158 Self-imposed medical stresses
and even denial regarding the potential of “finding something” often inter- feres with a prudent decision for that person if medical intervention is antici- pated. The threat of the doctor finding anything serious often prevents the very act that could rule it out or find a cure. When FAA medical certification is on the line (and hence a career), less-than-responsible choices are often made, and denial sets in.
Therefore, since people initially are looking for symptom relief, there is a huge market for medications and drugs that the public can purchase with- out a prescription or visiting a doctor. Over-the-counter (OTC) medications are a multibillion dollar business in the United States alone. Marketing departments in the drug companies have a great time creating new ways to package and sell the same medication—for reasons that sometimes are not even safe or healthy, especially to aircrew. Furthermore, international restrictions vary on treatment with OTC drugs such as pain pills, sleeping pills, and tranquilizers.
Although the U.S. Food and Drug Administration (FDA) is charged with pro- tecting the public from medications and chemicals whose labels mislead or imply false results, there is a continual struggle to keep ahead of the mis- leading claims with factual information. Current enforcement by the FDA to ensure legitimate labeling is helping the consumer. The choice still remains with the pilot.
Pilots especially are vulnerable to the hype of the many ads for quick-fix medications. Although not deliberately seeking unsafe or unhealthy therapy, the pilot is often swayed into judging that he/she knows how ill he/she is and thus self-diagnosing. This becomes a setup for the pilot who is anxious to return to flight if he/she could just get rid of the symptoms; it’s a case of denial. The catch is that although the symptoms might be relieved, the cause goes untreated. Plus, self-medication might mask the very symptoms the doctor needs to know to evaluate your problem. Drug stores and super- markets have bountiful shelves of a wide variety of chemicals, drugs, and medications to meet the need of the pilot looking for the quick fix. Some OTC medications are effective, but may have bad side effects.
Flight surgeons are often asked if it is okay to take a certain medication and still fly. The initial response has to be “No.” There is no list of approved drugs or medications that the pilot can use, prescription or self-medication, without approval by a flight surgeon or a clear understanding of its effects.
Technically, pilots are forbidden from any self-medicating. Obviously, there is a place for all medication and treatments, even OTC, but it must be with the full knowledge of both pilot and doctor as to why the medication is needed and the effect of this medication on safety and performance.
The military by regulation forbids any self-medication. All treatment must come from the flight surgeon. Because civilian aviation does not have the close relationship to the aviation doctor, the pilot must assume responsibility for determining what course of action to follow, as stated in FAR Part 61.53.
This regulation states that the pilot must not have any disqualifying medical problems to be legal (see Chapter 17). The pilot must assume a medical prob- lem is unsafe until proven otherwise. If in doubt, check with an AME or FS.
Over-the-counter medications 159
Marketing claims (the art of reading labels)
Reading labels on the containers of these OTC medications is often very revealing, and sometimes the claims are quite comical. It’s uncommon if there is any comment about cure or dealing with the cause of the symptoms.
And, of course, there is the ultimate disclaimer to see your doctor if symp- toms persist. The assumption is made that the purchaser has made the cor- rect diagnosis or has ruled out more serious causes of the symptoms. It’s like soap ads; there is just so much you can get out of soap, yet there are bigger and better ads coming out every day touting how much better one soap is over another in removing stains or grime.
Consider some of these claims for OTC drugs:
• Symptomatic relief! Some symptoms are relieved, but sometimes at the expense of causing significant side effects. “Symptom relief” is an effective statement because that is precisely what you are looking for in the medication.
• Temporary relief! This could mean a few minutes to a few hours. It does not mean permanent relief as would be expected if the medica- tion were curative.
THIS IS SOMETHING YOU INGEST:
Water Corn syrup Sodium caseinate Sugar
Salt Lutein Soybean oil Monoglycerides
Vitamin E acetate Diglycerides Soy protein
Sodium stearoyl-2-lactylate Polysorbate
Di-potassium Phosphate Sodium acid pyro-phosphate WHAT IS IT?
Nondairy coffee creamer Read labels: Is it really safe?
160 Self-imposed medical stresses
• Extra added ingredients! This implies greater potency or more reli- ability in meeting its claims, even though that extra ingredient could simply be caffeine. The FDA is cracking down on claims that these added ingredients really do what they are claimed to do. Side effects must also be explained.
• New and improved! Compared to what? The ingredients prob- ably are the same, but the amounts might be slightly different. Or perhaps the only difference is the shape of the pill or the color of the liquid. It doesn’t mean the drug is any more effective than the previous drug.
It is a good idea to always read labels just to see how creative marketing people can be to get you to buy their product. Yes, the side effects are listed, in small print, and so are the ingredients. But let’s face it, you’re more inter- ested in what the large print says that it can do for you. So, read labels, know what the ingredients actually do, and then make your own decision as to what you should do. OTC implies that it’s safe because a prescription is not needed or the FDA has cleared it. A good reference is the annual edi- tion of the Physicians’ Desk Reference or “PDR.” One edition of the PDR is dedicated to OTC medications. As an aside, reading labels on food products is also revealing, a good example being whole milk, skim milk, and low fat milk. Check the actual weight of fat present in each. Skim milk is the only one without fat.
Basic ingredients
Over 500 different drugs are made from a combination of one or more of the chemicals listed in Fig. 9-1. These eight ingredients make up a large percent- age of the usable chemicals that are allowed in OTC drugs. There are others, of course, but these are certainly the most common. In addition to discussing the effects and side effects, look at the half-life for each chemical. Half-life in this case refers to the amount of time that half of the chemical needs to get
BAN THIS KILLER!! (THE ULTIMATE HYPE) DiHydrogen Monoxide or DHMO
Colorless, odorless, tasteless killer of uncounted thousands of people every year. Most deaths occur from inhalation of DHMO. Symptoms include excessive sweating and urination, bloated feelings, nausea, and vomiting. For those dependent on DHMO, withdrawal means certain death. Also known as Hydric Acid. Can cause severe burns.
The above is all true! So what is it?
Be sure you know what you’re reading and why it’s being published.
Any doubt? Then make sure you understand what each term and acronym means. (By the way, di hydrogen is H2, and monoxide is O.)
Over-the-counter medications 161 out of the body. For example, if you ingest 1.0 gram of a drug and its half-life is 10 hours, then in 10 hours, 0.5 gram will still be in the body.
Antihistamines
Antihistamines are the most popular ingredients in allergy, cold, and flu OTC medications. Several kinds of antihistamines are available over the counter, and other antihistamines are available only by prescription. This is the drug for which most people buy cold and allergy medications. Some of the more common antihistamines used are brompheniramine, chlorpheniramine, dox- ylamine, and diphenhydramine. Note that each generic name ends in “ine.”
Effects Antihistamines primarily help dry up secretions from upper respira- tory mucous membranes (nose and sinuses) that cause sniffles and post- nasal drip, often leading to a mild, sometimes persistent cough. In addition, some of the symptoms associated with an itchy nose and eyes and sneezing are controlled; however, some of these symptoms are a result of the body’s attempt to cure the problem, whether a cold, flu, or allergy. That’s one of the Figure 9-1
Figure 9-1 Ingredients contained in a majority of over-the-counter medications.
162 Self-imposed medical stresses
trade-offs in self-medication: Are you interfering with the natural course of healing?
Side effects Drowsiness/sedation is by far the most serious problem with any OTC medication that contains antihistamines. Countless stories relate pilots who were incapacitated in some way as a direct result of taking such medica- tion. Some prescribed antihistamines do not cause drowsiness, according to certain studies. If such treatment is necessary to keep you flying comfortably and safely, then your doctor must be a part of that treatment and monitoring.
Furthermore, the FAA will certify most prescribed antihistamines.
Many other, often subtle, side effects of OTC antihistamines are unaccept- able in flight. These include decreased coordination, reduced visual accom- modation (see Chapter 7 regarding vision), dizziness, depression, and some cardiovascular effects (rapid heart rate, reduced ability to divert blood where needed, etc.).
Sleeping medications
It is important to note that virtually all OTC sleep medications are antihista- mines. Using the fact that antihistamines cause drowsiness, drug companies have simply changed the name of the product and put a different label on the bottle and box, thereby transforming the antihistamine into a sleeping pill.
Would you take a sleeping medication to treat a cold so you could fly? That’s what you’re doing if you take OTC antihistamines to treat a cold. Check the labels.
Because getting quality sleep is such a major problem and there is no good resolution without some trade-off to safety, there is continued interest in any cure that shows up in the press. L-tryptophan, which is found in dairy prod- ucts and appears to assist in sleep, was sought after in health food stores in pill form. Because of concerns of its effects on metabolism and its purity, there is continuing controversy as to its use.
The same problem and dilemma exists with melatonin, a natural hormone within the body known to be a part of the physiology of sleep. The assump- tion is that it can be singled out as a solution to assisting sleep, adjusting cir- cadian rhythms, and other concerns. Again, the complexity of its role in the body and its purity are concerns, yet anecdotal stories of success continue to add to its perceived credibility. The best advice is to wait until melatonin is scientifically proven safe and effective and dosages are well established.
Decongestants
Generally, decongestants are well tolerated by the body, have few undesir- able side effects, and offer more flexibility for use in flight. These are found in OTC medications (separately and in combination with antihistamines and other chemicals) and are the ingredients found in many nose sprays.
Common decongestant chemicals are phenylephrine, phenylpropanolamine, ephedrine, and pseudoephedrine. The misuse of ephedrine has now become
Over-the-counter medications 163 a major problem because of its use in manufacturing methamphetamines, also resulting in their removal from OTC shelves in drug and grocery stores.
Effects Mucous membranes usually swell during colds, flus, and allergies.
This swelling causes congestion in the nose, eustachian tubes, and sinuses.
The congestion creates the problems in flight (ear and sinus blocks), and decongestants are effective at reducing this swelling; they do little to reduce secretions.
Side effects The major problem with these drugs is their stimulant effects, similar to what caffeine can do. Included are such effects as making you nervous, jittery, and overactive plus keeping you awake when you are trying to get needed sleep. Most people are quite tolerant of these effects, but it is difficult to predict what happens to an individual in flight or on layovers. An already-heavy load of caffeine from coffee, tea, or colas plus the symptoms for which you need a decongestant might increase impairment. Pilots who have borderline high blood pressure should be aware that decongestants can aggravate blood pressure elevation; however, OTC decongestants can be used in some situations. It is wise (and expected of the pilot) to confirm the use with your flight surgeon or AME.
Nose sprays
The active ingredient in many nose sprays is a decongestant (i.e., phenyleph- rine), which can also be a vasoconstrictor. That is, blood vessels get smaller in the area of the spray. This helps reduce the congestion of the mucous membranes of the nose. Frequent use of short but fast-acting (less than three hours) nose spray decongestants can lead to rebound. The spray can be an irritant to the mucous membranes of the nose; therefore, as the expected favorable action begins to diminish in a few hours, one takes another spray.
Over a period of a few days, the irritation of frequent use causes its own swelling and congestion, for which more spray is used. Longer- but slower- acting sprays (over eight hours, as with oxymetazoline) might be better toler- ated, especially if used for no more than a few days. Rebound can also occur from overuse. A prescription nasal inhaler is available with a mild cortisone that can be very effective if long-term use is expected.
Another issue is the recommendation to keep a long-acting nose spray in your flight bag as a “get me down” treatment, when you get caught in flight with an ear or sinus block (see Chapter 5 regarding altitude physiology).
This is not to recommend using the nose spray prior to flight to overcome current congestion because, as stated elsewhere, if you think you need treatment before flying, then maybe you should not be flying. Keeping such medication in your flight bag might be challenged by some flight surgeons, and for good reason, because such a practice could lead to some pilots abusing an implied “okay” and flying with the assumption that the nose spray can be used if they have a problem even before flight. All things con- sidered, keeping a nose spray available during flight probably outweighs the risk of imprudent use by the pilot. If there is doubt, don’t fly but ask your AME.
164 Self-imposed medical stresses
Analgesics (pain relievers)
Analgesics are sold alone as pain relievers or in combination with other cold and flu medications. They are marketed in a variety of ways, all leading you to believe that a company’s OTC medication solves many problems. Discomfort, whether pain, achiness, or general malaise, is generally why you seek help from an analgesic, but your symptoms could also be nature’s way of telling you that you are impaired; therefore, it is more important with analgesics that you con- sider why you need the medication. The possible reasons include headaches, toothaches, sore throats, pains from injury, and other similar symptoms that could represent potential problems made worse in flight. The pain might affect specific pilot functions unique to flight, such as pushing a rudder after a blown tire or trying to reduce the discomfort of a sore back while seated. Pain or dis- comfort is a distraction, a common cause of incidents or accidents.
Aspirin As one of the most common pain relievers, aspirin is a medication that has several other effects, both good and bad. It is also an antipyretic (fever reducer), an anti-inflammatory medication for arthritis and other inflamma- tion problems, and a drug that can be taken once a day to thin blood in the prevention of heart attacks, among other medical situations. It is relatively safe if used as directed, that is, if taken with food or an antacid, not taken more often than recommended, and avoided if there is any history of previ- ous stomach distress. Aspirin has been associated with ulcers in some people and ringing in the ears with very high doses.
Acetaminophen (Tylenol) This ingredient often competes with aspirin in mar- keting OTC medications. It is an effective pain reliever for some people and is often found in combination with other chemicals in cold and flu medications.
It is not as effective in anti-inflammatory treatment. It appears to be toler- ated better than aspirin in those who have problems with gastritis. It is also relatively safe in usual doses.
Ibuprofen This was once a prescription medication, but now OTC pills con- taining comparatively small doses are sold. The prescribed medication is
SHOULD YOU AVIATE IF YOU MEDICATE?
If you feel the need for treatment for any ailment, then DON’T.
If you have bad symptoms of an illness, then DON’T.
If you are going to use an OTC medication for the first time, then DON’T.
Consider the combined side effects of medication and the illness.
Would you continue a three-day trip if symptoms got worse?
If in doubt, call your AME or call in sick.
GOTCHA!
Over-the-counter medications 165 usually used for inflammation, and the OTC is meant for pain (the analgesic properties were found as a side effect when it was used initially as a prescrip- tion). This is also relatively well tolerated in most people, but others do notice side effects such as stomach distress. Other such similar products that were initially by prescription only are becoming available as OTC medications, such as naproxen, which is a pain killer like ibuprofen.
Cough suppressants (antitussives)
In most cases, cough suppressants contain dextromethorphan, a fairly innoc- uous chemical that can assist in relieving coughs in some people. It has few if any significant side effects. One should keep in mind, however, that deriva- tives of codeine are often found in some OTC cough medication, especially when purchased in a foreign country. Codeine, usually only available by pre- scription in the United States, is a very effective antitussive agent, but it is considered a narcotic, a mood-altering drug that can cause drowsiness and will show up in drug-testing programs.
Extra added ingredients
Extra added ingredients include a variety of other chemicals that might enhance or not even affect the other ingredients and their effectiveness. The FDA is watching closely to see if these additions do any good. Caffeine is one of the most popular added ingredients and is commonly found in combina- tion with aspirin and diet pills. Another is an antacid, which basically helps overcome some expected side effects such as stomach distress. Some of these ingredients are considered inert or inactive, but they are still present, some- times in significant quantities. Alcohol is a common example; it is used as a solvent for the other ingredients. Up to 25 percent of some cold medication is alcohol. Consider also the synergistic effects of alcohol and medication on the brain. Even this small amount of alcohol can show up in a breathalyzer test. The rules deal with this problem by allowing the pilot to repeat the test 20 minutes later, which should allow for a negative test.
Phenylpropanolamine (PPA)
Phenylpropanolamine (PPA) deserves a separate section. It was a common ingredient in a variety of OTC medications: diet pills, cold and flu relief, and allergy control. It acts as a decongestant and an anorectic (appetite suppres- sant), depending on how it is packaged; however, PPA is also a very strong stimulant to some people, giving some a real “high” similar to amphetamines.
It can have a severe effect on blood pressure, often elevating normal blood pressure to the point where the diagnosis of hypertension is made. PPA can interfere with sleep and cause headaches, dizziness, rapid heart rate, mood changes, and nausea. The FDA is taking special interest in this chemical as a result of its many adverse side effects, and has banned its use in most OTC medications.
Whereas many effective drugs are not available as OTC medications, many are available in foreign countries and relatively easy to acquire by international flight crews. Despite the availability, the effects on performance remain.