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Prescription for Reform
[In Italy] small proposals bring protesters to the streets, one hurdle to making changes as protected interests seek to preserve themselves. Pharmacists shut their doors this year when the government threatened to allow supermarkets to sell aspirin. The cost for just 20 aspirin tablets at a pharmacy is $5.75.
That is from an excellent article in the NYTimes on Italy's malaise. We may snicker when we think that Italians couldn't buy aspirin at the supermarket but our prescription-only system isn't much better. Kerry Howley, writing in Reason, says Basta!
Posted by Alex Tabarrok on December 13, 2007 at 08:43 AM in Economics, Medicine | Permalink
Comments
Aspirin is an excellent candidate if you want to bring something to Italy:
http://padovachronicles.welton.it/articles/2006/03/25/aspirin
It's sad that the bureaucracy really is *that bad*:
http://padovachronicles.welton.it/articles/2007/08/18/confronting-the-bureaucratic-beast-registering-an-italian-domain
because the people are smart, hard working, very inventive, kind, and of course live in a beautiful place.
Thanks for the link, it's a good read, and an accurate description of Italy's problems at the moment.
Posted by: David N. Welton at Dec 13, 2007 9:15:18 AM
Supermarkets aren't allowed to sell aspirin and similar drugs in Sweden either. If you allow supermarkets to sell such things we will see a huge surge of teen suicides and society will become horrible in general, our socialist overlords tell us through the state run television network. I fear that you Americans have yet to see the light on this issue.
Posted by: Erik at Dec 13, 2007 9:47:30 AM
The point isn't that "our prescription-only system isn't much better," but rather that Europe may not actually be the health-care nirvana everyone wants to believe it is. It seems there is a side to the story never before considered. My goodness. If I could 30 cents a tablet on something a high-school kid can make in a chemistry lab, at sell it at much higher volumes than specialty prescription medications, I'd charge less for my other drugs too. Now I know the rest of the story. Thank you for this.
Posted by: Hovie at Dec 13, 2007 10:15:56 AM
Hovie - before jumping to conclusions, you'd have to look at where the money goes from the sale of things like aspirin. It might well go directly to the pharmacists, or to the drug companies, rather than feed back into the health care system.
Posted by: David N. Welton at Dec 13, 2007 10:30:43 AM
Prodi's so-called "liberalization" of pharmaceuticals was designed to advantage the "Red" COOPs (communist cooperatives) which thanks to preferential treatment (tax-exemptions, political links to the left, mafia ties, etc...) have grown into a commercial empire and control most of the supermarket distribution. I'd be all for liberalizing access to markets if the communist capitalists that control Italy right now were held to the same standards as everybody else.
Posted by: Unit at Dec 13, 2007 10:52:33 AM
Alex, that Reason article was abysmally researched!
I work at NIH, and our group prescribes a lot of statins for our patients. If you are going to analyze prescription drugs, you need to understand their medical context; let me explain some details that Howley omitted. First, drug dosage. Statins (and many other drugs) are not like Tylenol with just 2 or 3 levels of dosage. And to track whether your chosen dose is appropriate, you need routine blood cholesterol testing. You might not need an MD to decide the dose, but the type of people cited as beneficiaries of OTC policies (poor, uninsured) are probably not equipped to choose the dose and monitor it, either.
Second, there are the complexities of drug interactions and side effects that create public safety hazards if not overseen by a professional. For instance, statins absolutely MUST NOT be taken by pregnant women because cholesterol is needed by the developing fetus's brain. Or there is the fact that every drug is processed by the liver, and too many drugs or just a sensitive liver can lead to liver damage, sometimes permanently. Do you think the uninsured nurse's assistant can and will monitor her liver function tests on her own?
Finally, the people who take statins (and the poor uninsured) often have multiple medical conditions that interact. For instance, diabetics need to control their cholesterol even more carefully than non-diabetics. How about that nurse’s assistant controlling her cholesterol, diabetes, hypertension, and heart arrhythmia, (hypothetically) on her own?
Posted by: Rachel at Dec 13, 2007 11:36:08 AM
Rachel, statins have been available OTC in Great Britain for years.
http://news.bbc.co.uk/2/hi/health/3931157.stm
Posted by: Alex Tabarrok at Dec 13, 2007 11:43:48 AM
Rachel--you are letting the perfect be the enemy of the good. You can't just list all the problems that exist with making statins OTC and say "case closed." You have to compare the utilities of both options. There are also numerous problems with keeping statins Rx-only. The correct question is which system has the fewest problems and greatest benefits, or maximizes total utility. I happen to think that the benefits of liberalizing access to potentially life saving drugs greatly outweigh the potential downsides. The UK agrees with me.
(Of course, this doesn't even touch on the libertarian argument that people should have the right to do what they want with their own bodies, but I digress.)
Posted by: Nathan Benedict at Dec 13, 2007 11:54:32 AM
Rachel,
I'm on long term therapy with a hepatotoxic drug. I need liver function tests every 3 months. Know whose job it is to remember that and call the doctor? Mine. Know who has started every conversation I've had with the doctor about possible drug interactions, and who researches side effects? Me. All the points you make about drug risks are valid, but in the real world it's not as though patients are getting all that from their doctors just because a drug is prescription-only. I realized a long time ago that I need to educate myself about my medications, and I go to a high-quality academic medical center for my care- my doctors have no lack of skill or knowledge. When we talk about alternatives, let's not pretend the status quo is better than it actually is.
Posted by: LisaMarie at Dec 13, 2007 11:55:49 AM
If you live in a developing world country, like I used to, you will see the evils of NOT having a good prescription program. Chiefly, antibiotics are given over the counter; people take half a course; the bug gets more resistant; diseases get harder to sure.
Posted by: paul merrill at Dec 13, 2007 12:29:31 PM
Alex: sorry for ignoring that natural experiment. I'm searching for followup articles on its progress in the UK, but not finding much- if anyone knows I'd be interested to hear. I'm more ok with the British "behind the counter" approach that at least can screen for pregnancy and comorbidity than I am with true OTC.
Nathan: I'm well aware that one must compare the benefits of both systems. My goal was to respond to what I consider omissions by Howley when she called statins "safe drugs" and expressed tacit agreement that doctors against OTC statins are "paternalistic."
LisaMarie: I applaud your initiative, though I understand it is born of necessity. I admit I am influenced by the NIH environment and my lab in particular, which, I believe, is better than the average doctor's office in terms of making sure most bases are covered for each patient.
The point I wanted to make, though, is that the pro-OTC contingent in the US is saying they want to help the poor and/or uninsured, who are probably less well-educated and less able to inform themselves than you are (forgive me if I have assumed too much about you). They are also sicker than the rich/insured. My experience with many of these patients at NIH is that they are not, in fact, capable of the level of self-care you demonstrate, much less self-diagnosis and self-medication.
Posted by: Rachel at Dec 13, 2007 1:03:55 PM
"If you live in a developing world country, like I used to, you will see the evils of NOT having a good prescription program. Chiefly, antibiotics are given over the counter; people take half a course; the bug gets more resistant; diseases get harder to sure."
As opposed to the "advanced" nations, where doctor prescribes antibiotics, people take half a course, and the bug gets more resistant?
Posted by: Rex Rhino at Dec 13, 2007 2:27:50 PM
Rachel,
That you disagree with an article does not necessarily render it "abysmally researched." Are there factual errors you would like to address? If so, by all means let me know what they are so they can be noted at the end of the article.
The article is the product long conversations with doctors on the FDA advisory panel that recommended against OTC status. It is, in fact, extensively researched and reported. As articulated in the article, the panel's major concerns were the inability of patients to self-diagnose and to comply with simple directions. And as with hormonal birth control, there was a sense that doctors needed to control access to the drugs in order to force patients to visit them regularly.
Several dissenting members of the panel felt that their voices were not being heard. The article was an attempt to flesh out their views and put them in historical context.
Posted by: Kerry Howley at Dec 13, 2007 3:12:43 PM
Kerry:
Fair enough. I apologize for my overly dramatic opening sentence. What I should have said is that I didn't think your article gave enough medical context to the issue (which I attributed to research, perhaps wrongly). The factual points I wish you had addressed are mostly those I mentioned in my original post: the specifics about statins (and drugs in general) that make some doctors opposed to OTC status. A major premise in your article is that statins are safe drugs, but there is no medical consensus on that in the US, and I think readers should be informed of why they may not be safe for everyone. I also didn't buy into the uninsured nurse story, but that was less of a factual matter. Again, I'm sorry for the unfounded insult to your research.
Posted by: Rachel at Dec 13, 2007 5:03:01 PM
I'm heading to teach a semester in Rome 1/1/08, and high on my packing list is "250 count bottle of ibuprofen." When I taught the same program in 2003 and had a flare up of carpal tunnel I could only buy NSAIDs in packages of 12 or 20. VERY unpleasant.
Posted by: Michael Tinkler at Dec 13, 2007 5:40:41 PM
Rachel has been a good sport. Three cheers!
Posted by: Alex Tabarrok at Dec 13, 2007 5:51:46 PM
My wife feels very put upon by having her birth control being a prescription medicine. She fully understands the informational requirements and risks associated with 'self-medication,' but feels that she is part of the responsible majority penalized by inconvenience and cost because of an ignorant minority who would get themselves into trouble, then blame the government for not protecting them.
In my experience, every person I have known well enough to discuss such issues seems, like LisaMarie, to have done a fine job of educating themselves on drug matters. The basic question is whether or not the rules needed for ignorant people should be applied, at a cost and inconvenience to everyone.
Couldn't we presume that someone with, say, a college degree is rational and knowledgeable enough to be exempt from the medical micromanagement, the way certain "sophisticated investors" are exempt from some of the nominal protections of certain securities laws?
Posted by: M. Hodak at Dec 13, 2007 6:09:46 PM
We may snicker when we think that Italians couldn't buy aspirin at the supermarket but our prescription-only system isn't much better.
LOL. The US system while not perfect, is 100x better than European system. In Hungary, owning a pharmacy is a license to print money. Until recently, you couldn't get OTC drugs anywhere but a pharmacy.
Same with contact lens solution, only the opticians are allowed to sell it. Why? So they can enjoy their insane mark-ups.
Posted by: Varangy at Dec 13, 2007 8:16:25 PM
Thanks Alex (and Kerry)- I try not to let internet anonymity turn me into a pompous jerk but it can be tempting. Both of you have been quite patient and amiable.
Posted by: Rachel at Dec 13, 2007 9:12:41 PM
Folks - it's not just aspirin. In Germany at least, you have to go to the Apotheke for things like Nicorette (R). And while the prescription drugs are way cheaper than the US (price controls), things like aspirins and cortisone creams are way more expensive, as these products have to produce the profits for the pharmacies.
Posted by: Jean at Dec 14, 2007 6:54:44 AM
In Latinamerica aspirin is sold with prescription because dengue hemorragico( hemorragical) could be letal is people use aspirin to counter the symptoms of it.The person doesnt know and could not know she has dengue at the moment she began to feel headaches or fever
When anticonceptive drugs where ordered to be sold under prescription two of the three libertarian living in Venezuela acused the government they supported of surrender to chatolic churh pressure.
Antibiotic are sold under prescription in big chains drugstores.The independent drugstores will sell it to you under prescription and let you take the prescription with you and buy more
Posted by: Juan at Dec 14, 2007 5:30:35 PM
I'm a little puzzled here. Sure, it's silly to restrict aspirin sales to pharmacies, but isn't the real problem the exorbitant price? How is that maintained?
Posted by: Bernard Yomtov at Dec 15, 2007 5:05:26 PM
Levitra (vardenafil HCl) is a prescription medicine that is indicated to treat erectile dysfunction (ED). Consistent with the effects of PDE5 inhibition, administration of Levitra with nitrates and nitric oxide donors is contraindicated. Caution is advised when PDE5 inhibitors, including Levitra, are used concomitantly with stable alpha-blocker therapy, because of the potential for lowering blood pressure. Levitra is not recommended for patients with uncontrolled hypertension (>170/110 mmHg).
Posted by: Serg at Dec 16, 2007 7:17:35 AM
In men for whom sexual activity is not recommended because of their underlying cardiovascular status, any treatment for erectile dysfunction, including Levitra,
generally should not be used. In patients taking certain CYP3A4 inhibitors (eg, ritonavir, indinavir, saquinavir, atazanavir, ketoconazole, itraconazole, erythromycin, and clarithromycin), lower doses of Levitra are recommended, and time between doses of Levitra may need to be extended. See prescribing information for Levitra for dosing guidance.In clinical trials, the most commonly reported adverse events with Levitra were headache, flushing, and rhinitis. Adverse events were generally transient.
Posted by: Serg at Dec 16, 2007 7:18:27 AM
Nonarteritic anterior ischemic optic neuropathy (NAION) has been reported rarely postmarketing in temporal relationship with the use of PDE5 inhibitors, including Levitra. Sudden loss of hearing, sometimes with tinnitus and dizziness, also has been reported rarely in temporal association with the use of PDE5 inhibitors, including Levitra. It is not possible to determine if these events are related to PDE5 inhibitors or to other factors. Physicians should advise patients to stop use of PDE5 inhibitors, including Levitra, and seek prompt
medical attention in the event of sudden loss of vision or hearing.
Posted by: Serg at Dec 16, 2007 7:19:20 AM
