Yes, medications carry risk. But, "without a doctor's prescription" does not mean randomly. People still take advice from doctors and pharmacists, they just aren't required to have proof that a doctor has decided something. In any case, a pharmacist is a pharmacology specialist and probably more knowledgable about drug risk and safety than anyone.
>> makes pharmacists de facto community doctors.
Again, depends on the ideal you are comparing to. You are implying an ideal community doctoring setup, where a local doctor knows people and is accessible to them. An ideal that exists for maybe 1%-2% of the world. The problem that pharmacist/nurse led care solves is that this ideal does not exist. GPs are inaccessible, cost $75 for 10 minutes or don't have appointments available. A pharmacist probably sees someone every time they're sick. Doctors... only if it's bad.
I feel like this sort of issue comes up often, when discussing primary medicine. The comparison isn't fair. When listing the pros and cons of pharmacist or nurse led care, we get a laundry list of real life issues. When listing pros and cons of doctor led care, we get an idealisation. IRL, most GPs prescribing antidepressives do exactly as much "holistic care" as pharmacists would. Patient asks for ADs. Doctor spends 2-3 minutes going through a checklist. Done. Whether or not that's ideal has little to do with who writes the script.
Anyway, I don't have a problem with the way primary care works here. It works well. I didn't mean any of this as a slight on the job doctors do. But... I also think pharmacists and other trained people can prescribe medication, tests and such. There is value in accessibility. If they can (as I think some of these ideas take as premise) provide walk in service, there is good reason to do it.
I know people prescribed antidepressants from GPs, in the UK as well. 10 minute appointments several times per year.
A U.S. Pharma.D is a professional doctorate degree. They don't just study organic chemistry, but also little things like treatment indications and counter-indications, patient management, etc.
Having access to the patient's medical history is a solvable problem. Some pharmacists already have access to and make use of such information.
Regarding patient time, there are more pharmacists in the U.S. than primary care physicians--roughly 290,000 versus 250,000. (See https://www.statista.com/statistics/185723/number-of-pharmac... and https://www.ahrq.gov/research/findings/factsheets/primary/pc...)
The problem today is that we waste our physicians' expertise on trivial stuff. It's an inefficient allocation of resources. Pharmacists have traditionally always been on the front-lines. The past half century in the U.S. has been anomalous in how underutilized are our pharmacists. Fortunately their training is still quite rigorous. They regularly catch physician errors, including a significant portion not related to drug interactions. (See https://www.sciencedirect.com/science/article/pii/S131901641...)
As long as the lines of communication are kept open, what's the issue? An M.D. or O.D. doesn't make one omnipotent. And U.S. pharmacists are better trained than the pharmacists in many other countries who enjoy greater independence and authority. The sky isn't falling in those places, AFAICT.
I agree with you that a pharmacist is capable of dealing with many of these issues, but (at least in the uk) they are not primarily set up to deal with long term health conditions, and don’t develop that expertise in a single patient. If they become like GPs (which they feasibly could), it would work. But why do that when there is already a doctor who specialises in that? Maybe my arguments work less well in America, but my knowledge of that healthcare system is limited.
Ultimately though it seems we agree medications need some form of specialist oversight, rather than being freely available.
Probably due to people previously being able to buy saline over the counter, and using it to inject themselves with etc. Misuse of things by people generally ends up with knee-jerk responses by regulators.
I don't think you should need a prescription for saline, but it's a little more complicated than salt water.
I’ve absolutely benefited from my endocrinologists over the years, but 80 appointments for 2-3 prescription changes (prompted by my request each time) seems like excessive rent seeking.
I think there's a bit of Dunning-Kruger at play here. People think they can make their own judgements based on the drug monograph and simply checklist over the contraindications/interactions and call it a day. And there are others who share their pills with relatives/family members because "its worked for me before". There's another special group of people who think that piecing together a pharmacological narrative will bring about a clinically meaningful result (it works in theory, so it must work in practice!). Others think statistical significance == clinical significance.
The typical community pharmacist is absolutely not equipped with the tools, incentives, and workplace conditions to assume the role of a GP. We are trained in evidence-based drug therapy management, not diagnosis. I'm also deeply concerned about how retail pharmacy corporations will adapt to this. I imagine that there will be a new metric: prescriptions sold/visit that regional directors will be optimizing for. If not a prescription, then you need to sell an OTC product.
A lot of people think they can DIY medicine. It will be a disaster. I've worked in a very high-income area with a very professional clientele (business owners, health care workers, lawyers, finance), and many are completely swayed by false information or "studies" they read online (because they are intelligent professionals, after all).
We need better access to high-quality healthcare, but not through DIY medicine. This proposal is the result of people running out of ideas and giving up.
So, a person having an obvious anaphylactic shock and being denied an epipen (and dying) is not problematic to you because that would be "DIY medicine"
http://www.foxnews.com/health/2013/12/23/girl-dies-after-pha...
Then why not consult a doctor? It is already an immense legal risk to recommend starting a course of drugs like this without seeking medical advice, I don't see why it would be any different if you could technically self-administer an anti-hypertension drug.
Most people don't go to the doctor before taking Claritin or Sudafed; when you go to the doctor and get a "script" for Sudafed, that's your signal that you wasted yours and the doctor's time.
The tragedy of the situation is that most prescriptions aren't as effective as marketing campaigns lead people to believe. For example, statins are good for improving patients' cholesterol lab #'s, but make them achey, and only prevent a handful of heart attacks for every 100 patients treated (statins have a poor 'number needed to treat' [0] ratio).
[0] https://en.m.wikipedia.org/wiki/Number_needed_to_treat (the section titled "simple example" says ~98 people had to take the studied cholesterol drug for 3.3 years to prevent one cardiac event.)
Number needed to harm is another important factor. All patients were harmed by DES [1], before it was withdrawn...
>>> Americans may soon be able to get cholesterol-lowering medications
Going to the doctor to get such a medication is one more occasion to be reminded to check your diet before jumpin' on pills...
For the newly available medication, I'd suggest to raise their price by half the price of going to thte doctor to get the script. That money would then be given back to social health care system :-) So the patient pays less, have more flexible access to the medication and healthcare system benefits too :-)
It seems in the us, seeing a doctor already is a luxury.
I think allowing diabetics access to life saving medication is preferable, even if there's some moron that's going to kill himself by injecting something he has no idea about (and they do that already)
The proposal wouldn't allow the sale of controlled medication like antidepressants
The rest just sounds like undue gatekeeping
>Please don't insinuate that someone hasn't read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that."
In particular, I was replying to Lanthanide’s comment on the system in Saudi Arabia.
I agree with IanCal, giving insulin to someone not already prescribed it is hard to justify. The risk of harm is much greater than the possible benefit, especially when they could just go see a doctor (routinely or as an emergency). I am from the UK so perhaps I live in what you would consider a nanny state, as guns are not freely available. As a point of information, in the UK antidepressants are not controlled more than any other prescription drug, I don’t know how that differs in the USA
I don't think anyone is arguing for diabetics to not have access.
My problem here is how someone knows they are diabetic.
But I saw little in the article actually describe what the process would be for deciding what can be sold like this, I know diabetes is not mentioned.
Again, I don't really see why this would be the problem of the person selling it, unless you prefer living in a nanny state.
There are a multitude of OTC and other readily sellable stuff that if misused can cause death. Complaining about selling insulin freely and the dangers of it in a place where guns are sold like candy is a farce.
Make them sign a waiver and be done with it.
People regularly poison their livers with hypervitaminosis A, yet vitamin A supplements, liver meat, and other extremely dense sources of vitamin A are not labelled in any way which would indicate this danger. Beyond products, the sheer number of ways you could kill yourself in this world is staggering, why is it more wrong to be exposed to risk from pharmaceuticals than from something like traffic or supplements?
I currently live in the Maghreb and the situation is here as it was described for Saudi Arabia. An important difference to Western countries is that pharmacists seem to play a much more important role here: I have to justify every purchase (even for very common broad spectrum antibiotics) and locals tell me they regularly seek advice at the local pharmacy first. Think "doctor's appointment pre-screening". And my highly subjective impression is that the quality of this pre-screening surpasses service in western pharmacies by far.
Though, the problems you point out are very real, just mitigated by the different situation.
Another thing that makes the situation incomparable to western countries is the low density of qualified doctors: If you need psychotropics here in my village you would have to move several hours away into the next big city to do a therapy. So it is: diagnosis, prescription and off you go. One can go on with a single prescription for years and I dare to say that the debate on whether this is good or bad here is still open.
Being able to go from "Ask your doctor about..." to "Try..." is a major shift.
This type of aggressive drug ads is pretty much unique to the US. It's your MD's job to stay up to date with drug developments and prescribe what would work for you.
Big name pharmacies like Walgreens or CVS won’t dispatch u a medication without a prescription, the town pharmacies (Mom and Dad) would do it.
A week ago I avoid the hassle and loss of time (travel, waiting time, and $) just going through the town pharmacy and asking for a antibiotic, having a prescription won’t make any difference as the insurance plan won’t cover it.
As OP says, this system exists in the real world and how it actually works can be studied.
Preventing people from getting the medication they need is a terrible idea.
The self-medication thing is a seriously double-edged sword. You elucidated why very clearly. I have two reasons though to believe that it's a SLIGHTLY less risky practice over here;
1, pharmacists are very engaged with patients in recommending medications and constantly steer them to doctors- and they are more confidant with in-class substitutions rather than dispensing to a patient outright without vitals or history (beyond what is disclosed orally by the patient). However, they'll still recommend medications freely when they judge them as being unlikely to go to a doctor otherwise, hence risking more damage. Lesser evil and all that.
2, a long history of OTC availability of medications, where controlled prescriptions are the exception rather than the norm, seems to have lead to a culture of caution and careful reading of medication leaflets, asking the pharmacists, etc. I don't mean this as necessarily a good thing, I think this is more of a "you're on your own" mentality with regards to being careful with medications. This mentality grew, I think, partially from issues with access to doctors (governmental neighborhood health centers, kind of like small GP practices in the US/UK, are a somewhat new thing here. It was all centered around huge hospitals in the past). The bigger problem, in my opinion, is that this mode of thinking is about to be reinforced further by rising healthcare costs in the face of the rapid privatization of the healthcare sector, and it will clash with increasing OTC regulations.
One aside I will say about antidepressives which you mention; I think this merits a special examination separate from the rest of the healthcare issues. I've slowly come to realize that a massive portion of the population here are actually on antidepressants (mostly SSRI and SNRI meds). Why is this notable? Because it's not anywhere near commensurate with the number of people using psychotherapy or visiting psychiatrists. The reason, I believe, is because there is such a stigma around mental illness here that I think it would be very difficult to get many of these patients into more suitable therapy, and OTC Prozac or what have you helps hide the ""shame"". We're finally, FINALLY slowly moving past this stigma, probably catching up with the public attitude of the US/EU towards mental health in the 1980s or so. I really hope this will eventually lead to mental health patients not feeling that they need to self-medicate.
Edit: I forgot to mention that you're also completely correct in the assumption about quack medicine. It is, unfortunately, endemic here. It's a constant struggle to convince loved ones that, no, Supplement X is neither a peer-reviewed medication nor is it an alternative for treatment. At the very least the regulatory environment is increasingly more strict about misleading medical claims on herbal products, etc
Second, i think such a system makes pharmacists de facto community doctors, but without the time, training, or patient medical data to function correctly. Community doctors can make better decisions when they see the same patient multiple times, and have access to blood pressure readings, a list of other medical conditions etc. Buying over the counter makes a lot of this difficult and inefficient.
Third, I think it leads to a risk of encouraging patients to manage conditions without valid medical advice. For instance, depression is often treated best with psychotherapy. By buying antidepressives OTC, it prevents patients getting the holistic care needed. Similarly, patients may follow quack medical advice and do themselves significant injury by taking medications not needed (in the short term or long term).
Ultimately doctors offer a lot of value more than just prescribing medication, and often medicines need oversight to ensure the benefits outweigh the risk.