Distributing Over-The-Counter Medications To Clients

Q: The new medical advisor of our guiding company has advised us not to distribute over-the-counter medication to our clients. What is your opinion?

Technically, one could argue that giving medication under these circumstances (paid guide giving to a client, non-family member) could be considered practicing medicine without a license.  Many school nurses are prohibited from dispensing over-the-counter (OTC) medications, let alone specifically prescribed medication to students.

There are some good reasons not to routinely include OTCs in all first aid kits.  First, aside from pain medication, antihistamines (for allergic reactions and motion sickness), and maybe some of the gastrointestinal (GI) products for heartburn and diarrhea, most other OTCs have little real value.  If we focus on acute problems, you can usually toss out the GI.  Symptomatic relief for coughs and runny noses certainly do not change the course of an illness.  Second, you should not be dispensing OTC medications without training. To treat, you have to make a diagnosis and then have a realistic expectation of improvement.  OTC medications are not innocuous.   For example, not only will giving an antihistamine for a cold be useless, it could also cause complications.  And third, aside from acute pain from an injury, many of the conditions for which these would be used are either predictable or recurrent.  If either of these is true, clients can bring their own.

Each guiding company has its own unique challenges and capabilities.  Do you have standardized first aid kits and uniform care protocols?  Many have neither.  Are all of your trips the same?  For a group that could be hours from help, I would expect uniform first aid kits and training that would cover their contents and use.  The list of meds would be limited and focused, varying by the environment and duration.  A more comprehensive kit makes sense for longer and more remote trips.

Bottom Line

Routinely carrying OTCs often makes no sense.  Don’t feel compelled to have them included and don’t think badly of your medical advisors if, based on experience and knowledge of your company’s program, they don’t want you to dispense OTCs.  At the very least ensure your guiding service has a clear set of medical protocols and standardized first aid kits that are suited for your adventures. When developing these protocols, take into account liability issues to protect your company.


3 comments on “Distributing Over-The-Counter Medications To Clients

  1. henry henry

    I really disagree with the bottom line in this post. I think that – as you mentioned – several OTCs can actually change the course of illness and in fact life-saving. Look at antihistamine administration post-epinephrine for anaphylaxis. Great if you have an EpiPen and can use it, but in a long-lasting or biphasic reaction, that 10 minute window of epi activity will not help the patient much at all where as a simple generic antihistamine tablet can keep stop the reaction at the source (ie histamine). Also look at ASA (aspirin) for heart attacks, which is a standard of care in most pre-hospital and emergency room setting. Imodium and exlax for diarrhea and serious constipation, etc. These are all cheap and safe medications to use that could literally save lives (assuming of course, that a guide is properly trained in wilderness first aid, but this is another story).

    Serious stuff aside, I think OTCs can seriously mitigate suffering, discomfort, and unhappy campers on a trip. This may seem trivial, and its easy to take the attitude “get your own meds” but this truly misses the point. Its the responsibility of the guide to anticipate things that participants may have no idea about.

    If we trust guides to be administering EpiPens, leading people into potential dangerous conditions, and managing unexpected risk, I think its more than reasonable to trust them giving OTCs, many of which are relatively innocuous. Of course it is up to the medical director to decide what is right, but this decision should probably go challenged. What is his or her justification?

  2. David Johnson, MD David Johnson, MD

    Thank you for expressing your concerns about my earlier post. There are areas where we agree and others where we don’t. So be it. This is the point of civil and public discourse.

    1. My major point was to suggest to the questioner that their medical advisor’s cautionary advice has some merit. It was not meant as a blanket condemnation of over-the-counter (OTC) use but rather to try and explain a rationale for a cautious approach.
    2. I think there is a risk with their use. The fact that a medication is an OTC does not make it harmless. One can get side-effects and some potentially serious medication reactions with other OTCs and prescription medications. If the efficacy of the medication is negligible, this in itself could be a compelling reason not to use one. And, using one for the wrong reason can lead to serious outcomes. I see this happen in my hospital practice.
    3. It can be construed as practicing medicine without a license anytime a non-licensed practitioner dispenses any medication to someone other than a family member. This has implications following a bad outcome for the dispenser as well any licensed practitioner advocating for their use in the circumstances noted in the original query.
    4. You have given a number of examples of useful medications. I agree with you for some but I question some of your statements on others. To wit:
    a. I would agree that aspirin can be a powerful drug for a heart attack. Carrying it might depend on the population you are travelling with. Would you advocate taking a bottle or a couple of tablets on every trip?
    b. You have made a common error in your reference to epinephrine, anti-histamines and anaphylaxis. The impact of epinephrine goes beyond the “10 minute window” for vascular constriction and lower airway relaxation. Equally importantly, epinephrine stabilizes mast cells so that they do not continue to produce histamine and the host of other mediators responsible for the symptoms of anaphylaxis. Although I use them (and as you noted, recommended their use in the original post), no one has demonstrated their utility in treating anaphylaxis or preventing biphasic reactions.
    c. One of your points in the final paragraph is interesting. In essence you seem to be arguing that if epinephrine, why not OTCs that in your words are often “innocuous”? Their efficacies are not comparable on any level. In a properly trained person making the correct diagnosis, this has an enormous upside with surprisingly little risk. Except as I have noted in my original post, we cannot say that about most OTCs. Under the right circumstances, as a prescriber and potential adviser, I would have no reservation writing prescriptions for epinephrine. Not surprisingly, I would advise limitations on OTCs carried by the guides.

    You end by saying that an adviser’s decision against using OTCs “…should probably go challenged. What is his or her justification?” Safety and legality? Fair enough, though. For a relationship with an adviser to work, it needs to be open and trusting no matter what the final decision is.

  3. Mark Mark

    As a physician, I agree with Henry’s response. OTC medications can be extremely useful in some situations and comforting in others. And there is always the placebo effect if nothing else. I am not a lawyer, but I disagree that making an OTC available to a competent adult is the practice of medicine. An adult can choose to take the medication or not, just like they do at home. An unaccompanied minor child might be a different story.

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