In the U.S., drugs are either over the counter or scheduled. Scheduled drugs require a prescription (British: script) from a doctor to purchase. Over the coutner drugs can be purchased freely and include non-opiate painkillers, antihistamines, decongestants, caffeine, antacids, antibiotic ointments, and laxatives, among others. The distinction is made at the level of individual chemicals, though, so some drugs in any of the above categories may still require a doctor's okay (presumably because they are not sufficiently tested, or because their side effects are severe enough to require medical oversight).

Scheduled drugs include oral antibiotics, antidepressants, opiates, and many others. Schedules range from V (loosely controlled) to I (cannot be prescribed by any doctor; usable only in limited experimental contexts; supposedly highly addictive and life-threatening to use). If you wonder why I'm qualifying these terms so heavily, note that marijuana is schedule I.
A process of selling and buying stocks without using a organized stock exchange. Instead, sales are done directly via the telephone or computer. Some stocks and bonds are listed on the New York Stock Exchange but nevertheless traded over the counter. The Nasdaq is an example of an over the counter market--it has no central physical location.

The phrase refers to direct trading, as in a retail store where payment was made over a real counter.

Over the counter trades are transactions which have not taken place on an exchange or a market (which includes all electronic exchanges, such as LIFFE and NASDAQ). Whereas when trading in a market, there is anonymity in the transaction, for OTC trades, the buyer and the seller, the counterparties are not only known to each other, they are chosen by each other.

An OTC transaction is a bilateral agreement, between the counterparties, and includes a contractual requirement to fufill one or more obligations at some future dates.

Equities

Equities are traded mainly on exchanges. This is because, when buying 200 Joe Smith shares, you don't really care where the shares come from. For this, 'The Market' is a perfect vehicle for getting you the shares that you want, at the right price. Much the same is true of government bonds.

Loans

A very different picture emerges, when it comes to loans and deposits. The borrower and lender are very much interested in whom the other counterparty is. As such, loans are nearly always OTC transactions, and the agreement includes a contract for future commitment to repayments. The issue of credit risk becomes important.

Derivatives

Exchange traded derivatives are mainly options and futures. Both of these derivatives have very strict rules. Expiry of all contracts for a given derivative instrument occurs only on certain dates. For futures, these occur at three month intervals.

By contrast, OTC derivatives are much more flexible. As there is no central market, it is up to the two counterparties to negotiate terms and conditions, including dates. OTC derivatives include:

  • Forwards: These are the OTC equivalent of futures, and are used for short term hedging or speculation on an index. These include Forward Rate Agreements (FRAs).

  • OTC Options: These include Contracts For Differences (CFDs).

  • Swaps: A swap is an equal and opposite exchange of two loans for the same principal amount, but with different terms for each loan. For example, an interest rate swap might be between a fixed rate of 5% and a floating rate of LIBOR (London Inter-Bank Offer Rate). Swaps are generally long term transactions, and can last for up to 30 years.

  • Repos: An agreement to sell a bond (often a government bond) at one price with a simultaneous agreement to repurchase the bond at a later date at a price agreed today. Effectively, a repo trade enables the holder of a bond to borrow money while using the bond as financial collateral with the lender.

It sometimes amazes me how many people go around taking and recommending all sorts of over-the-counter medications without really understanding these drugs. When used correctly, OTC medications can be extremely safe and effective in reducing the discomfort of colds, flu, allergies, and pain. I've noticed a number of myths and misconceptions surrounding various OTC drugs. I am not a doctor, but I'm something of a health scholar, who has an obsessive interest in reading labels and ingredients lists.

Respiratory Distress: Colds and Allergies

First of all, let's address the decongestant / antihistamine issue. This is probably the biggest area of confusion, at least from what I've observed. Decongestants do exactly what they say they do: help relieve congestion. That is, they stimulate the sympathetic nervous system which in turn causes blood vessels (especially in the nose) to constrict. Decongestants include:

Antihistamines, on the other hand, work by blocking chemicals called histamines that are responsible for many symptoms of allergic reaction: swelling, itching, runny nose. They have a soporific effect on most people (though there can be a paradoxical reaction of hyperactivity, especially in children). There are a wide number of antihistamines available. Some commonly seen OTC antihistamines include:

Many people seem convinced that antihistamines will help them if they have a cold. This is highly unlikely -- a person with an acute viral respiratory illness would be far better off taking a decongestant. Taking Benardryl when you have a cold is just likely to make you sleepy, though it might dry up your nose a bit. However, the whole point of major mucus draninage during an infection is to get the nasties OUT of your body. A decongestant might make your nose a little more runny for a while, but would you rather keep all that goopy green stuff inside?

If you have allergies, there is no therapeutic benefit to sniffling and leaking everywhere. Therefore, an antihistamine can be useful in stopping the booger faucet and turning the whites of your eyes white again (rather than red). If you have sinus-related allergies, decongestants can help relieve pressure, so it might be in your interest to take both -- or even just the decongestant if your main complaint is sinus pain.

Pain and Inflammation

The most popular non-prescription pain relievers today are:

Just kidding about the beer.

Acetaminophen

Acetaminophen is an analgesic that works by raising the body's pain threshold. It also acts as a fever reducer by acting on the heat-regulating center in the brain. The mechanism by which acetaminophen performs its therapeutic tasks is not entirely understood, however, years of use and numerous scientific studies attest to its efficacy. Acetaminophen has its benefits and its drawbacks. On the positive side, acetaminophen is unlikely to cause stomach irritation, can generally be used safely by pregnant and nursing mothers, and will not prompt deadly complications if administered to a child with flu or chicken pox. On the negative side, acetaminophen can be harmful to the liver in large doses or if taken in conjunction with alcohol.

The most common misconception about acetaminophen is that it works just like aspirin or ibuprofen, without the potential for stomach upset. This is not the case, for practically all other OTC pain relievers also have anti-inflammatory action. Tylenol might relieve your pain and fever, but it won't relieve swelling of any sort.

Aspirin

Aspirin has analgesic, anti-inflammatory, and anticoagulant properties. Its uses range from simple headache relief to treatment of heart attacks. Due to its wide availability, varied utility, and low cost, aspirin is an extremely popular drug. All my grandparents and great-grandparents always had aspirin in their cabinets; it is likely that while they were growing up, aspirin was seen as something of a panacaea. Interestingly, "baby aspirin" has become something of a misnomer -- it is generally considered bad practice to give aspirin to babies and children due to the possibility of Reye's Syndrome (a potentially fatal brain complication). Baby aspirin is now marketed to middle-aged and older adults as something they should take daily as a sort of cardiovascular insurance. It has been determined that daily low doses of aspirin can help prevent heart attacks and reduce the chance of death if an individual experiences a heart attack. However, some studies have indicated that taking aspirin daily over an extended period of time can contribute to the development of pancreatic cancer.

Some individuals should not take aspirin, particularly those who are already taking prescription blood-thinning medications, or those with stomach ulcers or a tendency toward heartburn. Some manufacturers produce enteric-coated aspirin, which can minimize stomach upset in many people. So who should take aspirin? People with headaches, cramps, and sports injuries can probably benefit from aspirin's effective, if a bit short-acting, anti-inflammatory and analgesic effects. There is some question as to whether anyone should take it daily, however, if you are having a heart attack, aspirin might very well save your life.

Ibuprofen

Ibuprofen is a member of the non-steroidal anti-inflammatories, commonly known as NSAIDs. Formerly a prescription-only drug, ibuprofen quickly gained popularity in the 1980s as an alternative to acetaminophen. I remember commercials emphasizing the fact that, unlike Tylenol, Advil could reduce inflammation and therefore more effectively treat discomfort from arthritis. Non-prescription strength ibuprofen is normally around 200 mg per tablet or capsule. At this level, ibuprofen mainly acts as an analgesic, and secondarily as a fever reducer. In order to really take advantage of the anti-inflammatory properties of ibuprofen, you need to take doses of 600-800 mg at a pop, for at least several days in a row. I was given high doses of ibuprofen following dental work and a back injury and it definitely helped with the pain and swelling. However, it had some less-than-desirable gastrointestinal effects, so the relief came with a price.

Ibuprofen is a good basic everyday pain reliever. Most people find that at non-prescription doses, it is easier on the stomach than aspirin and can quickly help with headaches and menstrual cramps. Ibuprofen is relatively safe to give to children (Children's Motrin has been around since 1989) however it should not be given to anyone who has a known allergy to aspirin or any other anti-inflammatory. A few children have had serious reactions to ibuprofen (resulting in burn-like lesions and blindness), however, this is EXTREMELY rare -- and for every drug that helps millions, there is bound to be at least one person who reacts badly to it.

Naproxen

Naproxen sodium is the active ingredient in the newer OTC NSAID, Aleve. I love this stuff. Its main selling point is its long duration of action: one tablet can relieve pain for 6-8 hours. Like ibuprofen, its anti-inflammatory effects are much more pronounced at higher doses -- but generally you should not take more than two tablets at once without consulting a doctor. Naproxen's positive and negative properties are similar to those of ibuprofen -- naproxen just lasts longer. I've found naproxen to be much better on the stomach than ibuprofen, but your mileage may vary. Everyone is different.

Marketing, Advertising, and Customer Psychology

OTC medication manufacturers are some of the most persistently inventive advertisers and competitors in the retail industry. Why should you choose one pain reliever or decongestant over another? Newer drugs (such as Aleve and Claritin) try to portray themselves as revolutionary new treatments that are more effective than their predecessors. Older drugs (such as Bayer aspirin and Tylenol) take advantage of their senior status by emphasizing that since they've been around for so many years, they obviously must be safe and effective (i.e., they appeal to customer comfort and loyalty). In addition to this, some older drugs are popping up in new formats and formulations -- Tylenol now offers a sustained-release version marketed to arthritis sufferers, presumably to compete with Aleve.

OTC medication packaging is one of the most important components of the product. The imperial blue of Aleve, the deep teal of Advil, the red and white of Sudafed. You will notice that drugstore generic brands often mimic the color scheme of the national brands -- this has the effect of subconsciously assuring some customers that they are, in fact, getting an equally efficacious product. Notice that I say "some" customers. Even though generic medications generally contain the exact same chemicals as the brand name ones, and must meet the same quality standards (supposedly), many people are convinced that "their" brand is somehow more trustworthy than the store brand. It is a testament to the drug companies' understanding of human nature that major brands sell very well despite the fact that far cheaper alternatives exist. The price difference between a generic medication and a brand-name medication can be gaping: I've seen generic pseudoephedrine, for example, that is only 1/3 the price of brand-name Sudafed.

However, I generally end up buying the expensive stuff like the rest of the sheep. Why? Well, I've had some sketchy results with OTC medications. For instance, I am highly allergic to household dust. A few summers ago I got a really bad itchy rash on my hands because I made the mistake of dusting my apartment without gloves on. It was extremely uncomfortable, so I decided to get some antihistamines so I could sleep. Being a poverty-stricken college graduate, I went for generic diphenhydramine. Same chemical as Benadryl, same strength. It didn't work at all. I took 5 tablets in one night and didn't even get a wee bit sleepy, nor did my itching go away. Perhaps this box was past its expiration date, or perhaps my allergy was so severe that the antihistamine just couldn't touch it, but overall it gave me a bad impression of generic antihistamines. Both my boyfriend and I agree that the regular Sudafed does seem more effective on sinus pressure than the generic stuff. Are we victims of the placebo effect, or is there something more sinister (like dodgy manufacturing processes) at work here? I do not like to think that I'm susceptible to tricky advertising, but the possibility certainly exists.

Then there is the psychological trigger principle I learned about from my dad, who used to maintain swimming pools as a side project when I was a young child. On the East Coast, people's pools often get very nasty over the winter, especially if the cover is not properly fitted. Generally, when my dad would remove the cover (if there even was one), the water in his customer's pool would be green, brown, or both. This is what happens to stagnant water when it is left alone for months at a time: algae moves in, leaves drop in and decay, raccoons drown, birds use it as a toilet. Not fun to swim in. I often accompanied my dad on his pool maintenance missions and we always stopped off at the grocery store before going to the customer's house. My dad would purchase about 6 large bottles of household bleach, and proceed to rip the labels off them. He warned me not to use the word "bleach" around the customers.

When I asked why, my dad explained to me that if the customers knew it was just plain old Clorox he was dumping in the pool, they might not want him to do it. Putting bleach into a pool has the effect of decontaminating the water after a long winter (who wants to swim in dead raccoon juice?), and preparing it for regular summer maintentance with chlorine tablets. When the customers asked my dad what he was dumping into the pool, his first response was "chemicals". If they asked, "What chemicals?" he'd answer truthfully: "Sodium hypochlorite". They would generally nod and smile at this, and eventually go on to enjoying their nice clean pool. By not using the word "bleach", my dad was able to save a lot of money (they sell expensive pool "shock" kits that do the same job as regular bleach, but for ten times the cost) and keep the customers comfortable both physically and psychologically.

How does this relate to the OTC drug discussion, though? Well, when buying medication, it is always a good idea to look beyond the bright, bold text on the packaging and get to the fine print. I saw an advert recently for "Bayer Back and Body". This product is advertised as "aspirin, with a pain relief enhancer". Any reasonably intelligent consumer would probably wonder what, exactly, this "enhancer" was. Reading the package at a local drugstore, I discovered that the mystical pain relief enhancer is, in fact, caffeine. Many people probably buy this medication never knowing that it contains caffeine. There is no deception in Bayer's advertising -- after all, caffeine can enhance pain relief, especially headache pain, not to mention that it will probably make you feel more sprightly in general. It's a stimulant. Any literate individual can read the packaging and see "CAFFEINE" listed under Active Ingredients. But Bayer would probably lose some of their target market if their TV commercials stated outright, "This medication contains aspirin and caffeine".

What is the moral of all this? Basically, I am just urging people to be aware of what they are putting into their bodies, and why. The result will be that you feel better (because you'll know when to take what and when not to take certain things), and smarter (because you'll be an informed consumer, not someone at the mercy of clever advertising).


References:

The vast majority of this essay was straight out of my head, from years of careful label-reading. Some technical details were checked at the following: http://www.medhelp.org and
http://www.medicinenet.com

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