[Lanthanide]

I live in a country where this scheme is already the norm (Saudi Arabia) and I can say that while it's not necessarily ideal, I much prefer it to the alternative. It plugs some seriously annoying holes in the healthcare experience and frees up doctors' time for more patients.

As it is, the only medications that require a prescription to buy in Saudi are psychotropic ones, narcotics, and most recently, antibiotics. Things like insulin, birth control medications, hypertension medications, even antidepressants and anti-psychotics- they are all OTC. And I think they should remain so, because from what I've seen the damage from misusing those drugs against pharmacists' advice is far less than the damage from going without them due to the difficulties encountered in seeing a doctor.

The reason that this is the norm here is twofold; one, health insurance wasn't much of a thing here until a few years ago. The second reason (and the reason health insurance didn't factor in until recently) is that the socialized healthcare system here was (and still is) stretched thin; seeing a doctor to get prescriptions for every little thing becomes prohibitively difficult, with appointments taking months.

It's asinine to expect someone suffering from, say, an acute athsma attack to try to navigate ERs or try to see a doctor on short notice during a crisis, when a pharmacist would be able to dispense the exact medication needed, leaving the others free for more complex cases that need closer attention.

Edit: this actually created a bit of culture shock for an older friend of mine. He was traveling to an EU country for the first time and didn't do his homework- he thought he he could simply walk into any pharmacy and ask for a pack of his cholesterol medication, as he usually does back home. I don't envy the poor pharmacist that had to keep trying to explain the dispensing system to him and to emphasize that yes, they are aware that it's Lipitor, not morphine, it's just how the regulation is.

[Engineering-MD]

I’m not I agree. The first reason is that many medications carry significant risks. For instance you mention insulin. For someone already prescribed insulin, yes it should be easy to access in case they should be able to get more (and that is the purpose of a repeat prescription). However, to provide insulin over the counter to someone never previously prescribed it could be incredibly dangerous, and indeed fatal. This is Similarly true for some cardiac medication.

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.

[dalbasal]

I think it comes down to whether you are comparing to ideals, or regular life.

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.

[Engineering-MD]

I practice in the UK. The system is far from perfect, but does to a certain extent work in the idealistic system you propose. It is not true for all GPs, and some don’t practice holistic medicine, but the system is created to allow (and encourage) this method, and in my experience holistic medicine is practiced by GPs. Perhaps things differ in the USA, but this system works well in the UK.

[dalbasal]

I live in Dublin, so not that far. GPs here are generally private, though kids, older people and lower income people are subsidized or free. Some other parts of the medical system are more like yours. It's an eclectic system.

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.

[wahern]

> i think such a system makes pharmacists de facto community doctors, but without the time, training, or patient medical data to function correctly.

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.

[Engineering-MD]

I was not belittling the pharmacist’s qualification, they often helped advise me and fit a specific role in the health care system. They are however trained for a different role (at least in the uk where I am based). General practioners are trained to deal with long term conditions. These conditions often require patients to be managed over a long period of time, and seem several times, hopefully by the same clinician. They also see them for the majority of their other illnesses. General practitioners allow a patient to develop a long term relationship with a doctor, and allow the doctor to become an expert in the patient.

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.

[ScottBurson]

It gives me a bit of pause too, but I think things have gone too far in the controlled direction. My wife uses a nebulizer for her asthma, and recently was prescribed an albuterol refill. To her surprise, it came in a form where it has to be mixed with saline. She had to get a prescription for the saline. I'm sorry, that's nuts.

[King-Aaron]

> She had to get a prescription for the saline.

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.

[PhasmaFelis]

Isn't saline literally just salt water?

[pkkm]

Yes, it's just very clean water with 0.9% of salt.

[DanBC]

This is saline that you're going to warm up and then inhale. And you're only going to do this if you're already ill.

I don't think you should need a prescription for saline, but it's a little more complicated than salt water.

[morganherlocker]

Generic insulins are already available over the counter at any pharmacy in the US. The newer insulin variants are significantly easier to use safely, since they require less frequent injections (long lasting insulin) and have a faster response time (short lasting insulin used when ingesting carbohydrates or correcting high glucose). These newer variants require a prescription that is typically only issued by an endocrinologist who will require a visit at least every 3 months. I’ve had type 1 diabetes for 20 years now, and have only had my prescription changed a couple times over the entire period. 100% of my medication-related complications have occurred during times where I was unable to acquire a prescription for these higher quality insulin variants, either due to a change in doctor or insurance. Pre-ACA it was common for people to be locked out of insurance coverage of these drugs for up to a year without covering impossible markup on specialist care, and protections for pre-existing coverage are back on the chopping block as we speak. Even today, travel away from my doctor can result in stressful prescription renewal logistics despite having no change in dosing for over a decade. After seeing a doctor nearly 4 times per year for 20 years with almost every visit boiling down to “ok, here’s your renewal, see you in 3 months”, I’m not sure I understand the value for me personally. If someone wants to abuse insulin (I’m not sure why they would), they already can with a bottle of humulin, available at their local Walmart for about $20.

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.

[PiggySpeed]

I'm a pharmacist, and I completely agree with your assessment. People are waaaaay over-estimating their abilities here.

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.

[raverbashing]

> A lot of people think they can DIY medicine. It will be a disaster

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...

[mirimir]

I can't imagine safely prescribing anti-hyperlipidemia and anti-hypertension drugs without medical advice. Sure, we can all measure our own blood pressure. But choosing which anti-hypertension drug to use, or which combination, is nontrivial.

[microcolonel]

> But choosing which anti-hypertension drug to use, or which combination, is nontrivial.

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.

[tptacek]

The basic argument is that when you make seeing a doctor to get access to a drug optional, you also make it a luxury; it changes patient expectations and thus behavior.

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.

[tcj_phx]

You have a very good point about patient expectations. But patients have been trained to expect a prescription for magic pills from the doctor, and the doctors do their best to oblige, even when they ought to recommend a lifestyle intervention... As you note, people think they've wasted their time (and money) if they only get a recommendation that doesn't need a prescription.

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...

[1] https://en.m.wikipedia.org/wiki/Diethylstilbestrol

[wiz21c]

FTA,

>>> 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 :-)

[ant6n]

> The basic argument is that when you make seeing a doctor to get access to a drug optional, you also make it a luxury; it changes patient expectations and thus behavior.

It seems in the us, seeing a doctor already is a luxury.

[raverbashing]

Read the article, it will have a questionnaire to determine if people should be given the drug

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

[Engineering-MD]

I did read the article. In future, please refrain from insinuating someone has not read the article, it is against the guidelines for comments:

>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

[IanCal]

> I think allowing diabetics access to life saving medication is preferable,

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.

[raverbashing]

> My problem here is how someone knows they are diabetic.

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.

[microcolonel]

> The first reason is that many medications carry significant risks.

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?

[jlg23]

[on the risks of self-medication]

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.

[exolymph]

There are tradeoffs. My guess is that very few people will bother to abuse the drugs that can't get you high, relative to the benefits of increased accessibility.

[ethbro]

Presumably the slippery slope would be the profit incentive for manufacturers.

Being able to go from "Ask your doctor about..." to "Try..." is a major shift.

[m000]

You are already on the slippery slope if you allow public "ask your doctor about" advertisements for anything more substantial than mild painkillers or flu symptom remedies.

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.

[fjsolwmv]

So? We don't require a prescription for fruits and sandwiches.

[jerkstate]

Fruits and sandwiches don't have a long list of possible side effects (read quickly in a low tone of voice)

[ionised]

Really? You don't see any difference between a banana and an anti-depressant for example?

[edtruji]

The cap for repeat prescription is at 3, at least were do I live which is in Puerto Rico. So the patients that needs those concurrent medications like levodopa or Humalog goes to see the Doctor and they ask for a prescription refill without date.

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.

[BurningFrog]

This is an entirely theoretical argument.

As OP says, this system exists in the real world and how it actually works can be studied.

[ElixirIsCool]

A desperate person without money to pay for Drs to get prescriptions will order from mexico or use veterinarian medication (true story). If those two options are not available the person will suffer in agony.

Preventing people from getting the medication they need is a terrible idea.

[Engineering-MD]

I am based in the UK, and as such my opinions are based towards a national health service free at the point of use. I am against a system lacking free health care for reasons such as this.

[Lanthanide]

I actually agree with most of your points. I don't think this is ideal at all, I just think it's a less-harmful solution (and hopefully a temporary one) in the face of systemic dysfunction in healthcare. The alternative seems to skew less towards "oh I guess now I should see a doctor about that condition now" when facing pharmaceutical hurdles and more towards the "I guess I will tough it out; I can't handle the wait times for public hospitals or the costs of private ones". The lack development in centralized patient records entrenches this problem.

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

[flyGuyOnTheSly]

I have always thought that it was completely asinine and unnecessary that my female friends were having to visit a doctor to renew a prescription that rarely changed for years at a time.

[jessaustin]

Things like... hypertension medications, ...are all OTC.

This would be so nice. Every time I switch providers, I have to hear the same tired "Lisinopril is the modern blood pressure medication and it's certainly all that you need!" "No asshole, it doesn't work for me and it makes me cough 17 times a minute, 1440 minutes a day. Just give a water pill, which does work and has worked for years."

[StillBored]

This is actually what irritates me and keeps me away from doctors. Its seems to be 99% seat of the pants guess work, and in my case the doctors seem to have a pretty poor batting average. I get that antibiotics are over-prescribed, but do I really need to have the same test run again for the 3rd time to see if I'm lying about the antibiotic not doing a darn thing?

I get that treatment is frequently trial and error when it comes to medications, but the doctor/patient/pharmacist loop is BS, particularly for minor/frequent issues.

Take for example that I seem to run myself into poison ivy a couple times a year while mountain biking. Do I really need to fight to see a doctor/nurse/whatever just to have the same prescription I've gotten the last couple years straight? Or for that matter, maybe I should experiment more with stronger allergy medications to avoid the nasty withdraw I seem to get from prednisone.

Worse, what irritates me, is like the GP, it seems a lot of the common "safe" prescriptions in the US are over the counter in the rest of the world.. I know this, but got myself quite a surprise last time I was in mexico, because the hotel gift shop had viagra next to the advil!

[bumholio]

I find it doubtful that Atorvastatin was not available for health/risk reasons. I can buy it cash in 5 minutes, no questions asked.

What tends to happen in some EU countries is that the retail drugs are heavily subsidized by the government, and then all kinds of kludges are put in place to prevent people buying bulk quantities and reselling them in some other EU country where the price is much higher - the export itself being 100% legal on the single market.

[Lanthanide]

The subsidy/export explanation does make a lot more sense, since it's not exactly in a high-risk drug class. I suppose those regulations could have been misinterpreted by him to mean he needed a prescription.

(unless Austria, where this happened, really does have very strict OTC drug laws on medical grounds)

[api]

Off topic but: birth control is OTC in Saudi Arabia? That busts a stereotype.

[Lanthanide]

Aisle 5, right next to the condoms and lube bottles =) and Victoria Secret makes money hand over fist here.

This would be off-topic here, but I think most people outside of the region would be stunned about the state of sex-change operations over here. They happen VERY frequently, albeit with a heavy veil of privacy.

[avar]

Male -> female or female -> male? I have no desire to have a sex-change, but if I had to choose between living as a woman in Saudi Arabia and having invasive surgery and hormone therapy, I might choose the latter.

[Lanthanide]

Both. Anecdotally I’d actually say that the ratio of MTF surgeries to FTM ones is higher than usual over here.

[fjsolwmv]

Assuming that Christian laws apply to an Islamic country is a strange stereotype.

[talltimtom]

“ And I think they should remain so, because from what I've seen the damage from misusing those drugs against pharmacists' advice is far less than the damage from going without them due to the difficulties encountered in seeing a doctor.”

When people start self prescribing antibiotics even for minor stuff, it’s not a problem because of the minor risks to them, but because of the major risk to the entire society. We are seeing more and more antibiotic resistance germs and if we don’t collectively work to reduce antibiotic usage we end up exasperating the issue.

[AngryData]

Do you guys also allow drug advertisements? The only problem I see is our drug producers here using advertising to push people into buying and using drugs that they really shouldn't be using and inadvertently causing themselves a myriad of additional health problems. Im 100% for people being able to use whatever drug they wish, provided that they actually know what they are taking and what it does. Any half decent advertiser though would leave that as an open-ended as legally possibly interpretation in order to drive sales though.

[Lanthanide]

Not in the US style of drug ads, but not completely banned either; things like Tylenol and the various cold and flu drugs can be advertised. I’ve never seen ads for something that would be prescription-only in other countries except for Viagra and a coupe of other ED drugs, and that’s an edge case.

As far as I can see all drug advertisements (including things such as social media promotions) have to be approved by the Saudi FDA, and they don’t seem lenient at all in allowing ads for anything beyond the aforementioned meds.