As anyone with diabetes can tell you, managing the disease with insulin usually means regular checkups at the doctor’s office to fine-tune the dosage, monitor blood-sugar levels and check for complications.

But here’s a little known fact: Some forms of insulin can be bought without a prescription.

Carmen Smith did that for six years when she didn’t have health insurance and didn’t have a primary care doctor. She bought her insulin without a prescription at Wal-Mart.

“It’s not like we go in our trench coat and a top hat, saying, ‘Uh I need the insulin,’ ” says Smith, who lives in Cleveland. “The clerks usually don’t know it’s a big secret. They’ll just go, ‘Do we sell over-the-counter insulin?’ “

Once the pharmacist says yes, the clerk just goes to get it, Smith says. “And you purchase it and go about your business.”

But it’s still a pretty uncommon purchase.

Smith keeps the tools for controlling her diabetes in this kit, which contains metformin, syringes, fast-acting insulin for daytime use and slow-release for overnight. Lynn Ischay for NPR hide caption

toggle caption Lynn Ischay for NPR

Smith didn’t learn from a doctor that she could buy insulin that way. In fact, many doctors don’t know it’s possible. When she no longer had insurance to help pay for doctors’ appointments or medicine, Smith happened to ask at Wal-Mart if she could get vials of the medicine without a prescription. To figure out the dose, she just used the same amount a doctor had given her years before.

It was a way to survive, she says, but no way to live. It was horrible when she didn’t get the size of the dose or the timing quite right.

“It’s a quick high and then, it’s a down,” Smith says. “The down part is, you feel icky. You feel lifeless. You feel pain. And the cramps are so intense — till you can’t walk, you can’t sit, you can’t stand.”

Smith says her guesswork put her in the emergency room a handful of times over the years.

The availability of insulin over the counter presents a real conundrum. As Smith’s experience shows, without training or guidance from a health care provider, it can be dangerous for a patient to guess at the best dosage and timing from version to version of insulin. On the other hand, being able to afford and easily buy some when she needed it may have saved her life.

There are two types of human insulin available over the counter; one made by Eli Lilly and the other by Novo Nordisk. These versions of the medicine are older, and take longer to metabolize than some of the newer, prescription versions; they were created in the early 1980s, and the prices range from more than $200 a vial to as little as $25, depending on where you buy them.

Dr. Jorge Calles, an endocrinologist at MetroHealth, Cleveland’s public hospital, is alarmed to think that some people are self-medicating with any sort of insulin.

“It’s a very serious situation if they are selling it over the counter — without any control with a prescription, specifically,” Calles says.

According to the medical consulting firm IMS Health, about 15 percent of people who buy insulin in the growing U.S. diabetes market purchase it over the counter without a prescription.

The U.S. Food and Drug Administration declined multiple requests by NPR for an interview on this topic. But, in an email, an FDA representative said that the versions of insulin now available over the counter were approved for sale that way because they are based on a less concentrated, older formulation, “that did not require a licensed medical practitioner’s supervision for safe use.”

The broader availability of this form of insulin allows patients with diabetes to obtain it “quickly in urgent situations, without delays,” the FDA says, and is intended to increase patient safety.

Still, some people with diabetes, as well as some doctors, doubt that the benefits of that greater availability outweigh the risks, especially for patients who switch from one type of insulin to another without telling their doctor.

“This is not something that should be done without the help of a professional,” says David Kliff, who has Type 1 diabetes and writes the Diabetic Investors blog. Kliff has followed and written about the expanding business of diabetes for years.

FDA officials are “basically sticking their heads in the sand” on this issue, Kliff says, and making a lot of assumptions.

“They look at insulin as a drug,” he says, “and say, ‘There’s this enormous body of evidence that shows that the drug is safe.’ But, you know, there’s a little asterisk at the end there. What the little asterisk basically says is: ‘You know, that’s assuming that the patient is trained on it.’ “

When asked about safety concerns, the FDA told NPR that the agency welcomes more research into the safety of over-the-counter insulin.

One state does require prescriptions for all insulin. Dr. Kevin Burke, a health officer for Clark County, Ind., led the effort to require prescriptions in his state.

“I didn’t realize that insulin was over the counter in Indiana until two of my patients, who were in good control, suddenly had increased glucoses,” Burke says. He asked them if they had changed their diet, lost weight, altered their workout routines. They had not.

“They both admitted that they had decided to switch to over-the-counter insulin,” Burke says, “which was different from what I had prescribed.”

Over time, taking the wrong dosages destroys your body, Burke says. Poorly managed diabetes is the cause of a host of complications, such as high blood pressure, kidney disease, nerve damage, loss of eyesight and stroke.

Burke says he took his concerns to the American Medical Association. But the national doctor’s association told him there are no data showing that the drug’s over-the counter availability is a public health hazard. In fact, the AMA’s board noted, getting insulin without a doctor’s prescription may be an important way for some insulin-dependent patients to get access to the medicine they need.

Dr. Todd Hobbs is chief medical officer of Novo Nordisk in North America, which makes Novolin, one of the two versions of insulin sold over the counter. His company partners with Wal-Mart to sell its version under the brand name ReliOn. (Wal-Mart declined to be interviewed for this story.)

Hobbs says Novo Nordisk’s version of insulin is for people who don’t have insurance, or who have to pay a lot for their other prescriptions — “people who just, for whatever reason, have fallen through the cracks and either don’t have insurance coverage at the time or are without coverage.”

With ever-rising copays and premiums, he says, many patients are turning to nonprescription insulin because it’s cheaper and all they can afford.

“But we hope to try to help them to not have to do that,” Hobbs says.

“We clearly think the newer versions are more close to what the body would do on its own,” he says. The prescription versions are better and safer, he agrees, because they make it easier for patients to avoid wild fluctuations in blood sugar.

Carmen Smith doesn’t blame the insulin she was taking for her emergency room visits.

“Insulin is not the problem,” she says. “It is getting the insulin that is the problem. Once I got connected with my physician, life as a diabetic got a lot less complicated for me.”

Smith is now on Medicaid. She has a doctor — and a prescription for one of the newer generations of insulin.

This story is part of NPR’s reporting partnership with WCPN ideastream and Kaiser Health News.

Medical advisers to the Food and Drug Administration say that prescription drugs containing codeine should not be used to treat children or the majority of teens suffering from pain or a cough.

In their meeting Thursday, the advisers also voted overwhelmingly against the over-the-counter sales of codeine-containing cough syrup for children. Selling such products without a prescription is currently permitted in 28 states and the District of Columbia.

The votes to restrict codeine’s use among children came at the end of a daylong joint meeting of the FDA’s Pulmonary-Allergy Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, in Silver Spring, Md. The FDA does not have to follow the recommendations of its advisory committees, but it usually does.

“My concern, were I to be prescribing codeine in children, would be that I would, frankly, kill them,” said pharmacist Maria Pruchnicki, of the Ohio State University College of Pharmacy.

Several committee members noted that there are questions about whether codeine is even effective for alleviating children’s coughs, and whether there are potentially safer alternatives for alleviating pain.

Although the administration of products containing codeine to children has dropped sharply over the past decade, doctors often still prescribe medicines that contain the drug, and parents can buy cough remedies that include codeine without a prescription in many parts of the country.

Codeine combined with other painkillers, such as acetaminophen, is also commonly used to alleviate kids’ pain in a variety of situations, such as when they’re recovering from surgery.

But the FDA has been increasingly concerned because codeine has been found to trigger life-threatening breathing problems in some children.

Such complications seem to be fairly rare, but they do occur — especially among children whose bodies are genetically predisposed to quickly convert codeine into morphine.

The FDA convened the panel of outside experts to advise the agency on what action to take, if any, in restricting the drug’s use.

During the daylong hearing, FDA scientists made presentations on dozens of frightening cases in which children stopped breathing after getting codeine, including at least two dozen deaths in the last decade.

Also, representatives from the American Academy of Pediatrics , and the National Center for Health Research, an advocacy group in Washington, D.C., urged the FDA to follow the lead of regulators in Europe, Australia and Canada, who have sharply restricted the drug’s use.

“The use of codeine or any other opioid cannot be recommended for the treatment of cough in children,” said Dr. Constance Houck, an anesthesiologist at Boston Children’s Hospital, speaking on behalf of the academy. The pediatricians’ group recommended against using codeine for pain, and urged the FDA to bar the sale of products containing the drug without a prescription.

The Consumer Healthcare Products Association, which represents companies that make over-the-counter codeine products, urged the FDA to base any decision “on sound scientific evidence.”

The manufacturers’ association reminded the agency that codeine had been deemed earlier “to be generally recognized as safe and effective,” and any decision to remove codeine from over-the-counter sales should go “thorough a multi-step process.”

Robert Dear, the man accused in the mass shooting at a Planned Parenthood office at Colorado Springs, blurted he was guilty Wednesday in court, one of several outbursts during his arraignment.

Transcript

AUDIE CORNISH, HOST:

In Colorado Springs, the man accused in the mass shooting at a Planned Parenthood office there was arraigned. Robert Dear faces multiple charges, including first-degree murder. Dear’s legs and arms were cuffed, and he frequently interrupted the court proceedings, yelling several times. Colorado public radio’s Ben Markus was in the courtroom, and he joins us now. And Ben Markus, to start, this was the first time that Dear appeared in person in court since his arrest. Can you describe the proceedings? What happened?

BEN MARKUS, BYLINE: Sure. While his lawyers were discussing pretty routine matters related to future media coverage, Dear suddenly shouted that he was guilty and that he’s, quote, “a warrior for the babies.” Dear had more than a dozen outbursts in the hour-long hearing, including, quote, “kill the babies; that’s what Planned Parenthood does,” unquote. He ranted that he saw atrocities in the clinic and lots of blood. He accused his public defenders, at one point, of conspiring with Planned Parenthood against him. He said he wouldn’t submit to a mental health evaluation, fearing that his attorneys would try to drug him up.

CORNISH: What was the reaction in court to all of this?

MARKUS: It sent a jolt through the courtroom at first, but the judge pretty much let him rant throughout the hearing. Dear’s public defenders seemed to be shaken by the outbursts, especially when he accused them of trying to drug him up. When Dear wouldn’t let the judge talk near the end of the hearing, a deputy sheriff touched him on the shoulder, whispered something into his ear. And after that, he was pretty quiet.

CORNISH: Remind us what’s going on with this investigation, what’s known about this shooting which took place the day after Thanksgiving.

MARKUS: Right. The attack happened at a Planned Parenthood clinic which offers abortion services among many other things. Many of the details of the shooting are still not known. What is known is prosecutors allege that Robert Dear killed three people, one police officer and two civilians that day. He wounded at least nine more in what was a tense five-hour standoff with police until he surrendered.

CORNISH: So happens next for Robert Dear?

MARKUS: He’ll be back in court in two weeks for a status hearing. His public defender told the judge, obviously, in light of Dear’s repeated outbursts today, that there are mental health issues and issues of competency to work out before a preliminary hearing or any other hearings can be held in this case. After the preliminary hearing, if that happens, Dear can enter a plea in the case. And then at that point, the district attorney will have to decide if they seek the death penalty or not.

CORNISH: This is a closely watched case in Colorado Springs. What was the scene in and around the courtroom? I don’t know what kind of bystanders were there and what they were saying.

MARKUS: Victims and their family were here. There were many people milling about out front. You know, it is – as soon as somebody says the Planned Parenthood shooting, people know exactly what it is. It is – has been front-page news, headline news. It’s been in, you know, most newscasts every single day. So people know right away when you say Planned Parenthood down here what they’re talking about.

CORNISH: And you mentioned victims’ families being in the courtroom. What was their reaction to Robert Dear yelling out?

MARKUS: They seemed shocked, just as shocked as the public defenders were. Some gasped, clearly did not expect him to outburst like that in the middle of court proceedings.

CORNISH: That’s Colorado Public Radio’s Ben Markus. He’s following the mass shooting case at a Planned Parenthood office in Colorado Springs where there was a court appearance of the defendant in that case today, Robert Dear. Ben, thanks so much for talking with us.

MARKUS: Thanks for having me.

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In a brick plaza next to the Chelsea, Massachusetts city hall, Anthony, a bald but still-youthful man in grey sweats, tells me he spent the previous night in the hospital for what he says was his twelfth overdose.

Anthony and other users of illegal drugs agreed to speak to NPR for this story on the condition that we use only their first names. He blames his overdose on what his dealer told him was a particularly strong bag of heroin laced with the anesthesia drug fentanyl — or something like it.

“He told me how strong it was,” Anthony says, “but everyone says that to sell their dope. The potency now is so inconsistent, you don’t know. So you’ll eat a bunch of Klonopins and do a shot of heroin, and then you’re dead.”

Among 501 overdose deaths assessed by the Office of the Chief Medical Examiner in Massachusetts in the first six months of 2014, and analyzed by the Harvard T.H. Chan School of Public Health, the vast majority were caused by heroin or a prescription opioid taken in combination with some other drug or alcohol. Fentanyl, a synthetic opiate that’s many times more powerful than heroin, was present in about 37 percent of the deaths, the researchers found. Klonopin, Xanax and other anti-anxiety benzodiazepines showed up in 13 percent of the Massachusetts overdose deaths.

Anthony says many users figure the risk from taking one of these multi-drug “cocktails” is worth the extra $2, or so, per additional pill.

“It intensifies the heroin high, and keeps you high longer,” he says.

On the street, there’s a hot market for lots of different prescription medications.

Using heroin in combination with other drugs is certainly not new. The speedball mix of heroin and cocaine that is present in some of the overdose deaths has been a popular high-risk choice for decades. Patients on methadone describe another popular cocktail taken after their daily dose of methadone treatment: gabapentin (anti-seizure medication), Klonopin, clonidine (treats high blood pressure and attention deficit hyperactivity disorder) and an over-the-counter allergy medicine.

“Little do you know that they all take a toll on your heart and on your breathing,” says Nicole, another drug user, who says she’s on methadone treatment for her heroin addiction.

Some heroin users pill-shop, she says, knowing which symptoms to mention so their doctor will prescribe something for anxiety or depression. And patients who have a legitimate need for these medications, who take them as prescribed, sometimes also experience an overdose.

“You trust your doctor,” Nicole says. “You think, ‘Oh, my doctor’s giving this to me, so it’s fine. Nothing’s going to happen to me — like I’m prescribed to take it.’ “

But many other people take the mixture with the aim of getting high, she says. “I think that the cocktail’s a more common thing than heroin is now. Or, most people that take heroin take the cocktail as well.”

Doctors who treat patients in recovery face difficult choices. Patients often describe increased anxiety, depression or trouble sleeping. But methadone and benzodiazepines can both suppress breathing; for someone who is on methadone, using benzodiazepines to calm anxiety can trigger a serious adverse reaction.

Even physicians who specialize in addiction medicine have trouble figuring out what to prescribe for anxiety or depression when a heroin patient is the doctor’s office begging for help, says Dr. Kavita Babu, a toxicologist at the University of Massachusetts Medical School.

“Not only is it difficult to put our knowledge of pharmacology into play,” she says, “but sometimes, [when] managing patient expectations about how their pain or anxiety should be treated, our clinical knowledge falls apart at the bedside.”

Now, with the revelation that most overdose deaths in Massachusetts stem from a toxic mix of heroin or prescription pain medicine with alcohol, cocaine or fentanyl, leading physicians and officials are urging all doctors to be more careful in their prescribing habits. They’ve pledged to update a state database where doctors are supposed to input the drugs they prescribe for each of their patients.

Mixing these drugs in toxic ways is “a big problem,” says Dr. Jim O’Connell, president of the Boston Health Care for the Homeless Program. “We’ve just been scratching the surface on it.” O’Connell says he asks patients which pills are big sellers on the streets and tries to avoid prescribing them.

“We, as doctors, don’t really have a good sense of what we should be prescribing, what we shouldn’t,” O’Connell says. “It’s really the combination of other drugs that is going to be the battle down the line.”

Many addiction specialists say society also needs to pay more attention to the emotional pain at the root of addiction.

In Chelsea, Anthony shows me the park bench where’s he’s overdosed a dozen times.

“There’s times when I really do want to die,” he says.

I ask him why, and Anthony’s face crumples in silent sobs.

“The more I do, the more guilt I feel and the more I want to kill myself,” he says. He struggles with “the guilt and the pain and shame” for the repeated relapses.

Anthony clutches his hospital discharge notes in one hand. The notes say he should call his doctor and psychiatrist, and schedule follow-up appointments. Anthony doesn’t have a phone. When I offer him mine to make the call, he gets the answering service. He doesn’t leave a number.

This story is part of NPR’s reporting partnership with WBUR and Kaiser Health News.

The ongoing conflict in the Gaza Strip has damaged hospitals, clinics and other medical facilities, leaving major gaps in health care.

Children with cancer, in particular, struggle to get the proper treatment they need. They often have to travel to Israel or much farther.

So one American nonprofit — called the Palestine Children’s Relief Fund — aims to change that. The PCRF is building a large new pediatric cancer center in Gaza.

“We found a significant gap in the services that are available in pediatric oncology and hematology. Our organization wants to address those, because children who are suffering from cancer have virtually no care at all in the Gaza Strip,” Steve Sosebee, co-founder and CEO of the group, tells NPR’s Lynn Neary.

“As you can imagine … the most basic chemotherapy, pain management, palliative care and so on being unavailable in Gaza is just a huge burden on the health care system, on the families and most importantly, on the patients.”

Interview Highlights

On the challenges children and their parents grapple with in Gaza

The problem facing children in Gaza far exceeds just the issue of cancer. Children in Gaza face food issues, face educational issues, face health care issues on a much larger scale than just cancer. And our organization addresses those issues.

On what kids with cancer in Gaza must do for treatment under current circumstances

Most of the kids are referred outside, if they’re able to get outside. There is no free access in and out of the Gaza Strip. You must have a permit from the Israeli army to leave the Gaza Strip.

Now, Israel does issue permits for humanitarian cases to leave and to go to Israeli hospitals for specialized oncological care. It’s an extremely long and bureaucratic process, and it’s also a very challenging one for the patients and for their families, because now, a new order just came down that children cannot travel with anyone under the age of 55. So it’s a big burden for the families. You can imagine that means the grandmother has to go.

On the challenges of building the center, given the political situation

Let me first give you a little bit of background. We built the first and only public pediatric cancer department in the West Bank, in Bethlehem, about two years ago. The problem is that those children in Gaza are unable to get out on a regular basis, therefore we need to build services for them in the Gaza Strip. About half of the population of Gaza are children. So it’s a very poor and impoverished land.

The challenges that we face are extreme. The political challenges are that getting equipment in is under the regulation and control of the Israeli military. The government in Gaza is run by Hamas, which the U.S. government deems as a terrorist organization, so there’s no contact with them. And getting things like cement in, getting drugs in is very challenging and extremely difficult.

On how far along in the construction process they are

We just finished the initial stages of the design being finalized, choosing a contractor, and we’ll start building before the end of this month. …

We hope, in the best-case scenario, that it will be done within one year. But unfortunately the circumstances now on the ground throughout the occupied territories is extremely volatile, and we do hope that the situation in Gaza will not deteriorate.

All we can do is try to provide services based on the needs of the people and not prevent the realities of working on the ground there to stop us from doing what our role and responsibility is, as a humanitarian organization — which is to look beyond politics, look beyond the religion and look strictly at the needs of the children there and try to serve those needs to the best of our ability.