Bottled Water: FAQ on Safety and Purity

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy WebMD.com. Health and Cooking /em>

By Salynn Boyles -Reviewed by Louise Chang, MD – WebMD Health News

Americans drank 9 billion gallons of bottled water last year, or slightly more than 29 gallons for every man, woman, and child in the country.

They also spent $22 billion on a product that critics of the bottled water industry say they should be getting for free from their home faucets.

Most of the criticism has focused on the environmental impact of bottled water. But an investigation released recently also raises questions about the purity and even safety of commercially available water.

WebMD looked into many commonly asked questions and concerns about bottled water. Here is what we found:

What did the new report find?

The Environmental Working Group tested 10 best-selling brands of bottled water for 170 contaminants and found different mixtures of 38 contaminants, including bacteria, fertilizer, and industrial chemicals at levels similar to those allowed in tap water.

Two of the samples, bought in San Francisco, contained the chemical compound trihalometrane in levels that exceeded the amount allowed in California.

“The bottled water industry really presents this image of purity, but our investigation demonstrated that it is really hit or miss,” Environmental Working Group senior scientist Olga Naidenko, PhD, tells WebMD.

But the International Bottled Water Association, which represents most bottlers, charged that the group’s report contained “false claims and exaggerations” and noted that the group’s sample was not representative of the hundreds of bottled waters on the market.

Joseph Doss, president of the International Bottled Water Association, tells WebMD that California has much stricter contamination restrictions than the FDA. He says the state’s allowed level of trihalometrane is eight times lower than the level allowed by the federal government.

How can I tell if the water I purchase started out as tap water?

Roughly 45% of the water sold in single-serve bottles comes from a municipal water source.

By law, bottled water that comes from a municipal water supply has to disclose this on its label unless the bottler takes steps to further purify the water, which most do. In this case, the label will say “purified water” or “purified drinking water,” but the original source is probably tap water.

Water labeled “spring water” comes from an underground water spring, but it may be piped to the bottling plant.

“Mineral water” comes from an underground source and must contain no less than 250 parts per million total dissolved solids, such as salts, sulfur compounds, and gasses. No minerals may be added to the water by the bottler.

“Artesian water” or “artesian well water” must come from a well that taps a confined aquifer.

How can I tell if there are contaminants in the bottled water I purchase?

You probably cannot. Tap water is regulated by the Environmental Protection Agency (EPA), which requires yearly public reports identifying the contaminants found in local water sources. But bottled water is regulated by the FDA, which has no such requirement.

The Environmental Working Group and the Natural Resources Defense Council, which released its own report critical of bottled water purity in 1999, want the FDA to require bottlers to list contaminants on water bottle labels.

In its report, the National Resources Defense Council noted that the EPA requires more frequent testing of municipal water than the FDA requires for bottled water, and that bottled water rules allow some contamination by E. coli or fecal coliforms, which indicate possible fecal matter contamination.

The report noted that the FDA does not require bottled water to be tested for parasites such as cryptosporidium or giardia; the EPA does require this testing for tap water.

Doss says consumers have a right to know what is in their bottled water, and they can find out by calling an 800 number that appears on every bottle. “If a consumer calls that number and does not get the information they want, they can and should choose another bottled water brand.”

Does calling the 800 number really get you the information you want?

That depends on what you want to know.

WebMD called the 800 numbers found on three best-selling water brands, purchased at a minimart in Nashville, Tenn. In each case, we were able to find out the source of the water and the purification process used by the bottler.

But in all three cases we were told that there were no contaminants in the water we were calling about because of the extra purification. While this may be true, water quality experts say it is unlikely that the purification process removes all contaminants. And the Environmental Working Group investigation showed that some of the bottled waters they tested had the same type and level of contaminants as the tap water source used by the bottler.

The brands we checked included Pepsi’s Aquafina, Coca-Cola’s Dasani, and Deer Park Spring Water, marketed by Nestle.

When we called the Pepsi number, a customer service agent helped us find the date stamp and production code on the bottle of Aquafina we had purchased.

With this information, she was able to tell us that our water came from a municipal source in Mankato, Minn. She further informed us that the bottler used a seven-step purification process that included reverse osmosis, carbon, and UV light filtration.

When we called the Coca-Cola number, a customer service agent was able to tell us that our Dasani came from a municipal source in Birmingham, Ala., and that the purification process included reverse osmosis filtration.

Our Deer Park call was answered by a customer service agent who told us where our spring water was bottled and how it was purified.

Sarah Janssen, PhD, who is a scientist with NRDC, says the 800 numbers may help you figure out where the water you purchase comes from but not what is in it.

“I cannot imagine that anyone standing in a store trying to make a decision about which water to buy is really going to go to all that trouble,” she says.

Which is safer, bottled or tap water?

Assuming that both the municipal tap water source and the bottler are in compliance with regulations, the experts contacted by WebMD say bottled water is no safer than tap water and tap is no safer than bottled.

The experts point to two cases where bottled water may be recommended — in emergency situations when contaminants in the local water supply exceed permitted standards and in homes where corroded plumbing could cause lead or copper to contaminate drinking water.

In the first instance, water suppliers are required to notify the community and they may even provide bottled water until the problem has been solved. Homeowners worried about their pipes can have their drinking water tested. Halden says most people choose bottled water for convenience, not safety.

“We have invested in the infrastructure to provide pure, safe, drinking water to the population,” he says. “In large cities, water quality is tested hourly, not just once a day.”

While that may be true, a recent report by the Associated Press raised new concerns about the purity of tap water.

Its five-month investigation found evidence of a wide range of prescription and over-the-counter drugs — including antidepressants, antibiotics, anticonvulsants, and sex hormones — in tested samples of municipal water taken from taps throughout the country.

Twenty-four of the 28 water samples taken from major metropolitan area water supplies contained evidence of drug contamination.

The concentrations of these pharmaceuticals were very small. But the report noted that the EPA has not set safety limits for drugs in water and does not require testing for them.

If I drink tap water, should I use a filter?

If you live in a home with older pipes, have odor or taste issues with your tap water, or just want an extra level of protection, a filter may be a good idea. But you have to get the right one for your specific problem, Janssen says.

“It is important to know what you are trying to filter out before you spend the money,” she says. “A reverse osmosis filter will get rid of most contaminants, but charcoal may be enough for odor and taste problems.”

The Natural Resources Defense Council web site is a good source for information on filters.

The consumer watchdog group Consumers Union, publisher of Consumer Reports, also weighed in on commercial filters in a report published early last year.

To find out which filter is best for you, the report recommended consulting the Consumer Confidence Report (CCR), published online each July by the EPA.

The report provides detailed information about where your tap water comes from along with detected levels of dozens of regulated contaminants and the corresponding state and federal limits for these contaminants.

To determine the quality of the water actually coming from your faucet, you will have to have it tested. The EPA’s Safe Drinking Water Hotline (800-426-4791) can provide the names of state-certified testing labs in your area. Or you can do it yourself for under $20 with a commercially available kit sold at most hardware stores.

Is it safe to drink old bottled water?

The FDA considers bottled water to have an “indefinite safety shelf life” if it is unopened and properly sealed, but drinking water quality expert Rolf Halden, PhD, of Arizona State University is not so sure.

“Even water stored for emergency use should be replaced periodically,” he tells WebMD. “You would not want to keep it for 10 years.”

Can chemicals leach from plastic bottles and pose a health risk?

Most experts who spoke to WebMD say there is little to worry about.

The major concerns have involved the chemicals bisphenol A and phthalates.

Bisphenol A is used in the production of multiuse polycarbonate water bottles, but not in single-use bottles used by commercial bottlers.

Likewise, phthalates are not typically found in plastic beverage bottles used commercially in the U.S. But Janssen says phthalates have been found in bottled water, suggesting that it may leach from the plastic cap or liner.

“These chemicals may be in your water, but you would never know because the water companies are not required to test for them,” she says.

Is freezing bottled water or leaving it in a hot car dangerous?

Both of these concerns have circulated widely in emails and on the Internet. One email that has been around for several years warns that freezing bottled water leads to contamination with carcinogenic dioxins.

The email was erroneously attributed to Johns Hopkins University, and it was so widespread that Johns Hopkins’ scientists felt compelled to publicly set the record straight in a news release.

Rolf Halden, PhD, PE, who is an adjunct associate professor with the Johns Hopkins Center for Water and Health, called the claim “urban legend.”

He notes that there are no dioxins in plastics and that freezing actually slows or prevents the release of chemicals.

The industry group representing single-use beverage bottle manufacturers, known as NAPCOR also used the term “urban legend” to describe claims that it is unsafe to drink water that has been left in a hot car.

“The idea that (these) bottles ‘leach’ chemicals when heated in hot cars is not based on any science, and is unsubstantiated by any credible evidence,” the group noted in a recent news release. “This allegation has been perpetuated by emails until it has become an urban legend, but it just is not so.”

Is there fluoride in bottled water?

If it is added by the bottler, the label must say so. But most bottled waters probably do not have as much fluoride as fluoridated tap water.

The CDC has stated that most bottled waters contain fluoride at levels that are less than optimal for oral health. It weighed in on the issue in a news release last February.

“If you mainly drink bottled water with no or low fluoride and you are not getting enough fluoride from other sources, you may get more cavities than you would if fluoridated tap water were your main water source,” the statement noted.

The CDC also warns that preparing infant formula with fluoridated bottled water could cause dental fluorosis, a condition in which permanent white spots occur on the teeth.

EDITOR’S NOTE: Mines a beer please!

SOURCES:
Gary Hemphill, Beverage Marketing Corp.
International Bottled Water Association web site: “Frequently Asked Questions.”
FDA: “Bottled Water Regulations and the FDA,” September 2002.
National Association for PET Container Resources Q&A.
Rolf Halden, PhD, PE, associate professor of civil and environmental engineering, Arizona State University; adjunct associate professor of environmental health and science, Johns Hopkins Bloomberg School of Public Health.
Joseph Doss, president, International Bottled Water Association.
Sarah Janssen, MD, PhD, MPH, scientist, Natural Resources Defense Council.
IWG Bottled Water Investigation, Oct. 15, 2008.
CDC Fact Sheet on Questions About Bottled Water and Fluoride.
WebMD Medical News: “Many Tap Filters Work Well.”
Associated Press: “Drugs Found in Drinking Water,” Sept. 12, 2008.
National Resources Defense Council: “Summary Findings of 1999 Bottled Water Report.”

© 2008 WebMD, LLC. All rights reserved.(http://www.webmd.com/food-recipes/news/20081107/bottled-water-faq-on-safety-and-purity?ecd=wnl_day_041309)

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Chronic Opioid Therapy Guidelines Offer Direction for Physicians

From the FMS Global News Desk of Jeanne Hambleton

Courtesy of Fibromyalgia Network – February 2009

While patients are rightfully concerned about not receiving adequate pain relief, physicians harbor fears about drug abuse, safety issues, and government oversight. New clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain patients, developed by consensus of the American Pain Society and the American Academy of Pain Medicine, may ease both patient and physician concerns.

The guidelines, published in the February issue of the Journal of Pain, offer a roadmap for physicians on how to safely prescribe opioids to patients with moderate to severe pain.* The authors specifically state that their report applies to patients with “chronic non-cancer pain conditions, including common conditions such as back pain, osteoarthritis, fibromyalgia, and headache.”

Throughout the guidelines, physicians are urged to evaluate their patients’ pain and function on a regular basis. And, if doctors are worried that a patient is abusing or misusing the prescribed opioid, they may need to reduce the time between scheduled office visits. In addition, physicians are encouraged to look at all of the available options for treating patients’ chronic pain, including the use of opioids, and it is emphasized that this class of medications will seldom provide sufficient pain control. This means that patients placed on opioids will likely need to be prescribed medications from other drug classes as well as non-drug therapies. And, physicians who do not have the skill-set to prescribe opioids need to coordinate their patients’ care with another doctor who is experienced in providing this therapy.

The American Pain Society emphasized the following three points to all its members this month:

The guidelines are comprehensive and evidenced-based to assist physicians in managing chronic opioid therapy, according to the American Pain Society President Charles Inturrisi, Ph.D

“Regular monitoring of chronic opioid therapy patients is warranted because the therapeutic benefits of these medications are not static and can be affected by changes in the underlying pain condition, coexisting disease, or in psychological or social circumstances,” said Gilbert J. Fanciullo, M.D., director of the division of pain and palliative care at Dartmouth Hitchcock Medical Center.

Cochair Perry Fine, M.D., professor of anesthesiology at the University of Utah Medical Center, added that doctors do not have to solely rely upon patient self reports. Pill counts, urine drug screening, family member or caregiver interviews, and prescription monitoring data may all be used to check for possible abuse or other opioid-related problems.

The message is clear that under most circumstances, there are reasonable ways for physicians to prescribe chronic opioid therapy for their patients in pain while emphasizing safety issues and minimizing side effects or the potential for drug misuse. The guidelines offer physicians 25 recommendations with detailed explanations on how to follow them—all to help doctors prescribe opioids to their chronic pain patients in a responsible fashion. In addition to the key points already made, here are other highlights from the published guidelines:

Clinicians may consider a trial of chronic opioid therapy (COT) for moderate to severe pain that is having an adverse impact on a patient’s function or quality of life as long as the therapeutic benefits outweigh the risks (abuse, misuse and addiction). Three different patient screening tools (questionnaires that are easy to administer) are included with the guidelines to help doctors assess potential risks associated with COT for a given patient (the SOAPP, the ORT, and the DIRE).

Before initiating a trial of COT, physicians should provide their patients with informed consent, which alerts patients to all of the potential risks associated with taking opioids. After informed consent, doctors should discuss with their patients a COT management plan that outlines the goals of therapy, expectations, monitoring requirements, etc. A sample consent form and management plan are included in the guideline.

Initial treatment with an opioid should be regarded as a therapeutic trial to determine if COT is effective. If the first opioid does not work or produces adverse side effects, other types of opioids may be tried, but patients need to keep in mind that opioids are prescribed on a trial basis.

Physicians should anticipate, identify, and track common opioid-associated side effects. Constipation is the most frequent problem, and unfortunately it does not go away or get better with continued use of the medication. With this in mind, doctors should recommend stool softeners or increased fiber intake when issuing patients an opioid prescription. Nausea or vomiting may occur but tends to diminish over a few days. If it lasts longer, doctors can prescribe a medication to treat this side effect. Sedation and clouded thinking usually goes away with continued opioid use, while reduction in sex hormones may appear down the road with COT. If a patient begins to experience a decrease in libido, sex hormones can be checked and supplemented if necessary. Other side effects may also occur, so patients and physicians need to be on the lookout for them.

Chronic pain is often a complex condition and physicians who prescribe COT should routinely promote other therapies, such as psychotherapy (pain can be awful to cope with), physical and occupational therapies for restoring function, and other non-drug approaches in addition to prescribing other non-opioid medications. The purpose of this recommendation is to treat the whole person and improve the odds that a patient with chronic pain will achieve a more fulfilling life.

Doctors need to counsel patients prior to starting COT and continue until a stable dose is reached or if the dose is later increased as the patients’ cognitive skills may be impaired for a short period of time. If clouded thought processes do occur, driving should temporarily be avoided … so patients might want to start an opioid on a weekend when they do not have to drive. After a stable dose is reached, there is no evidence to suggest that patients on COT should be restricted from driving or engaging in most work activities.

The opioid guidelines give your doctor the “how to” advice for prescribing opioids, including sample copies of patient screening questionnaires, a consent form, management plan, and full details on how to responsibly prescribe opioids. However, they also assume that the prescribing physician is already knowledgeable about issues concerning this class of medications (i.e., the guidelines cannot possibly convert a novice into an expert on COT). Neither the patient nor physician should feel awkward about the consent and management forms, or random urine tests. Doctors who follow these guidelines should be better equipped to implement opioid therapies for their chronic pain patients (such as fibromyalgia) in a safe manner.

* Chou R, Fanciullo GJ, Fine PG, et al. J Pain 10(2):113-130, 2009.

Calling the Kettle Black
… editorial comment

By Kristin Thorson, Editor, Fibromyalgia Network

Posted: February 27, 2009

If your newspaper ran the February 8th Associated Press article “Drugmakers’ push boosts ‘murky’ ailment,” implying that the drug industry has fabricated fibromyalgia in an effort to churn a profit, you have every right to be furious!1 Controversy sells, and that was what the reporter, Matthew Perrone banked on. Perrone sought out Fred Wolfe, M.D., of Wichita, KS, because he knew from the January 14, 2008 front-page article in the New York Times that Wolfe had a track record for trashing patients with fibromyalgia and big, bad pharma as well. It is ironic, however, that Wolfe would make derogatory statements about the drug industry when he is heavily funded by six drug companies himself.

Wolfe is the director (and paid employee) of the National Data Bank for Rheumatic Diseases, a nonprofit registered as The Arthritis Research Center Foundation, Inc. Its mission is “conducting ongoing research to improve conditions for people with arthritis, fibromyalgia, lupus and other conditions.” He openly declares in his research papers, in which he is testing the effectiveness and safety of drugs for rheumatoid arthritis, that he is funded by Centocor, Aventis, Pfizer, Bristol-Myers Squibb, Amgen, and Abbott. So perhaps Wolfe’s dislike is not so much for the drug industry as it seems for fibromyalgia.

Prompted by mixed reports on increased cancer rates in people with rheumatoid arthritis (RA), Wolfe conducted an observational study on the incidence of cancer in RA patients who took the tumor necrosis factor (TNF) blocking agents Enbrel (etanercept) or Remicade (infliximab).2 His findings were derived from information in the National Data Bank (NDB) and per the NDB’s agreement with Centocor, the maker of Remicade, the drug company was allowed to review Wolfe’s manuscript prior to publication. But Wolfe does not just cater to Centocor. His NDB organization has similar contractual agreements with Bristol-Myers Squibb and Sanofi-Aventis.

Wolfe’s study contradicted earlier reports of increased cancer risks for RA patients taking Enbrel or Remicade. It also confirmed that TNF blocking drugs are linked to skin cancers, including potentially deadly melanomas. Instead of using his findings to alert the medical community that these drugs may pose a health hazard, Wolfe went on record with WebMD as stating: “The drugs, at this moment, do not seem to add any risk except for skin cancer and melanoma. This is a small overall risk and I do not think people should be concerned.” He also added that the risks did not outweigh the benefit for patients who truly need the new drugs.3

While there is no argument that people with RA deserve effective therapies, do you not think it is odd that Wolfe is the one pushing drugs on RA patients while in the recent AP article he bashes the drug industry for fabricating fibromyalgia to boost their sales? Yet he is quoted in the AP article as saying, “I think the purpose of most pharmaceutical company efforts is to do a little disease-mongering and to have people use their drugs.” Further in the article he says, “The underlying purpose here is really marketing, and they do that by sponsoring symposia and hiring physicians to give lectures and prepare materials.” Wolfe’s negative sentiments about fibromyalgia appear clear in a February 2009 report in which he writes, “Recently, regulatory authorities have approved treatments for fibromyalgia, offering some de facto support, although no proof, for fibromyalgia as a distinct disorder.”4 However, there was a time when RA had no “proof,” but that does not mean that the patients who suffered with it years ago did not have a real disease.

It is true that Wolfe was the lead author for the 1990 American College of Rheumatology criteria for fibromyalgia, but that was 18 years ago and much has changed.5 In 1990, the number of rheumatologists who were skeptical about the realness of fibromyalgia far outnumbered the believers. I should know, because I hosted an information booth on fibromyalgia at the annual rheumatology meetings throughout the 1990s, and in the early years I can attest to the ugly controversies surrounding this disease.

In 1994, Wolfe orchestrated a consensus conference (paid by the insurance industry) whose primary goal was to trivialize fibromyalgia and restrict patient care.6 Why he wanted to turn his back on fibromyalgia is still unknown, but his efforts failed. During the past eight years, the rheumatologists have rallied to increase the legitimacy of fibromyalgia by developing guidelines for improving the quality of research and for testing therapies to treat this patient population. Today, Wolfe and many of his colleagues do not see eye to eye when it comes to issues concerning fibromyalgia. At age 74, he appears to get his jollies by trash-talking fibromyalgia to headline-mongering reporters.

For all of you who were subjected to the AP story, I hope my comments help you understand the nonsensical nature of the article and that you can ignore any future reports that happen to quote Wolfe. I also want to make three additional points about the AP article:

Although Wolfe’s own nonprofit takes money from the drug companies, this does not mean that all nonprofits and organizations that help patients must do the same to stay afloat. Fibromyalgia Network and its sister organization, the American Fibromyalgia Syndrome Association (AFSA), have never received money from the pharmaceutical industry or other companies that could bias the way these two organizations operate.

Daniel Clauw, M.D., of the University of Michigan, did receive a small grant award from the National Fibromyalgia Research Association (NFRA) in Salem, OR, but the NFRA should not be confused with the National Fibromyalgia Association (NFA). NFRA does not receive money from the drugmakers.

The article implies that Clauw’s brain imaging research, which has documented many brain processing abnormalities over the past ten years, was tainted by drug money. That simply is not true because the funding for these studies came from government grants based on the merits of his proposals. “Most of us conducting research in the field of fibromyalgia were here ten years before the drug industry even took notice of this disease,” Clauw points out.

Perrone M. Associated Press © hosted by Google, Feb 8, 2009; (AP article).
Wolfe F, Michaud K. Arthritis Rheum 56(9):2886-2895, 2007.
DeNoon DJ. WebMD Health News Aug. 29, 2007; (WebMD article).
Wolfe F, Michaud K. J Rheumatol First Release Feb. 15, 2009; doi:10.3899/jrheum.080897.
Wolfe F, et al. Arthritis Rheum 33(2):160-72, 1990.
Wolfe F. J Rheumatol 23(3):534-9, 1996.

Kaufmann I, et al. Rheumatol Int [epub ahead of print] December 4, 2008.
Kaufmann I, et al. Clin Immunol 125:103-111, 2007.

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