Over the last six months, Cook Children's has released 20 articles regarding mental health, suicide in youth and teens, and resources to help young people in crisis. Recently, we spoke with experts to learn more about what families can do to help reduce the risk of suicide attempts and learned that there are a few things that start at home. 

What do you do with expired and unused prescription drugs? Do you throw them in the trash? Do you continue to take them after expiration? Or do you simply let them sit in your home?

Experts at Cook Children’s Medical Center say it is more important now than ever to dispose of unused drugs because of the alarming statistics of young people overdosing. In July, Cook Children’s reported a record number of pediatric hospitalizations for drug overdoses in 2021 compared to previous years, particularly with opioids. 

"It is a huge problem right now. We’re seeing more kids in the hospital for opioid overdoses than ever before. The vast majority of them are intentional ingestions," said Artee Gandhi, M.D., medical director of Pain Management at Cook Children’s. 

“Teens and young adults are having ‘pill parties,’ where they are taking pills from their homes, and bringing them to a party with their friends. They then put them in one large bowl and grab handfuls,” Dr. Gandhi explained. “Not only is this unsafe, but different medications have potencies after their expiration dates and you can get sick from the medication being expired.”

Experts at Cook Children’s say the best thing to do is to safely dispose of any drugs that are expired or no longer being used for their intended purposes.

Savannah Panagopoulos, a child safety, and poison prevention specialist for the Center for Children’s Health led by Cook Children’s, says there are a plethora of take-back boxes in the area that allows people to dispose of drugs safely.

“These are permanent sites, where people in the community can come and drop off drugs, to get them out of the house. Taking medications that are no longer needed or expired out of the household could significantly reduce the chance of accidental poisoning or misuse that's intentional,” Savannah said.

Savannah says “50% of potential drug and substance abuse cases start with a friend or family member giving it to someone in the home that it’s not intended for.”

She goes on to explain that only 4% are purchased from a stranger or a drug dealer.

“Not only does disposing of the drugs safely give you peace of mind, but it’s also important to dispose of them to keep our environment safe. Not flushing the drugs down the toilet, putting them in cat litter, etc.,” Dr. Gandhi said.

She also reminds families that flushing drugs down the toilet is dangerous because of the harm it can do to our water systems. Dr. Gandhi says Cook Children’s pharmacy has a take-back box, which is easy and convenient to use. The box is located inside the retail pharmacy at Cook Children's and accepts any medication, with the exception of liquids. 

“You don’t have to talk to anybody, you don’t have to see anyone. You put it in the disposable container and walk away,” she said. 

Cook Children’s also has a system in place that also texts families to remind them to take back their unused medications and to keep them out of the reach of children.

“We do this so families don’t run into a problem with children unintentionally or accidentally ingesting medication that is not safe for them,” Dr. Gandhi said.

Savannah says while most take-back locations are located in pharmacies, there are other locations, such as police stations, that are open 24 hours a day for safe disposal.

“A good rule of thumb is to take off all labels with any identifying information before you drop them off,” Savannah said. ”Although all drop-off locations are in secure areas that is something we tell people to practice for safety and privacy.”

The United States Drug Enforcement Administration (DEA) also hosts national take-back days across the country every year. In April, more than 4,000 law enforcement agencies participated, which resulted in nearly 900,000 drugs being taken out of homes and disposed of safely. The next National Take Back Day is Oct. 23, 2021. Information about national takeback days can be found here.

Both Cook Children’s experts want families to know and spread the word about this resource. It is important to know that you don’t have to wait for a medication to expire and if the medication is expired, you can drop it off before you go and get a fresh prescription.

Cook Children’s Center for Children’s Health has a page dedicated to poison prevention. The North Texas Poison Center is open 24/7 and can be reached at 1-800-222-1222. You can find information about drop-off locations in North Texas, pain management, and more.

It is important to note you cannot dispose of items such as needles, oxygen tanks, thermometers, and sharps when dropping off your medication.

Dr. Gandhi says the most important thing to remember is, if you are done taking medicine and have used it for the intended purpose, dispose of it like you would an antibiotic or anything else.

“This goes for over-the-counter medication such as Tylenol, Ibuprofen, Aleve, etc,” she said.

“One thing to keep in mind is that while the stewardship focuses on our opioid utilization and prescribing habits and aiming to keep children safe, we can’t ignore the fact that kids will have pain—either acute or chronic. So, it has to be addressed,” says Artee Gandhi, M.D., medical director of Pain Management at Cook Children’s, who also oversees the stewardship program. “It’s not a matter of getting rid of one thing and not replacing it with anything else, or not using it sparingly in conjunction with other ways to treat pain. We recognize both sides of the coin.”

The goal of Safe and Sound is to use other methods of managing pain, she says. It aims “to improve patient safety, reduce the risk for potential child addiction, ingestion, misuse, overdose and death, while promoting best practices through the safe and sound management of pain,” according to its mission statement.

From 1999 to 2019, overdose deaths involving prescription opioids more than quadrupled in the United States—leaving about 247,000 dead, according to the Center for Disease Control and Prevention.

The trend has hit locally, as well. As of May, Cook Children’s admitted 17 patients for opioid-related overdoses, representing a significant jump from 2020 when 16 patients were admitted for the same condition for the entire year. In March, at least four area teens died from overdosing on fentanyl, a synthetic opioid that is 100 times stronger than morphine and 50 times stronger than heroin. The teens purchased the pills thinking they were Percocet, but they were laced with fentanyl, according to reports. Drug dealers often package and sell fentanyl on the streets disguised in forms of other popular medications, such as OxyContin, Percocet or Xanax.

Opioids, which “bind to or activate opioid receptors on cells located in the brain, spinal cord and other organs in the body,” block pain signals and release large amounts of dopamine throughout the body, according to the National Institute on Drug Abuse (NIDA), the leading federal agency supporting scientific research on drug use and its consequences. That flooding of dopamine can reinforce using the drug and make users want to repeat the experience, the agency reports. NIDA lists the most common drugs containing opioids as hydrocone (Vicodin), oxycodone (OxyContin, Percocet), oxymorphone (Opana), morphine (Kadian, Avinza), codeine and fentanyl.

In the late 1990s, the medical community was given the green light to prescribe opioid pain relievers after pharmaceutical companies assured them patients wouldn’t become addicted, according to the U.S. Department of Health and Human Services. Increased prescriptions of opioid meds led to widespread misuse of both prescription and nonprescription opioids before their highly addictive nature became clear. The department declared a public health emergency in 2017 and announced a 5-Point Strategy to Combat the Opioid Crisis.

Despite these efforts, 10.1 million Americans reportedly misused prescribed opioids last year, according to department data released in December.

At first, physicians and prescribers thought opioid medications were a safe, long-term way to manage acute pain and chronic pain—“not recognizing the effects opioids have on the pleasure-seeking parts of our brain,” Dr. Gandhi says. “Opioids not only helped control pain, but they also helped reduce anxiety and depression. By stimulating endorphins, one would feel more outgoing, confident and increase motivation. This property, along with the chemical changes in the brain, alters our biological or physiological set point. Now we need more to achieve the same effect. And if we don’t get the drug, we have withdrawal, which is a horrible feeling. So, now one becomes addicted and seeks ways to get the medication that may not be safe or legal.”

In the 2000s, opioid substance misuse, abuse and overdose deaths continue to climb, she says, adding, “Physician prescriptions have definitely decreased, but unfortunately substance abuse, opioid use and overdose has not. Those numbers are still increasing and are still in the hundreds of thousands of people who die each year from an overdose.”

The increase in opioid overdoses and deaths has trickled over into the younger population, bringing attention to what opioids can do to children and adolescents brains. Research studies show that the earlier children are exposed to opioid substances, the higher the risk of long-term addiction, Dr. Gandhi says.

“What we’re recognizing in the pediatric population is the adolescent brain is set up for risk-taking behaviors. The brain is changing in a way that the prefrontal cortex is the last to develop—it’s developing from the back to the front,” she says. “The front is the part that regulates. But the back is the part that’s about risk-taking, asking questions, wanting to rebel, wanting to find answers for themselves, not wanting to listen to what other people say.

“It’s kind of like they’re a high-speed car without any brakes,” Dr. Gandhi says. “We can prescribe opioids in a safe way to kids, but we really need to be conscientious of how many doses we’re giving them, whether there are other ways to control their pain, making sure parents are the ones giving them their medications and that the medication is locked and secured in a safe place.”

Educating physicians, parents and patients on alternative ways to manage pain is one of the most important goals of Safe and Sound. For instance, under the program, guidelines to manage acute pain have been created, using a multimodal analgesia regimen of acetaminophen and ibuprofen as the primary medications for post-surgical pain management.

“There are studies that show when those medications are used together and scheduled for the first 72 hours after surgery, you need less narcotics, if any at all,” she says. “And that they’re more effective than even an oxycodone.”

During surgeries, physicians may use local anesthetics or nerve blocks as a proactive way to minimize postoperative pain. Families also are educated ahead of time on what to expect during post-op and what the plan will be for medications.

“Every patient goes home with a handout and discharge instructions on how to manage pain, including things like ice and heat, rest, utilizing relaxation and breathing apps, ways to help cope with distraction,” she says. “We tell parents that it’s OK for them to have a little bit of pain after surgery. As long as they can function, they can eat, do the things they need to do to recover, that’s the focus, as opposed to saying, we’re just going to give you these pills and this will be it.”

There’s a natural course for acute pain, Dr. Gandhi says, and if a patient is not healing accordingly, the individual needs to be reevaluated. “If someone’s not following that natural course, we want to assess why that is the case. It’s important because pain can always be a sign of something else. We want to be able to address it before blankly prescribing a pill,” she says.

The Safe and Sound approach appears to be working, says Lorrainea Williams, Cook Children’s Patient/Medication Safety Officer. In the past, surgical patients were usually sent home with a medication that contained both an opioid and acetaminophen. Now, they’re sent home with a medication plan that uses alternating acetaminophen and ibuprofen doses as the primary method to control pain. Patients also may receive a small amount of low-dosage medication that contains only an opioid to be used as a “rescue” in case their pain intensifies, she says.

In 2018, patients who needed pain relief were sent home with an average of 25 doses of medication that contained an opioid. That number has steadily decreased since the program began, and now the average is 12 doses for patients who need additional pain relief, she says.

The number of post-surgical patients who returned to the emergency room or had to be readmitted because of severe pain also has lowered since the hospital decreased the amount of opioids prescribed, Williams says, adding the number of return patients from 2018 to present dropped by 34 percent.

“Based on the numbers, we can determine that we are effectively managing our patients’ pain with less opioids,” Williams says.

The Safe and Sound program also established guidelines on prescribing opioids, and all opioids are prescribed electronically through our system, which tracks them, Williams says. Under the law, physicians can still write paper prescriptions for opioids if special circumstances exist.

But there are exceptions for prescribing opioids under the guidelines developed for Safe and Sound. Opioid therapy is to be considered only if the physician expects the benefit for pain and function to outweigh the risks and is reserved for moderate to severe pain in patients with conditions such as post-operative pain, trauma, sickle cell disease, palliative or end-of-life care.

As for patients dealing with chronic pain, the preferred first-line treatments under the Safe and Sound program include using more beneficial non-opioid medications, making positive lifestyle changes (such as getting enough sleep) and trying complementary therapies, depending on each individual’s condition. The non-pharmacological therapies include acupuncture, aromatherapy, biofeedback, cognitive behavioral therapy, massage, positioning, and Transcutaneous Electrical Nerve Stimulation (TENS).

It all comes back to an evidence-based approach.

“For example, there are some wonderful studies that show the benefits of acupuncture for chronic headaches and the benefits of massage for chronic back pain,” Dr. Gandhi says. “There also are studies that show the benefits of Tai-Chi for insomnia, fatigue and other chronic conditions.”

When it comes to treating chronic pain conditions, physicians must rely heavily on functional ability, such as how difficult is it for patients to walk to the bathroom, meet with friends, sit in a car or go to school, she says. The goal is to improve functional ability because that improves patients’ lifestyles, relationships and healthy routines.

“Trying to keep that routine is what we talk about when it comes to chronic pain, and then maximizing the appropriate types of medications,” Dr. Gandhi says. “All pain medicines are not the same. I would not throw opioids on top of opioids for chronic pain because that would be like trying to treat an ear infection with an antibiotic that treats urinary tract infections. Opioids have a limited role in chronic pain. They can actually induce a hyperalgesia response, where the sensitivity of those pain receptors increases. So, you actually could experience more pain with longer exposure to those opiates.”

For patients who are prescribed opioid medications for acute pain, it’s important to return unused pills once the pain has been managed, she says. The pharmacy at Cook Children’s has become a take-back location, where families can drop off unused meds. Other area pharmacies also have been designated as take-back locations.

“They don’t have to talk to anyone. There’s a little slot, you put your bag in there and walk away,” Dr. Gandhi says. Patients sent home with opioid prescriptions get a text message within a week reminding them to dispose of their unused medications and providing a website link that shows them the nearest take-back pharmacy location.

The program’s success hinges on physicians and parents working together and, so far, they have responded favorably, Dr. Gandhi says, adding the evidence-based approach is much more proactive than in the past. It focuses on pain management for each individual rather than a generalized approach, she says.

“Where it comes back to is all of us working together and being really consistent in our messaging,” she says. “We’ve done a lot of education for our staff as well, learning modules, training modules, continuing education opportunities. Parents are hearing the same message from the beginning, and not just when their children are in the throes of a situation.”

Dr. Kirk Pinto, M.D., a Cook Children’s urologist, says he has found the stewardship program to be helpful for his patients.

“I was skeptical at first, but I learned from my colleagues, who do essentially the same things I do, that these patients could be adequately managed with fewer or less opioids,” Dr. Pinto says. “I have always promoted the use of Motrin and Tylenol as first-line therapies. With all the bad publicity that opioids have gotten lately, parents are much more receptive to nonnarcotic pain management after surgery.”

Dr. Gandhi says she has been pleased by the overall response to the stewardship program.

“I have to say our surgeons and providers have been very open and receptive to this information because everything that we’ve brought forward has been evidenced-based,” she says. “Once we’re able to give them factual information, they’re very willing to change their culture or their prescribing habits, knowing that there’s literature that supports this change.

“We also monitor readmissions for pain or emergency room visits for pain. So we’re able to give them the data that shows kids are not coming back in with more pain, even though we’re prescribing less opioids,” Dr. Gandhi says.

Overall, families also have been on board with the Safe and Sound approach. They get a lot of education through media and commercials, she says, so they’re more aware of concerns surrounding opioid medications.

“They don’t necessarily want their kids to be on them long-term or to get high doses or go home with a lot of medications,” Dr. Gandhi says. “Obviously, you still get into situations where maybe there’s a little bit more stress around it, but I think everyone’s done a great job rallying around parents and supporting them. We’re not letting their kids suffer—they’re still getting the relief they need, just in different ways.”

Statistics, no matter how alarming, sometimes blur into faceless numbers when parents hear them on TV or read them in a news story.

That’s until it’s your child in the emergency room, hooked to an IV while receiving treatment for ingesting too many pills—in this case, over-the-counter pain meds often used to relieve menstrual cramps—with the intent of harming herself.

And then suddenly, those numbers have a face. For Betty, a Tarrant County mom who asked not to be identified to protect her 14-year-old from any stigma attached to her attempted suicide, the face that came fully into focus was her own teenage daughter’s.

Betty’s daughter is among the many children and young adults across the country who’ve used excessive doses of common drugs, like pain relievers or allergy medications, with the intent of harming themselves. National studies have shown OTC meds as the No. 1 means used by youths in suicide attempts and the third-leading cause of youth suicide deaths.

“I really didn’t put those in the category of prescription medications, so I never put them away,” Betty said of the handful of OTC meds—a combination of Motrin and Midol—her daughter swallowed earlier this year. (Motrin contains ibuprofen, and Midol is a mixture of acetaminophen, caffeine and pyrilamine maleate, an antihistamine.) “I want other people to know, and to even have lockboxes for their medications, so that someone else doesn’t have to go through what we went through.”

Her daughter, who went to school but said it wasn’t the same because of COVID restrictions, had felt isolated and been sad because she missed her friends, she said. She faced the typical teenage stuff like low self-esteem, Betty said, but she had no idea her daughter was considering suicide.

“She’s seeking treatment now, but I want to be really clear, ‘Put all your medications away, not just your prescription medications,’” she said.

Betty is far from alone in facing this issue. Other parents across the nation also are grappling with children and teens who are intentionally overdosing with easily accessible OTC meds.

In a study published by The Journal of Pediatrics in May 2019, Nationwide Children’s Hospital and the Central Ohio Poison Center found that suspected suicide attempts by self-poisoning in children and young adults had doubled in the past decade. The research, which targeted ages 10 to 24 during 2000 to 2018, also showed suicide attempts using OTC meds had tripled among girls and young women.

The same researchers later expounded on the initial report, pointing out that the two most commonly used substances among all age groups were OTC pain relievers—such as acetaminophen, ibuprofen and aspirin—followed by antidepressants.

Last year, a study conducted by the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital focused specifically on the use of OTC pain relievers in suicide attempts, showing a 57-percent hike in overall cases from 2000 to 2018. Children and young adults between 6 to 19-year-old made up half of the cases, and of those, 73 percent were female, the study showed.

Researchers analyzed 549,807 suicide-related calls made to poison control centers across the United States that involved OTC medications. The study, published in Pharmacoepidemiology and Drug Safety journal, also determined a 34-percent rise in the frequency of those cases during that time period, caused primarily by a jump among calls involving 6- to 19-year-old females, researchers said.

The results from the study showed the breakdown of OTC substances involved in the calls: 48 percent, acetaminophen alone; 33 percent, ibuprofen; and 19 percent, aspirin. Acetaminophen and aspirin accounted for 65 percent and 33 percent of deaths, respectively. Aspirin created the most serious medical outcomes for 36 percent of the cases and 68 percent of the cases with aspirin were admitted into a health care facility compared with other OTC pain relievers. Overall, while suicide-related cases using acetaminophen and ibuprofen climbed, the number involving aspirin decreased, researchers found.

Although local numbers on these types of cases are not yet readily available, physicians at Cook Children’s Medical Center are noticing a similar increase in intentional OTC medication overdoses.

Stacey Vanvliet, M.D., an inpatient pediatric hospitalist at Cook Children’s, said suicide attempts “have become part of my daily practice” and most are overdoses on a substance that’s “convenient for the children and teens to grab.” While it’s mostly older ones, children as young as 8 or 9 come in for attempting suicide, she said.

“Commonly, we see Tylenol, Motrin, aspirin, Benadryl—things that people just stock in their cabinets to have on hand,” she said. “We see teenagers take huge handfuls of them.”

Many people have a misconception of how dangerous these drugs can be when ingested over the recommended dosage, Dr. Vanvliet said. For example, high levels of acetaminophen (as in Tylenol) can cause liver damage or acute liver failure as well as other serious health issues.

“I think another misperception is that there’s a certain type of patient or type of teen that might try to overdose. Or that there’s a certain stressor or pattern, so to speak, that this happens and then the teen goes for pills or whatever it may be,” she said. “But in my experience, that’s not the case. We certainly have children who have undergone significant trauma and have mental health issues…but we also have children who haven’t shown a whole lot of warning signs and are very high achievers.”

When a child or teen attempts suicide, it’s usually an impulsive decision, Dr. Vanvliet said, which makes the accessibility to OTC meds more dangerous.

“You’d be amazed at some of the things that trigger them to make a serious attempt. It can be something as small as, ‘My mom took my phone away because I got a bad grade,’ or ‘My best friend is mad at me,’” she said. “It’s not necessarily anything that’s huge…but they make these snap decisions, and they go take a handful of pills, and it could be really damaging. It happens over and over, unfortunately.”

So, what can be done to keep children safe? Many health experts and researchers propose restricting the amount of OTC meds that can be purchased at one time and suggest unit-dose packaging, such as blister packs, as well as promoting safe storage for OTC and other medications.

Responding to that call, The Jordan Elizabeth Harris Foundation, a Fort Worth-based nonprofit group that targets suicide prevention, plans to launch Keep All Meds Secure (KAMS) public awareness initiative this summer. Christina Judge, the foundation’s executive director, said the initiative includes educating families and caregivers on the dangers of various medications, providing lockboxes for safe storage and advocating safe disposal of old medications. The foundation also offers free suicide prevention training to help parents to know what to look and listen for with a child who might be considering suicide.

The initiative began with a phone call that Judge received. A frantic mother, whose daughter had taken a handful of Tylenol and a handful of Advil, called the foundation seeking help in finding a bed at a mental health facility for her daughter.

“The pivotal moment was just hearing the anguish in the mother’s voice,” Judge said. “I asked her, ‘Did you know that these drugs in the hands of a suicidal child could be lethal?’ She said, ‘No. We just keep them in the cabinet above the sink.’”

“Well, that was enough for me,” Judge said, who researched the topic, presented a case for it and sought funding for the initiative.

Vanvliet believes programs such as KAMS will help with suicide prevention among children and teens.

“Education for parents and keeping those substances safe, I think, is a big part of preventing this from happening,” she said.

For Betty, what happened to her daughter has made her even more vigilant. She has always paid close attention to safety in her house. The family’s guns are always locked away in a safe, along with prescription medication. Now, she secures her OTC meds, too, she said.

She’s thankful her daughter, who’s getting ongoing treatment, didn’t suffer any long-term health effects from the incident. But Betty is highly aware that it all could have ended much differently that day her daughter tried to overdose.

“I think she got scared and came to me and told me. I’m so glad she did,” Betty said. “And I have to say if there were more pills in the bottles, we would have had a much different situation…it could have been much more harmful.”

“Like I said, we’d locked up everything else except for that. And if we had locked that up, maybe we would have avoided this,” she said.

Imagine you are 5 years old. It’s a beautiful day and you are stuck in the house with a fever. Your wonderful mother gives you little orange tablets that taste like oranges. You think taking these little tablets that look a lot like M&M’s will make you feel better really soon. What a wonderful Mom! Then she leaves the bottle with the little orange flavored tablets on the table just a few feet away. What would you do?

I was the child that decided if a couple of little orange things would make me feel better than the bottle of little orange things would get me well quicker and I could get back to playing with my friends. What I didn’t know was that there were enough tablets in that bottle to cause a very large overdose. After I took the pills, my mom noticed that I wasn’t responding to my name. I was nearly unconscious. So I was given a trip to the emergency room at our local hospital. I was fortunate that someone noticed and that it wasn’t something worse. 

A recent study in Pediatrics found that 640,000 emergency department visits were made in the U.S. from 2004 to 2013 because children were able to to get medication without adult supervision.

When I became a mother myself, I was very diligent in keeping medications away from little hands by keeping the medications in a high or locked cabinet. We can protect our children from an accidental poisoning at home by looking at things from their eyes. Everything that looks like candy is interesting to them.

Every year Cook Children’s receives more than 600 children due to poisonings. Seventy-five percent are medication related. Children can be accidentally poisoned by finding medication belonging to a friend or family member at their house or in their purse or bag. Or by getting into a cabinet that contains household cleansers like bleach or window spray. Remind your friends or family members to keep medication and household cleaners out of the reach of your children. Often Grandmother’s medication looks like candy, just like my little orange pills, or the cleanser bottle looks like lemon/lime drink.

Sometimes it’s as simple as not measuring a liquid medication correctly. Ask your pharmacist for a medication measuring spoon or oral syringe so you give the correct amount of medicine to your child. The spoons in your kitchen will not always measure the same amount as a medication spoon.

Also, make sure to keep the poison control number (1-800-222-1222) near your phone in case you need it.

Rosanne Thurman is director of Pharmacy at Cook Children's. Cook Children's pediatric pharmacists are available at the medical center to make sure your child's medicines are safe and effective.That includes helping parents understand what their child's medicine is for, the best times to take the medicine, the right dose, side-effects and any possible drug interaction with other medications that their children may be taking, such as other prescriptions, over-the-counter medications like cough syrup or antihistamines and herbals. They can even tell parents what food and drinks might cause an interaction.

A recent study done in the adult oncology world and published in JAMA, found that doctors had a perception that patients were demanding extra treatment and testing. Review of the patient encounters showed that doctors perceived demands that did not actually occur. Many of the requests that did occur were medically appropriate.

In pediatrics, the most common issue where this comes to a head is the desire to give children antibiotics. It can also play out in other areas as well. Another common one that comes to mind is request for further testing for diagnosis.

Fortunately, in my experience, parents are becoming more informed about what situations require antibiotics and which illnesses will pass with a little time and TLC.

The problem is that many doctors have gotten into the unfortunate habit of wanting to provide what the parents are requesting without actually asking the parent what they expect. Doctors may perceive that parents want antibiotics or further testing when, in fact, they simply want reassurance that waiting is OK. This becomes a particular problem in urgent care or retail clinics where patient satisfaction plays a bigger role in getting patients to come back and see you.

So, how can you prevent this from happening to you?

Here are five casual statements that you might use the next time you visit the doctor to help them understand your expectations:

1. I’m pretty sure I’m just over concerned. I just wanted you to check things out so I can be sure.

2. I don’t really like to give my kids medicine but I wanted your opinion about what we should do next.

3. I’m totally OK with waiting, if that’s what you think is best.

4. What would you do if it were your child?

5. Are there other things we can try first or other options?

Your doctor should not feel threatened by these statements. If antibiotics are the only right choice, they should be able to explain the reasons why that is.