[Jach]

I don't think GLP-1s are particularly expensive, so my top preference would be to just see them easily available. While not quite the same, it's a win that Rogaine/Minoxidil were once prescription-only but for a long time now can be bought at any grocery store and taken to the self-checkout. Still, I think the subsidy approach has been done for smoking problems via nicotine products before, and e.g. nicotine gum cost never seemed that high to me (especially compared to cigarettes).

But it's also worth remembering the relative risks involved. Obesity isn't quite the ticking time bomb / public menace it's often made out to be... For smoking, you'll find studies with relative risk numbers for lung cancer over 5 for casual 1-4 times a day smokers, and the number quickly exceeds 20 for heavier smokers. In contrast, with obesity, the most severe relative risks for things like heart disease or diabetes you'll find topping out around 4 to 5 for the most obese, even then often under 3, with milder 1.1 to 2 for the bulk of obese people. (Here, ~31% of the US has BMIs between 30-40, and ~9% have BMIs over 40.) For other harms, like there was a study on dementia a few years back, you'll also find pretty mild (1.1ish) relative risks, but these end up being similar with other factors like "stress", "economic status", or "low educational attainment". Just some thought for people thinking about subsidizing or providing free stuff, the cost tradeoff with paying for other things later might not work out so neatly, and there's reason to not focus solely on obesity but also do the same sort of analysis with other factors and severity of a factor as well.

[paulpauper]

yeah this is true. When people say that obesity is worse than smoking, I'm like "Have you looked at the actual stats on this?"

[eru]

Smoking is pretty good for pension systems.

[Aurornis]

> I don't think GLP-1s are particularly expensive

On-patent GLP-1s (all of them right now) are actually extremely expensive. Right around $1000 per month.

I don’t want to discourage anyone who needs them from seeking treatment, but their discontinuation rate can be somewhat higher than you’d think from a life-changing drug because many people don’t like certain effects or even encounter side effects.

Weight loss drugs are also a challenging category for OTC because they’re a target of abuse. People with eating disorders and body dysmorphia already seek out black market GLP-1s at a high rate and it would be a difficult situation if they could pick them up impulsively from the medicine aisle. It’s also common for people to misuse OTC medications by taking very high doses hoping for faster results, which has to be considered.

There’s a libertarian-minded angle where people say “Who cares, that’s their own problem. Medications should be free for everyone to take.” I was persuaded by those arguments when I was younger, but now I have a very different perspective after hearing about the common and strange world of OTC medicine abuse from my friends in the medical field. Just ask your doctor friends if they think Tylenol should still be OTC if you want to hear some very sad stories.

[bananapub]

> On-patent GLP-1s (all of them right now) are actually extremely expensive. Right around $1000 per month.

what does that mean? in the UK it's for sale from numerous national-chain pharmacies on a private prescription (ie the pharmacy is selling it commercially and customers are paying cash, no insurance and no state subsidy) for less than $US270/month. it seems unlikely to me that the pharmacies or the manufacturers are taking a loss on this, and the UK has at least as strict drug quality standards as the US.

sounds like the US monopoly-holders are just charging a lot more because they can, because the insurance system obfuscates prices and gives everyone involved cover to rip off patients?

[terminalshort]

People who want to misuse the medication are going to be the ones most willing and able to jump through the bureaucratic hoops. Increasing the difficulty to get the medication will only make it more difficult for legitimate users and won't decrease abuse. In 1920, 1970, and now, heroin was legal, illegal with minimal enforcement, and illegal with harsh enforcement (except in SF), and the same percentage of the population was addicted at each time.

Doctors' jobs are to deal with the cases that go wrong. These anecdotes have no relevance without actual data on how often these problems occur.

[Aurornis]

> People who want to misuse the medication are going to be the ones most willing and able to jump through the bureaucratic hoops

This thinking seems correct to people who grew up knowing about the dark web, Silk Road, and who believe they could access any substance they want if they wanted it.

It is not accurate for the majority of the population. For the average person, misuse of drugs isn’t a calculated decision. It’s one of convenience and opportunity.

> In 1920, 1970, and now, heroin was legal, illegal with minimal enforcement, and illegal with harsh enforcement (except in SF), and the same percentage of the population was addicted at each time.

This is a very misleading statistic for multiple reasons, as if it was engineered for the purpose of obscuring the problem.

Why pick 3 separate dates and limit only to 1 drug? There is a massive opioid epidemic that was fueled by increased availability of different forms of opioids beyond heroin. In the 1920s and 1970s they didn’t have OxyContin being diverted, Fentanyl flowing into drug distribution networks, or even Kratom products available at the local gas station. The availability and convenience of these different opioids has unquestionably increased opioid addictions.

Even more recently, the widespread legalization of marijuana has led to an increase in the number of daily users and the doses that people consume, even thought the libertarian arguments maintained that no such thing would happen.

At this point I can’t buy any arguments that claim that availability of drugs has no impact on misuse or addiction.

[NoMoreNicksLeft]

≥At this point I can’t buy any arguments that claim that availability of drugs has no impact on misuse or addiction.

I don't much care whether more people are addicted or not. When alcohol was illegal, booze dealers had machine gun fights in broad daylight on Main Street over it. When's the last time you heard about machine gun fights over whiskey?

Legalize it all. Heroin, cocaine, meth... sell it retail out of liquor stores in plain wholesale packaging. Manufactured by pharmaceutical companies, supervised by pharmaceutical engineers, unadulterated by poisons, measured doses, and include a dose of the antidote in the box. Make the junkies pay a deposit on a red plastic sharps container for their disposable needles.

I do not care how bad you think things will get... they're already that bad, but right now you're able to pretend that they're not. For every soccer mom addicted to oxy that you save, ten undesirables are dying of overdoses of fent in some filthy truck stop restroom somewhere. And we're spending half a trillion every year to do it, too.

[terminalshort]

> The availability and convenience of these different opioids has unquestionably increased opioid addictions.

You are making my point for me. The harsh restrictions on opioids haven't actually decreased the availability for addicts who are willing to go to black markets and risk dangerous injectibles and fent laced street drugs. All the restrictions have done is make it much more difficult for legitimate users like me. I broke my collar bone a few years back and was barely given any pills and had to live with a lot more pain than I should have. And the justification is that these harsh restrictions make it harder for addicts to get it, but as you pointed out, it actually doesn't even do that.

As for marijuana I would bet that the increase in the number of users has been more due to the decrease in public perception of how harmful it is rather than from its legalization. Is the usage increase limited to the states where it has been legalized? Furthermore, it doesn't matter if the usage increases, only if the problematic usage increases. Is there any indication that this increase corresponds to more serious potheads or just more casual smokers?

[fnord77]

I pay about $40/month for mine, grey market from china

[sizzle]

How do you mix the powder for injection?

[toraway]

The typical grey market buyer exclusively buys vacuum or inert gas sealed sterile vials that contain pre-measured lyophilized powder and then uses BAC water from medical supply stores (or just Amazon) for reconstitution transferring from one vial to the other with a fresh needle.

[diet_jerome]

How do you find a grey market source?

[Jach]

$1000/mo is very high, yeah, but Ozempic isn't the only thing in town. My price info is from looking at https://www.brellohealth.com/ and similar ($133/mo semaglutide, $166/mo tirzapatide) -- i.e. just getting a prescription for compounded semaglutide. Reading anecdotes on twitter and elsewhere about grey market sources suggest the prices can be even lower. The innovation of Ozempic having the dose in a ready-to-go single-use injector is probably not worth an extra ~$900/mo for most people if they have to pay for it themselves, and if these things were available on shelves (or just over the counter, like sudafed (pseudoephedrine version)) you'd probably see that reflected.

> it would be a difficult situation if they could pick them up impulsively from the medicine aisle

It would be a different situation, not necessarily any more or less difficult. Anorexics and bulimics are already in difficult situations. Without research into the actual patterns of GLP-1 abuse and their problems, I'd still bet on it being a better situation. That is, abusing GLP-1s is probably better than destroying your esophagus from bulimia. But perhaps not.

I was persuaded by libertarian-minded arguments when I was younger, too -- though not typically ones framed from "who cares", but rather those rooted in a framework of freedom. People will always be free to destroy themselves in numerous ways, singling these things out to try and curtail destructive use is an unprincipled exception. Furthermore, the methods typically available for such curtailing (laws, law enforcement, and medical gatekeeping) are crude, heavy-handed, and often inconsistently applied themselves, leaving a lot to be desired in preventing abuse while certainly doing a good job impeding legitimate use which causes harm. When you go drug by drug, we also see the argument from other countries with laxer (or no) regulation not becoming anything like what you might predict if you just listen to what medical professionals say will happen if you got rid of requiring them as middlemen.

I'm older now, and I still believe such arguments, for the most part, despite direct experience with people trapped in cycles of abuse, not just anecdotes from people with an incentive in perpetuating the current system. (If you want sad stories, you can hear them from all sorts of people, not just from doctors. If you want tragedy, open your eyes, it's everywhere. Nevertheless such things by themselves aren't evidence and shouldn't weigh strongly in policy decisions.)

The first qualifier to unpack "for the most part" is that I think if society turned a lot more totalitarian, it would be possible to actually prevent almost all abuse. But if we did, we would also need to crack down on already legal and available things. You bring up tylenol, but I raise you alcohol. I don't drink, I think it's bad for you, tens of thousands of deaths each year support my claim, I don't even need all the rest of the non-death negatives affecting/afflicting far more. I'm not going to advocate making it as illegal as fentanyl. I do think there's a missing consistency here though and it's better for policies to be consistent. But consistency and the medical industry mix as well as oil in water. Modafinil, a stimulant that seems as harmless as caffeine, is regulated in the US as Schedule IV (same as Valium, which Eminem and many others were famously addicted to). But adrafinil isn't regulated that way, you used to be able to get it OTC / ordering online e.g. from walmart pharmacy, there's even an over-priced energy drink containing it now https://adraful.com/ yet it metabolizes to modafinil. Fladrafinil works similarly, is unregulated, and you can buy it in powder form by the gram on Amazon. Or just get modafinil from grey market sites (not even on the dark web) that ship generics from India because its status is never enforced, and save your liver some effort.

The second qualifier is that restricting access can sometimes be a good thing, and worth it on margin, when such restriction is considerately targeted and probably temporary. Part of the cycle of abuse for a lot of people is voluntarily committing themselves to a rehab center where their freedom of choice and access to many things is severely restricted for a while, and after enough cycles, it can work out in the end. That's a targeted restriction on the individual level, and having it forced on someone (involuntary commitment) is something hard to do and generally requires other harmful crime. Since fentanyl was brought up in the other reply chain, it's notable that this year fentanyl related deaths in the US continue to decline, this year by quite a lot. NPR gives 8 guesses as to why that is, with the top one being increase of access (just as I want for everything) for naloxone, which can reverse overdoses: https://www.npr.org/2025/03/24/nx-s1-5328157/fentanyl-overdo... Notably none of the theories are directly related to restricting access on top of current efforts, only in reason 2 (weakened product) do they suggest that some have thought the current enforcement in China, Mexico, and the US might be a factor in that. (I would have naively guessed as one of my theories that the current administration's various efforts could have something to do with it.) And notably none of the theories, except weakly 2 (weakened product) and 7 (skillful use) suggest that removing the barriers to getting fentanyl would lead to significantly more deaths. So while I think there's room for the government to make targeted time-limited society-level decisions that can produce marginal benefits by restricting access to something, the current poster child case of fentanyl doesn't seem like a strong candidate to support that view for either it or other drugs (especially those with more positive uses). (Indeed, a common libertarian point is that a lot of fentanyl harm specifically is because of reduced access to other drugs, so users get surprise-fentanyl from their illicit sources. And no, people getting those other drugs is not from growing up with the dark web, it's still often just "I know a guy who knows a guy" -- or just strolling down to various bus stop hubs in major cities like Seattle and looking for the loiterers with hoodies.)