New study reveals disturbing price variation within chain retailers – National Consumers League

/in imported/by

Chain drugstores are convenient, but are their prices fair and transparent? While savvy consumers know comparison shopping between physical retailers and online outlets is essential to saving money, new research reveals that comparing in-store prices at different locations of the same chain is just as important.

With drugstores expanding their offerings and vying for more of our dollars, Change to Win Retail Initiatives in partnership with the National Consumers League surveyed 485 Walgreens, CVS and Rite Aid locations throughout the country to see how consistent in-store pricing is within each chain and how shoppers can get the best deals.

“Certainly consumers expect different chains to offer different deals,” said Sally Greenberg, Executive Director of NCL, the nation’s pioneering consumer advocacy organization. “But price variation within a single chain is a wake-up call for consumers, who don’t tend to shop around and compare within a chain. This is a reminder that caveat emptor – let the buyer beware – applies even within the same chain, where prices may vary depending on where you’re shopping.”

Key findings for all markets surveyed include:

  • Walgreens prices were all over the map. Walgreens stores in a single market were up to five times more likely than a competitor to charge different prices for the same item. This price variation was not limited to one or two items; researchers encountered storewide price differences at Walgreens at a rate several times higher than the other chains in most markets.
  • Price differences at Walgreens often meant consumers were paying more. In every market surveyed, Walgreens had the greatest percentage of products that cost at least 10 percent more than the market’s lowest price.
  • Walgreens had the biggest price differences between its stores. In all markets surveyed, Walgreens had twice the number of products with a 20 percent or greater price range than did CVS. Rite Aid had virtually no products with that big of a gap. Walgreens also had significantly more items with a price range of a dollar or greater.

The study includes several tips for how shoppers can get the best price at drugstore chains. Tips include avoiding Walgreens flagship stores and asking managers about price matching.

Tips for Getting the Best Price
In addition to searching for sales and coupons, here are some tips for getting the best price at your drugstore:
Ask about price matching.
While none of the chains will match their online prices at brick-and-mortar locations, managers often have the ability to match prices from other stores within their chain.

Watch your wallet.

Shoppers can’t count on the price on the shelf to be the best the chain offers—especially at Walgreens. Keep track of the prices of your drugstore staples and shop around to find the best ones.

Avoid Walgreens “flagship” stores.

Walgreens has said that flagship stores are more expensive, and the survey found proof of that. The basket of items in the survey cost nearly 20 percent more —or $38 extra—at a flagship store in New York than it typically did at other Walgreens in the city.

‘Double Check, Don’t Double Up’ on acetaminophen this cold and flu season

/in imported/by

A bad cold or the flu can stop you in your tracks. Each year, Americans catch an estimated 1 billion colds, and up to 20 percent get the flu. And most of us turn to medicine to relieve symptoms; but it is important that you read the label on your medicines to check for acetaminophen and don’t double up.

After the first of the year, it seems like influenza (flu) season magically appeared, with a fierce intensity. Cases of flu are growing fast, and it is predicted that this season might be one of the worst in years.

More than 600 different over-the-counter and prescription medicines contain acetaminophen, including many for cough, cold and flu. It is the most common drug ingredient in America and can be in many prescription medicines taken by people who suffer from chronic health conditions such as fibromyalgia, arthritis, or back pain. It can also be found in many different types of over-the-counter medicines taken by people with temporary conditions such as fever or aches and pains. Acetaminophen is safe and effective when used as directed but there is a limit to how much you can take in one day. Taking more than directed is an overdose and can lead to liver damage.

The National Consumers League is a member of the Acetaminophen Awareness Coalition, which educates consumers and patients about how to use medicines containing acetaminophen appropriately and to help change behaviors that could lead to an unintentional acetaminophen overdose. The Acetaminophen Awareness Coalition’s Know Your Dose Campaign wants consumers to “double check” their medicine label so they don’t “double up” on medicines containing acetaminophen. If you take medicine to relieve cold or flu symptoms, check your medicine label to know if your medicine contains acetaminophen.

Know Your Dose is promoting four important steps for safe acetaminophen use:

  1. Check if your medicine contains acetaminophen
  2. Never take two medicines that contain acetaminophen at the same time
  3. Always read and follow the medicine label
  4. Ask your healthcare provider or pharmacist if you have questions about dosing instructions or medicines containing acetaminophen.

If you are wondering how to actually read the label on your medication, check out this interactive Drug Facts Label. Here you can find out where to look to see if your medicine contains acetaminophen.

Learn more at www.KnowYourDose.org. Follow the Campaign on Twitter @KnowYourDose.

Changes for asthma medication – National Consumers League

/in imported/by

Recently there has been important news from the Food and Drug Administration about the medications used to treat asthma. Understanding your asthma medications will help you understand your asthma and keep you healthy.

If you have asthma you should be seeing a health care practitioner and have a treatment plan in place, which may include medications. Asthma is usually treated with two kinds of medications – fast-acting inhalers (or rescue inhalers) and long-term controllers. Recently the Food and Drug Administration (FDA) made some important announcements regarding both long-term controllers and fast-acting inhalers.

Long-term controllers: long-acting beta-agonists (LABAs)

LABAs are used as long-term asthma controllers relax muscles in the airways and lungs. They can help patients breathe easier and lessen symptoms of asthma such as wheezing and shortness of breath. Because of safety concerns, FDA is requiring changes to how LABAs are used to treat asthma. Studies have shown that use of LABAs increase the risk of hospitalization and even death.

FDA is now requiring the following to appear on the label to ensure the safe use of the LABAs:

  1. LABAs should only be used by those who cannot control their asthma with other medications, and then only for the shortest possible time.
  2. LABAs should never be used without also taking an asthma controller medication, like an inhaled corticosteroid. Medications that include both a LABA and an inhaled corticsteroid are Advair and Symbicort. Single ingredient LABAs such as Serevent and Foradil, should not be used alone.
  3. Children and teens should be prescribed only the combination LABAs to ensure compliance with both medications.

In addition to the label changes, FDA is requiring the manufacturers of LABAs to study the drug’s safety when combined with other drugs, such as inhaled corticosteroids. The manufacturers must also develop risk evaluation and mitigation strategies. These include new medication guides for patients and an education plan for healthcare professionals about the appropriate use of LABAs,

Fast-acting inhalers

Recently the FDA announced the phase out of seven fast acting inhalers that use chlorofluorocarbons (CFCs). Due to concerns about how CFCs damage the earth’s ozone, which protects life from the damaging effects of the sun’s ultraviolet rays, the US has been banning the use of CFCs since the 1970s. CFCs, which make the contents of a canister spray out, have been banned in most consumer aerols, (such as hairspray) for decades. CFCs aren’t harmful to people. Medical devices using CFCs are among the last to be affected.

Many manufacturers have reformulated or are reformulating their inhalers so they don’t contain CFCs. Four of the seven inhalers that were part of FDA’s announcement are no longer being made. The three other inhalers will be phased out over the next three years, and will be banned after the end of 2013. A new way of delivering asthma medications has started replacing CFCs and is called hydrofluoroalkane (HFA). It has been used in inhalers for more than a decade and will continue to replace CFC inhalers as they’re phased out.

The asthma medication in the new inhalers is the same. Only the way the inhaler gets the medicine to your lungs is different. If you use one of the CFC inhalers being phased out, talk to your health care practitioner about using another type of inhaler that does not use CFCs

For more information on the devices that are no longer being made and whose sale will be forbidden after 2013 see the FDA’s announcement.

Consumers wary of therapeutic substitution – National Consumers League

/in imported/by

Therapeutic substitution, known also as drug switching and therapeutic interchange, is the practice of replacing a patient’s prescription drugs with chemically different drugs that are expected to have the same clinical effect. Many times patients switch to a different drug with no problems. However, for certain medications and conditions, therapeutic substitution could cause problems.

Consumers with a few specific conditions may be more likely than others to encounter a switch. Here are some of the conditions in which therapeutic substitutions may be more common, as well as the concerns about substitution expressed by some patient groups. As always, it is important to talk to your doctor about any potential therapeutic substitution.

In the lists of medicines, the Brand Name comes first, (and generic version is in parentheses).

Antidepressants 
Antidepressants stimulate chemical changes that increase the levels of neurotransmitters in the brain responsible for a person’s mood.

Some examples of antidepressants:
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram). Antidepressants are associated with drug groups known as MAOIs, tricyclics, and SSRIs and are commonly prescribed by psychiatrists and other physicians to treat depression, bipolar disorder, and other mental illness.

Substitution concerns:
The American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and the National Council for Community Behavioral Healthcare oppose therapeutic substitution based on the substantial risk of serious adverse outcomes in people with mental illness. These groups support policies that provide patient access to the medications their doctors think they need, and they encourage shared patient-physician decisions based on the unique needs of individuals.

Cardiovascular Medications
There are several classes of drugs used to protect your heart, monitor your cholesterol level and blood pressure, and prevent other damage.

  • ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing stroke, and preventing kidney damage in people with hypertension or diabetes. They also improve survival rates in patients who have had a heart attack.
  • Examples of ACE Inhibitors include: Capoten (captopril), Vasotec (enalapril), Prinivil (lisinopril), Accupril (quinapril) and Univasc (moesxipril)
  • Statins are used to lower cholesterol levels in people at risk of developing heart disease.
  • Examples of statins include: Lipitor, Zocor (simvastatin), Crestor, Pravachol (pravastatin), Mevacor (lovastin).

Substitution concerns:
The American Heart Association and the American College of Cardiology oppose therapeutic substitution and believe that only the prescribing doctor is equipped to determine the best drug or combination of drugs. These organizations believe that therapeutic substitution may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.

Epileptic medications
The drugs taken by patients with epilepsy are called antiepileptic drugs (AEDs) and are designed to change the electrical signaling in the brain to stop or prevent seizures. 

Examples of AEDs include:
Dilantin (phenytoin), Luminal (phenobarbital), Tegretol (carbamazepine), Neurontin (gabapentin), Lamictal (lamotrigine), Gabitril, Keppra, and Zonegran (zonisamide).

Substitution concerns:
The Epilepsy Foundation is concerned that there are enough differences among AEDs that any kind of medication substitution, (including switching from brand-name to generic), could be dangerous, and it could result in less control over seizures. The Epilepsy Foundation says that changing from one drug formulation to another can usually be done successfully if the patient’s blood levels, seizures, and toxicity are carefully monitored, but it says any medication change must require the permission of the treating doctor and the patient.

Proton-pump Inhibitors
Patients with dyspepsia, peptic ulcer disease, or acid-reflux may be prescribed a proton-pump inhibitor (PPI), drugs that result in long-lasting reduction of gastric acid production.

Examples of PPIs include:
Prilosec (omeprazole), Prevacid (lansoprazole), Nexium.

Substitution concerns:
As with any substitution, it is important to talk to your doctor, and be aware of the benefits and risks of substitution.

Don’t waste your money-or your health-on counterfeit drugs – National Consumers League

/in imported/by

When shopping around for prescription medications, watch out for fakes! You could throw your money away on drugs that don’t work, or — even worse — get sick by taking counterfeits that aren’t what they pretend to be.

  • Counterfeit drugs may not have the same active ingredients as the real thing. They may also be produced in unsanitary conditions. Counterfeits could actually make you MORE ill.
  • Only buy prescription drugs from safe, reputable sources. Check unfamiliar sellers with your state board of pharmacy or the National Association of Boards of Pharmacy (NABP). Go to www.nabp.net, click on “Who We Are,” then “Boards of Pharmacy” for a list, or call 847- 391-4406. When buying online, look for Web sites displaying the NABP’s VIPPS seal, indicating that the pharmacy meets state and federal requirements.
  • Don’t be fooled by the packaging. Know the size, shape, color, taste, and side effects of the drugs you take, and examine new packages to make sure everything is right. If you notice anything different about the packaging or the actual medicine, alert the pharmacist and your doctor immediately.
  • Also report your suspicions to the U.S. Food and Drug Administration (FDA). If you bought the drug by mail, telephone, or in person, contact the FDA Medwatch program, 800-332-1088. To report counterfeit drugs purchased on the Internet, use the form at www.fda.gov/oc/buyonline/buyonlineform.htm or call the Medwatch number.
  • For more information from the National Consumers League about counterfeit drugs, visit fraud.org.

Don’t waste your money – or risk your health – on counterfeit drugs – National Consumers League

/in imported/by

When shopping around for prescription medications, watch out for fakes! You could throw your money away on drugs that don’t work, or — even worse — get sick by taking counterfeits that aren’t what they pretend to be.

  • Counterfeit drugs may not have the same active ingredients as the real thing. They may also be produced in unsanitary conditions. Counterfeits could actually make you MORE ill.
  • Only buy prescription drugs from safe, reputable sources. Check unfamiliar sellers with your state board of pharmacy or the National Association of Boards of Pharmacy (NABP). Go to www.nabp.net, click on “Who We Are,” then “Boards of Pharmacy” for a list, or call 847- 391-4406. When buying online, look for Web sites displaying the NABP’s VIPPS seal, indicating that the pharmacy meets state and federal requirements.
  • Don’t be fooled by the packaging. Know the size, shape, color, taste, and side effects of the drugs you take, and examine new packages to make sure everything is right. If you notice anything different about the packaging or the actual medicine, alert the pharmacist and your doctor immediately.
  • Also report your suspicions to the U.S. Food and Drug Administration (FDA). If you bought the drug by mail, telephone, or in person, contact the FDA Medwatch program, 800-332-1088. To report counterfeit drugs purchased on the Internet, use the form at www.fda.gov/oc/buyonline/buyonlineform.htm or call the Medwatch number.
  • For more information from the National Consumers League about counterfeit drugs, visit Fraud.org.

Common therapeutic drug substitutions – National Consumers League

/in imported/by

Therapeutic substitution, known also as drug switching and therapeutic interchange, is the practice of replacing a patient’s prescription drugs with chemically different drugs that are expected to have the same clinical effect. Many times patients switch to a different drug with no problems. However, for certain medications and conditions, therapeutic substitution could cause problems.

Consumers with a few specific conditions may be more likely than others to encounter a switch. Here are some of the conditions in which therapeutic substitutions may be more common, as well as the concerns about substitution expressed by some patient groups. As always, it is important to talk to your doctor about any potential therapeutic substitution.

In the lists of medicines, the Brand Name comes first, (and generic version is in parentheses).

Antidepressants 
Antidepressants stimulate chemical changes that increase the levels of neurotransmitters in the brain responsible for a person’s mood.

Some examples of antidepressants:
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram). Antidepressants are associated with drug groups known as MAOIs, tricyclics, and SSRIs and are commonly prescribed by psychiatrists and other physicians to treat depression, bipolar disorder, and other mental illness.

Substitution concerns:
The American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and the National Council for Community Behavioral Healthcare oppose therapeutic substitution based on the substantial risk of serious adverse outcomes in people with mental illness. These groups support policies that provide patient access to the medications their doctors think they need, and they encourage shared patient-physician decisions based on the unique needs of individuals.

Cardiovascular Medications
There are several classes of drugs used to protect your heart, monitor your cholesterol level and blood pressure, and prevent other damage.

  • ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing stroke, and preventing kidney damage in people with hypertension or diabetes. They also improve survival rates in patients who have had a heart attack.
  • Examples of ACE Inhibitors include: Capoten (captopril), Vasotec (enalapril), Prinivil (lisinopril), Accupril (quinapril) and Univasc (moesxipril)
  • Statins are used to lower cholesterol levels in people at risk of developing heart disease.
  • Examples of statins include: Lipitor, Zocor (simvastatin), Crestor, Pravachol (pravastatin), Mevacor (lovastin).

Substitution concerns:
The American Heart Association and the American College of Cardiology oppose therapeutic substitution and believe that only the prescribing doctor is equipped to determine the best drug or combination of drugs. These organizations believe that therapeutic substitution may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.

Epileptic medications
The drugs taken by patients with epilepsy are called antiepileptic drugs (AEDs) and are designed to change the electrical signaling in the brain to stop or prevent seizures. 

Examples of AEDs include:
Dilantin (phenytoin), Luminal (phenobarbital), Tegretol (carbamazepine), Neurontin (gabapentin), Lamictal (lamotrigine), Gabitril, Keppra, and Zonegran (zonisamide).

Substitution concerns:
The Epilepsy Foundation is concerned that there are enough differences among AEDs that any kind of medication substitution, (including switching from brand-name to generic), could be dangerous, and it could result in less control over seizures. The Epilepsy Foundation says that changing from one drug formulation to another can usually be done successfully if the patient’s blood levels, seizures, and toxicity are carefully monitored, but it says any medication change must require the permission of the treating doctor and the patient.

Proton-pump Inhibitors
Patients with dyspepsia, peptic ulcer disease, or acid-reflux may be prescribed a proton-pump inhibitor (PPI), drugs that result in long-lasting reduction of gastric acid production.

Examples of PPIs include:
Prilosec (omeprazole), Prevacid (lansoprazole), Nexium.

Substitution concerns:
As with any substitution, it is important to talk to your doctor, and be aware of the benefits and risks of substitution.

Aspirin and coronary vascular disease – National Consumers League

/in imported/by

Aspirin is a very common medication. It can be used to reduce pain, fever, and inflammation. Aspirin has another important benefit: it can reduce the risk of another heart attack or stroke in a person who has already had one. Studies are being conducted to see whether aspirin can prevent a first heart attack or stroke; some doctors recommend aspirin to certain patients who are at risk.

To be effective in helping prevent a heart attack or stroke, aspirin must be used properly. Using aspirin for the prevention of coronary vascular disease (CVD) is very different from using it to treat a headache or fever.

Like all medications, there are risks when taking aspirin—including stomach bleeding and kidney, heart, and liver problems—when taken daily for weeks, months, or years. This Web site will help answer some basic questions about aspirin use for CVD. Talk to your health professional before taking aspirin for CVD prevention. Follow all directions on the label before you take any over-the-counter medicine. If you are not sure, or have any questions about any medication, ask your doctor, pharmacist, or other health professional. 

Questions and answers

Aren’t all pain killers/analgesics the same?

No. There are many types of pain killers/analgesics. They work in different ways in the body, and some are more appropriate than others for certain types of conditions.

How do I know which analgesic is right for me?

You should talk with your health professional (doctor, nurse, pharmacist) about the most appropriate medicine for your situation.

I heard that aspirin is effective in helping to reduce my risk of heart attack or stroke. Are any other analgesics/pain killers also effective?

Only aspirin (salicylic acid) has been proven to effectively reduce the risk of CVD. Many common analgesics contain other ingredients such as ibuprofen (Advil‘, Motrin IB‘), acetaminophen (Tylenol‘), and naproxen (Aleve‘, Naprosyn‘) that have not been proven to reduce the risk of CVD. Read the labels to make sure you are taking aspirin. Many products have more than one active ingredient, including aspirin.

Can I just take the same aspirin that is in my medicine chest at home?

A. You should consult with your health professional before beginning an aspirin-therapy regimen. There are many different varieties of aspirin products to meet your needs. For example, if you have gastrointestinal (GI) problems or are already on medication for GI problems, you may want to take an “enteric coated” (Ecotrin‘, Ascriptin‘) or “buffered” (Bufferin‘) aspirin to reduce your chances of stomach upset. Enteric-coated aspirin is specially designed to dissolve more slowly to avoid stomach upset. Buffered aspirin contains antacids to neutralize the acid in your stomach that causes upset. Read the label to make sure you are taking the appropriate product.

How many aspirin should I take to get the benefit? What is the right dose?

A. Studies have shown that a low-dose (81 mg.) a day is effective in reducing the risk of CVD and stroke. Most aspirins come in doses of 325 mg. or extra strength doses of 500 mg. Look for the product with the dose recommended to you by your health professional

Are aspirin products available in a low-dose form?

Yes. There are a variety of low-dose aspirin products available. Your doctor can recommend one for you. Some common low-dose products include Ecotrin‘ and Bayer‘. If you have trouble finding them at the pharmacy, ask your pharmacist to help you.

What about side effects or interactions with other medicines?

As with any medication, you should talk to your health provider about any and all medicines, including over-the-counter and prescription medicines and dietary supplements (vitamins, minerals, herbals) you are currently taking. Certain medications and dietary supplements can interact with aspirin and cause serious problems. Aspirin is a blood thinner. If you are on a blood-thinning medicine such as coumadin/warfarin or heparin, taking high doses of vitamin E or certain other dietary supplements (gingko biloba, ginseng, garlic, willow bark), check with your health provider. Always read the labels of all your medicines to check for side effect and interaction warnings.

Speak the language of your drug coverage plan – National Consumers League

/in imported/by

If you’re facing the opportunity to choose a new drug coverage plan for you and your family, you need to speak the language in order to weigh the costs and benefits.

Brand name (drug): A one-of-a-kind drug that is still protected by a patent.

Co-pay (or co-payment): A fixed amount, for example $10, that an insured individual pays for health services, regardless of the actual cost of that service.

Co-insurance: A percentage of the cost of a health service, usually 20%, paid by the insured individual.

Deductible: An amount an insured individual must pay for health services before their insurance plan begins to pay any benefits. For example, the individual may be required to pay the first $500 before the insurance company will pay for subsequent services.

Formulary:A list established by a health plan or PBM to indicate which drugs they cover or which tier drugs are in.

Generic drug: A drug that is no longer patent protected, so that many companies can copy and manufacture the drug with the same active ingredient as the original inventor.

Mail Order: Prescriptions that are received in the mail.

Out-of-Pocket Maximum: An upper limit on how much an individual or family must pay in a year for health services. Once the limit is reached, co-insurance and sometimes co-payments do not have to be paid.

OTC Drugs: Over-the-counter (OTC) drugs can be purchased without a prescription and are generally not covered by insurance.

Pharmacy Benefit Manager (PBM): A company that administers a pharmacy benefit plan. They aren’t insurance companies; but are often subcontracted by health insurers or employers to manage the prescription drug portion of the health plan.

Prior authorization:A requirement that a physician obtains approval from the health plan or PBM in order to get the medicine covered.

Step therapy: A requirement of the health plan or PBM to try a less expensive drug first. If that drug fails to work on the patient, the health plan or PBM will then approve the use of a more expensive drug.

Therapeutic substitution: The process of switching an existing prescription to one that is less expensive and chemically different, but has the same expected clinical effect.

Tiered co-pay (co-payments): A co-payment that is determined by which tier the drug is assigned to by the health plan or PBM. There may be a few tiers, each with a different co-payment amount. This design is intended to encourage the use of drugs that are in the less expensive tiers.

OTC pain relievers and pregnancy – National Consumers League

/in imported/by

If you are pregnant or breast-feeding, ask your doctor or nurse before taking any medication (OTC or prescription). It is especially important not to use aspirin, ibuprofen, or naproxen sodium during the last three months of pregnancy unless directed to do so by a doctor, because these medicines may cause problems in the unborn child, or complications during delivery.

Acetaminophen

Acetaminophen has not been shown to cause birth defects or other problems in laboratory studies. However, to be on the safe side, talk to your doctor before taking any OTC medications during pregnancy.

Aspirin

Laboratory studies have found that aspirin can cause birth defects in animals. Do not take aspirin during the last three months of pregnancy unless your doctor has ordered it. Some reports have suggested that too much aspirin use late in pregnancy may cause a decrease in the newborn’s weight and possible death of the fetus or newborn infant. However, the mothers in these reports had been taking much larger amounts of aspirin than are usually recommended.

Studies of mothers taking aspirin in the doses that are usually recommended did not show these unwanted effects, but there is a chance that regular use of aspirin late in pregnancy may cause unwanted effects on the heart or blood flow of the fetus and newborn infant. Use of aspirin during the last two weeks of pregnancy may cause bleeding problems in the fetus before or during delivery, or in the newborn infant. Also, too much use of aspirin during the last three months of pregnancy may increase the length of pregnancy, prolong labor, cause other problems during delivery, or cause severe bleeding in the mother before, during, or after delivery.

Ibuprofen and Naproxen Sodium

FDA-approved labeling for both ibuprofen products and naproxen sodium products contain the same warning, which states that women should not take these medications during the last three months of pregnancy (unless directed to do so by a doctor), because they may cause problems in the unborn child or complications during delivery.