**3.7 Self-Medication (over-the-counter):**

Definition of over-the-counter self-medication

Description of the most common over-the-counter medications

Pharmacological effects of the most common over-the-counter medications

Symptoms, signs and performance effects of the most common
over-the-counter medications

Aviation accident investigation and post-mortem toxicological testing

FAA regulations concerning the use of over-the-counter medications

**SECTION II, 3.7 SELF-MEDICATION (OVER THE COUNTER)**

Non prescription medications are medicines that the patient can obtain
or purchase that can be used to treat a condition that does not require
authorization by a physician or licensed medical practitioner.

[DEFINITION OF OVER THE COUNTER SELF-MEDICATIONS]{.underline}

"Over the Counter" medications (OTCs) are legal, non-prescription
substances taken for the relief of discomforting symptoms that may be in
capsule, tablet, powder or liquid form. This could also include topical
agents as well as agents that use a dermal delivery system (i.e. patch).
In the Physicians Desk Reference for non prescription drugs (NP/PDR) and
dietary supplements there are over 100 categories of medications that
one can be obtained [without]{.underline} a prescription. These,
according to the NP/PDR treat conditions ranging from acne to wart care
preparations. Also included in the NP/PDR are dietary supplements as
well as diagnostics (i.e. pregnancy). Therefore, a person sometimes not
only has the ability to treat but, in some cases, confirm a diagnosis
that, heretofore, could only be made under the direction of a physician
or licensed medical caretaker.

[DESCRIPTION OF THE MOST COMMON OVER THE COUNTER
MEDICATIONS]{.underline}

Some of the more common over the counter (OTC) medications would
include:

Analgesics: This would include Non-steroidal anti-inflammatory drugs
(NSAID) such as Ibuprofen, aspirin, and acetaminophen

Cold and flu preparations which fall into categories such as
antihistmines, decongestants, and cough preparations

Bowel, or gastrointestinal agents such as laxatives and anti-diarrheals.

Appetite suppressants, often in the sympathomimetic category of
stimulants, such as penylpropanolamine (PPA), were recently taken off
the market due to reported adverse reactions, and ephedra, a similar
agent, is currently coming under scrutiny for its deleterious effects on
the user, and in some cases, abuser.

Sleeping aids generally have low dose antihistamines in them

Stimulants such as caffeine

Dietary supplements, including agents such as amino acids, vitamins,
herbal and mineral/vitamin combinations.

[PHARMACOLOGIC EFFECTS OF THE MOST COMMON OVER THE COUNTER
MEDICATIONS]{.underline}

[ANALGESICS:]{.underline}

Aspirin: Produces analgesia by an ill defined effect on the hypothalamus
and by blocking pain peripherally, which may involve prostoglandin
synthesis via inhibition of cyclo-oxygenase enzyme. This inhibition may
also have an effect on inflammatory mediators as well. The antipyretic
action is by the effect on hypothalmic heat regulating centers to
produce peripheral vasodilatation, increasing peripheral blood supply
and promote sweating, thus cooling.

Acetaminophen: Mechanism and site of action though to be related to
inhibition of prostaglandin synthesis in the CNS, thus elevating the
pain threshold. Antipyretic action through increased heat dissipation
through sweating and vasodilatation.

Ibuprofen: Mechanism unknown. Probably through inhibition of
prostaglandin synthesis.

COLD/FLU PREPERATIONS:

Antihistamine: H1-recptor antagonist. Competes for the H1 receptor sites
on smooth muscle of the bronchi, GI tract, uterus and large blood
vessels by binding to cellular receptors and to suppress histamine
induced allergic symptoms, though it does [not]{.underline} prevent
histamine release. Antiemetic/antivertigo/antidyskinetic most probably
acts via central antimuscarinic actions. The mechanism of sedative
action is unknown.

Decongestants: adrenergic; stimulates the adrenergic receptors of the
respiratory mucosa to produce vasoconstriction , shrinkage of nasal
mucosa, reduction of tissue hyperemia and edema. Relaxation of bronchial
smooth muscle may result from direct stimulation of the β-adrenergic
receptors. CNS stimulation may occur.

BOWEL PREPARATIONS:

Laxatives: (Magnesium salt): An antiulcer agent, it neutralizes gastric
acid, decreasing the direct acid irritant effect. This increases the pH
leading to pepsin inactivation. The laxative effect is by increasing the
osmotic gradient in the gut thus drawing in water, causing distention
which, in turn, stimulates peristalsis and bowel evacuation.

Anti-diarrheal: (Hydrated magnesium aluminum silicate): Though its
action is unknown, it is thought to be related to absorbing large
numbers of bacteria and toxins thus reducing water loss in the GI tract.

APPETITE SUPPRESANTS: (Dexatrim) Ephedra stem /caffeine et al. This is
an adrenergic agent with direct and indirect --acting sympathomimetic
effect. It may cause stimulation as well as vasoconstriction from the
α-adrenergic effects adding to the pressor effects, in addition to
cardiac stimulation.

SLEEPING AIDS: Cimetadine, diphenhydramine (See antihistamines, above)

STIMULANTS: (Caffeine): Xanthine derivative. It increases the levels of
CAMP by inhibiting phosphodiesterase which can stimulate all levels of
CNS. It increases contractile force and decreases skeletal muscle
fatigue.

SYMPTOMS, SIGNS AND PERFORMANCE EFFECTS OF THE MOST COMMON OVER THE
COUNTER MEDICATIONS

  ------------------- ----------------- ------------------------------------
  ANALGESICS          Aspirin           Tinnitus, nausea, stomach ulceration

                      Acetaminophen     Hepatic toxicity in large or chronic
                                        doses

                      Ibuprofen         Upset GI tract, itching, dizziness,
                                        water retention

  COLDS/FLU           Antihistamines    Sedation, dizziness, rash, GI upset,
                                        impaired coordination blurred
                                        vision, dryness

                      Decongestants     XS stimulation, palpitations,
                                        dizziness, urinary difficulty

  BOWEL PREP          Laxatives         Unexpected bowel activity,
                                        especially at altitude

                      Anti-diarrheals   Drowsiness. Depression, blurred
                                        vision

  APPETITE            Acutrim,          XS stimulation, dizziness,
  SUPPRESANTS         Dexa-trim         palpitations

  SLEEPING AIDS       Nytol, Sominex    Prolonged drowsiness, blurred vision
                                        (antihist)

  STIMULANTS          Caffeine          Tremors, palpitations, headache,
                                        tremors
  ------------------- ----------------- ------------------------------------

AVIATION AND ACCIDENT INVESTIGATION AND POST MORTEM TOXICOLOGICAL
TESTING

A \[*retrospective*\] study of accidental non-commercial aircraft
fatalities was performed on the case files of the Office of the Medical
Examiner of Metropolitan Dade County in Miami, FL, U.S.A., between the
years 1977 through 1983.  A total of 57 cases were collected and
analyzed as to the age of the A study of accidental non-commercial
aircraft fatalities was performed on the case files of the Office of the
Medical Examiner of Metropolitan Dade County in Miami, FL, U.S.A.,
between the years 1977 through 1983.  A total of 57 cases were collected
and analyzed as to the age of the victim, the race and sex of the
victim, the cause of death, the blood alcohol content at autopsy, the
drugs detected at autopsy, the type of aircraft, the occupant role, the
risk factor responsible for the crash, the time of the fatality, and the
nature of usage of the aircraft.  Essentially, these 57 cases comprised
1.2% of the non-vehicular accidental fatalities during the period.  The
age of distribution is relatively evenly distributed from age 16 to 65
years with white males predominating.  Multiple injuries were the most
common cause of death although conflagration injuries (e.g., smoke
inhalation, burns) were frequent.  [The victims were sober and free of
drugs in the majority of cases. ]{.underline} Most fatalities occurred
in a single engine plane with the victim, the pilot, flying for private
reasons in the afternoon or evening hours.  The most common identifiable
risk factor was human error (e.g., judgement), rather than mechanical or
plane failure.

Toxicological findings in all military aircraft fatalities investigated
by the Division of Forensic Toxicology at the Armed Forces Institute of
Pathology from 1986-1990 are presented.  Carbon monoxide saturation
levels greater than 10% were found in 4% of the 535 cases where
appropriate specimens were collected.  [Positive ethanol findings were
more indicative of postmortem formation than antemortem consumption.  In
only 1 case was an abused drug (cannabinoids in a passenger) detected. 
Other drugs identified included nicotine, chloroquine and
over-the-counter analgesic agents, antihistamines and sympathomimetic
drugs.]{.underline}

In a series of 2326 deaths (in 1983) there were 314 positive drug tests
found. The most often found was aspirin (109), acetaminophen (61),
ethanol (51), and diphenhydramine (1).

FAA REGULATIONS CONCERNING THE USE OF OVER THE COUNTER MEDICATIONS

  ----------------------- ----------------------- ------------------------
  [NONPRESCRIPTION        [PRESCRIPTION           [ILLICIT
  DRUG]{.underline}       DRUG]{.underline}       DRUG]{.underline}

  ----------------------- ----------------------- ------------------------

  ----------------------- ----------------------- ------------------------
  Antacids                                        

                          Amphetamines            Amphetamines

                          Anticoagulants          

                          Antidepressants         

  Antihistaminic          Antihistaminic          

                          Antihypertensive        

                          Antiviral               

                          Anxiolytics             

                          Barbiturate             

  Aspirin                 Aspirin                 

                                                  Cocaine

                          Contraceptives          

                          Cyclic hormones         

                          Desensitization         
                          injections              

                                                  Hallucinogens

                          Hypnotics               

                          Hypoglycemic drugs      

  Ibuprofen               Ibuprofen               

                          Insulin                 

                                                  Marijuana

                          Mood ameliorating       

  Motion sickness         Motion sickness         

                          Mydriatic               

                          Naproxen                

                          Narcotics               

  Opioids                 Opioids                 

                          Oral hypoglycemic       

  Phenylephrine           Phenylephrine           

                          Psychoactive            

                          Sedative                

                          Steroid                 

  Stimulant               Stimulant               

                          Sucralfates             

                          Tranquilizers           

                          Warfarin                
  ----------------------- ----------------------- ------------------------

The drugs/medications are those listed in the Guide for Aviation Medical
Examiners. Each category will be discussed in the appropriate section.

SUMMARY OF ALL DRUGS

  ----------------------- ----------------------- -----------------------
  NAME OF DRUG            FAA GUIDE FOR AVIATION  PAGE CITATION: AME
                          MEDICAL EXAMINER        GUIDE

  Antacids                ND                      51

  Amphetamines            DIS                     28, 66, 71

  Anticoagulants          MPC/ DFR                22, 27, 49

  Antidepressants         DIS                     70

  Antihistaminic          MPC see footnote        22
                          below\*                 

  Antihypertensive        MPC see footnote        22, 27, 95
                          below\*\*               

  Antiviral               MPC/ DFR                22

  Anxiolytics             DIS                     22, 28, 86, 70, 71

  Aspirin                 ND see footnote re:     27, 58
                          dipyramidole            

  Barbiturate             DIS or DFR              22

  Cocaine                 DIS                     28, 66, 71

  Contraceptives          ND                      55

  Cyclic hormones         ND                      55

  Desensitization         ND                      25
  injections                                      

  Experimental drugs      DFR                     22

  Hallucinogens           DIS                     28, 66, 70, 71

  Hypnotics               DIS                     28, 66

  Hypoglycemic            MPC/ DFR                3\. 22, 28, 72, 75, 98

  Ibuprofen               Tolerated? No side      58
                          effects?                

  Illegal substances      DIS                     28

  Insulin                 DIS                     3, 28, 72, 75, 98

  Investigational         DFR                     22

  Marijuana               DIS                     28, 71

  Mood ameliorating       DIS, DFR                22

  Motion sickness         DFR                     22, 29

  Mydriatic               EX Not recommended for  40, 92
                          exam                    

  Naproxen                Tolerated? No side      58
                          effects?                

  Narcotics               DIS                     22

  Opioids                 DIS                     28, 66, 71

  Oral Hypoglycemic       MPC/ DFR                3, 74

  Phenylephrine HCl       EX: May be used in ENT  36
                          exam                    

  Psychoactive            DIS                     28,66, 71

  Psychotropic            DIS                     68, 70

  Sedative                DIS                     28, 66, 70, 71

  Steroid                 MPC/DFR                 22

  Stimulant               DIS                     66

  Sucralfates             ND Tolerated? No side   51
                          effects?                

  Substance, abuse/depend DIS                     3, 28, 30, 31, 66, 67,
                                                  71, 72,

  Tranquilizers           DIS                     22, 70

  Warfarin                MPC/ DFR                49
  ----------------------- ----------------------- -----------------------

DIS=DISQUALIFYING

ND=NOT-DISQUALIFYING (Medication well tolerated? No side effects?)

DFR=DEFER TO FAA

EX=USED IN EXAMINATION

MPC/DFR=MAY PRECLUDE CERTIFICATION (DEFER)

ANTIHYPERTENSIVES: Diuretics, α-adrenergic blocking agents, β-adrenergic
blocking agents, Calcium channel blocking agents, ACE inhibitors, direct
vasodilators. This assumes the medicine is well tolerated and does not
produce side effects.

\*\*ANTIHISTAMINES: Loratidine, Astemizole or Fexofenadine not
disqualifying assuming that the medication is well tolerated and does
not product side effects.

\*\*\*ASPRIN (Dipyridamole, a coronary vasodilator and platelet
aggregate inhibitor, may not be disqualifying

According to one of the FAA's publications which offers the following
advice and recommendations:

READ and follow label directions for use of **[all]{.underline}**
medications

If the label warns of side-effects, do **[NOT]{.underline}** fly until
twice the recommended dosing interval has passed. For example, if the
label says "take every 4-6 hours" then wait at least 12 hours!

Remember, the condition you are treating may by as disqualifying as the
medication itself.

When in doubt, ask your physician or Aviation Medical Examiner.

As a pilot, you are responsible for your own personal "pre-flight." Be
wary of any illness that requires medicine to make you feel better.

If an illness is serious enough to require medication it is also serious
enough to prevent you from flying.

Do not fly if you have a cold, changes in atmospheric pressures with
changes in altitude could cause serious ear and sinus problems.

Avoid mixing decongestants and caffeine

Beware of medications that use alcohol as a base for the ingredients

IN SUMMARY: IF **IN DOUBT, ERR ON THE SIDE OF CAUTION!** TO QUOTE THE
WISE PILOTS OF YESTERYEAR, **"TIS BETTER TO BE A LIVE CHICKEN, THAN A
DEAD DUCK!"**