speaking in a patronizing tone.

Jabulani said...

In 1995, I joined my parents at a game farm in South Africa. It is always recommended to take anti-malaria drugs when going to game farms, so I went along to my GP to get them. The label said: "To be taken twice daily morning and evening." It didn't say how many, so I rang the surgery. The receptionist told me 2. I asked if this meant 2 pills twice daily morning and she agreed. So I started taking them.

Then, 4 weeks later I came out in a horrid, itchy rash 3 days before I was due to fly home!! We had the most amazing pharmacist when I was growing up in SA and Mom took me off to see him with my pills in my hand. He took one look at me, told me to stop them immediately as I was either allergic to Sulphur (in the tablets), or I was overdosing on them and should check when I returned. Sure enough, I went to see the GP when I returned and was told it was 2 tablets per day, not 4. And was a little amazed when he said "How could you get that wrong?" He was disbelieving when I told him his receptionist had gotten it wrong as well!!

Pffft, English is a very confusing language ...

Anonymous said...

So true!
Write it down.
Spell it out.
Encourage questions.
Great post!


Zoe Brain said...

"Apply two patches on Monday and Thursday every week"

Turned out the Endo meant 2 patches per week, one on Monday, one on Thursday.

I was fortunate that the intended prescription was an underdose.

BrainDame said...

About to write post on similar issue-thanks for yours!