"Behind-the-counter" drugs (no rx needed)

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BME103

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What do you guys think of the FDA creating behind the counter meds that do not require a prescription from the physician?

http://www.latimes.com/features/health/la-fi-drugs5oct05,1,3582811.story?ctrack=1&cset=true

The agency is floating the idea of letting patients get certain routine medications just by consulting with a pharmacist. Physicians, of course, are wary.

By Daniel Costello, Los Angeles Times Staff Writer
October 5, 2007

Physicians may be losing their lock on Americans' medicine cabinets.

For years, consumers have had two options at the drugstore. They could either show up with a doctor's prescription or settle for less powerful medications sold over the counter.

Now the Food and Drug Administration is considering creating a different option, a class of medicines dubbed behind-the-counter drugs. It would let consumers purchase routine medicines that could include birth control pills, cholesterol drugs and migraine medicine without a prescription -- as long as they discuss it with a pharmacist first.

Pharmacists and drug companies like the idea; doctors think it's dangerous. If approved, the drug classification could go into effect as early as next year.

"We believe having certain drugs behind the counter but available only after a consultation with a pharmacist could significantly increase patient access," said Ilisa Bernstein, the FDA's director of pharmacy affairs.

But doctors are on alert. Dr. Anmol Mahal, a Fremont gastroenterologist and president of the California Medical Assn., said the federal agency's proposal was ill-conceived and unsafe for consumers.

"Patients are not clinicians," he said. "Allowing people to self-diagnose and self-treat is not in their best interest. Nothing could be farther from the truth."

Jaime Abramowitz disagrees. The 28-year-old human resources manager from Burbank said she would be comfortable getting at least routine medications without having to visit her doctor.

Abramowitz currently takes birth control and has to take as much as half a day off to get a checkup and refills every 12 months. "It's a pain going sometimes," she said.

Currently, only a few drugs are available behind the counter without a prescription. Best known is the morning-after birth control pill that was banned for over-the-counter sale in the U.S. until last year. Girls under 18 still need a prescription for the drug.

However, a much wider selection of behind-the-counter medications is available in Australia, Canada and several European countries. Several other countries are considering similar plans.

In the U.S., pharmacists, manufacturers and some consumer groups have made a concerted push in recent years -- with little success until now -- to create a federal regulatory category for medications that are known to have few safety issues and side effects.

Over-the-counter drugs typically sell for less than prescription medicines but often at much higher volumes and thus are potentially more profitable for manufacturers in certain cases.

Much will depend on which behind-the-counter drugs insurers decide to cover. Most insurance plans today cover prescription drugs but not over-the-counter drugs. Insurers say they are researching the FDA's proposal.

"Increasing patient control and access to medication while dramatically lowering cost to the consumer is a laudable goal," said Nicole Kasabian Evans, a spokeswoman for the California Assn. of Health Plans. "We would like to work with the FDA to learn more about their efforts."

The FDA announced plans Wednesday to examine the issue and spelled out details in the Federal Register. The move signals a possible change of heart in public policy and an indication that the government is trying novel ways of increasing the public's access to medications and reducing drug costs.

Just two years ago, an FDA panel turned down a bid by Merck & Co. and Johnson & Johnson to sell the cholesterol-lowering drug Mevacor without a prescription. At the time, several panel members said the agency should consider a behind-the-counter approval option. In January, Pfizer Inc. said it was considering seeking approval for its anti-impotence drug Viagra over the counter.

John Tilley, who owns four Zweber pharmacies in Downey and serves as president of the National Community Pharmacists Assn., sees the FDA's proposal as a "win-win" for patients.

Pharmacists are trained to consult about routine medical information, he said, and are often more accessible and spend far more time with customers than do their doctors. He added that greater access to medications might help patients without health insurance who otherwise might not be getting care.

"It's not like people would be getting these medications from a vending machine," he said. "This would include an adequate level of care."

Critics of looser oversight over the nation's drug supply, especially doctors, are less optimistic.

Mahal, of the California Medical Assn., said a main worry was that patients would buy medication and then lack supervision to ensure that their treatment was safe and effective. Another worry: that women who skip regular doctor visits to get prescriptions for birth control pills may also forgo gynecological examinations.

Bernstein, of the FDA, said the agency had several unresolved questions about how such a proposal would work in practice -- including how it could affect patient safety and whether it really would improve access to medications as much as some predict.

"We're still in research mode," she said.

The agency is planning to address those and other issues at a Nov. 14 public hearing about the plan and will seek written and electronic comments until Nov. 28.

There is no deadline by which the agency must make a final decision, although the process is likely to be concluded in the next several months.

On Thursday, the agency also said it would institute policies to shorten the backlog of more than 1,300 generic drugs awaiting approval by giving priority to decisions on products that are the first of their kind and giving applicants more feedback.

Generic drugs, which cost as much as 80% less than their brand-name counterparts, are now likely to get faster review, the agency said.

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Ashers

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I can't read the article because I'm not going to sign up for the LA Times.com membership.

For my own personal use, I don't mind the behind the counter stuff, I just get annoyed every time I have a cold and can't breathe, I have to sign for pseudephredrine, since phenylephrine will not do anything for congestion for me. At least I don't have to go get an Rx for it. I also don't mind formerly Rx drugs going generic and OTC. I know that makes my life easier, no calling for refills, etc.
 

werd

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i'm 100% opposed to this idea. it's not appropriate to rx drugs without a full hx and pe by someone qualified and trained to evaluate the data they gather in said visit. moreover, who would pts with complications turn to when they get muscle aches from statins or a clot from bcp's? pharmacists know the drugs but they don't have the training to rx appropriately or follow up the treatment. pts would be hurt, probably by the billions. that last part was hyperbole.
 
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genesis09

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This has been talked about for years. Most other countries have this. The FDA was not concerned about whether pharmacists were qualified to do this; their reservations more had to do about the importance of profit in pharmacy. Most pharmacists do know the prescribing criteria of medications. We are taught how to take histories and all that.
 

Annette

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We are taught how to take histories and all that.

Yes, like medical students are taught about chemical structures of drugs, pharmacokinetics, etc. I have been doing histories and physicals for over 4 years now, and I am still making improvements to my techniques.

While some drugs maybe safe to do behind the counter (PPI's for example), I would worry about many others. While it may be safe to dispense BCP, having a patient come in yearly for an exam reduces cervical cancer because of screening (pap smears). Personally, I don't like going in to the gynecologist, but if I want the pill, I have to go.

And, are you going to look at someone's abdomen to see caput medusa? Feel for hepatomegally? Confronting patients about history and exam not matching is not a comfortable situation for most people. So, most likely, pharmacists are likely to believe a patient who says he doesn't drink EtOH on a regular basis, and give the statin. Or, how likely are some patients to come in to get blood tested for elevated LFT's before they turn yellow if they can just get the meds from behind the counter?

Also, being able to get medications without a doctor's prescription may make patients believe the medications have fewer risks than "prescription" meds- something that isn't true. What about patients who confuse the name of the medication they want? Do they want xanax or zantac?
 

kronickm

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didn't read the article fully, but the FDA aren't complete *****s (we are better off then the Jungle aren't we?). I wouldn't think they would pull all these drugs that are currently prescription and make then "behind the counter drugs".
 

McDoctor

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I am totally for this idea. Maybe I can get home before sunset if I didn't have 30 scripts for Allegra, Clarinex, Singulair, Prevacid, Albuterol, Viagra, Levitra, and any number of primarily benign medications that I typically fill without a glimmer of thought.
 

Annette

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. . . Allegra, Clarinex, Singulair, Prevacid, Albuterol, Viagra, Levitra, and any number of primarily benign medications that I typically fill without a glimmer of thought.


I can see allegra and clarinex as mostly benign. When Joan Lunden did the commercial for claritin, people would demand it from their doctors without even knowing what the drug was for. Singulair? Asthma not controlled so someone puts themselves on this? Couldn't be maybe a lung ca/ pulm htn/CHF causing the SOB, or maybe they need a steroid . . . same with albuterol. Prevacid- alright, prilosec is now OTC. But what about those with weight loss, coffee ground emesis (doesn't look like blood), or other red flag symptoms? No reason to diagnosis Barrett's early. Viagra/ levitra- hmm, pts with CAD or HTN on nitrates passes out- talk about going faccid.

While the medications may be benign, the symptoms they treat maybe signs of another dangerous disease.
 

McDoctor

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I can see allegra and clarinex as mostly benign. When Joan Lunden did the commercial for claritin, people would demand it from their doctors without even knowing what the drug was for. Singulair? Asthma not controlled so someone puts themselves on this? Couldn't be maybe a lung ca/ pulm htn/CHF causing the SOB, or maybe they need a steroid . . . same with albuterol. Prevacid- alright, prilosec is now OTC. But what about those with weight loss, coffee ground emesis (doesn't look like blood), or other red flag symptoms? No reason to diagnosis Barrett's early. Viagra/ levitra- hmm, pts with CAD or HTN on nitrates passes out- talk about going faccid.

While the medications may be benign, the symptoms they treat maybe signs of another dangerous disease.

The lung cancers and GI bleeds will find their way in to my office either way. Singulair is not going to mask the signs/symptoms of cancer.

Pharmacists can discuss side effects, they're getting paid to do it. I'm not, when I'm refilling over the phone.

People who are not feeling well will still come see you, at least if they are concerned about their health in any meaningful way. We have an opportunity to trim away low acuity scut-work with this "behind the counter" plan, and free up more time for the patients who need it.
 

genesis09

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Zyrtec is actually going OTC in December. I always wondered why Allegra has never gone OTC.
The FDA also wants to expand access to certain medications without making them OTC. Some of them see this as an issue of public health. The FDA is having a meeting about this at the end of October, and we'll see how they are leaning. Even if approved, we don't now what will be the procedure. If Birth control and statins make it through, will there be a laboratory required component to it. A number of pharmacies can already to simple diagnostic testing like cholesterol screenings.
 

sdn1977

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This whole argument is sooooo funny! When I got out of school - Bendadryl - yes diphenhydramine was rx only (1977!).

I've lived thru the concerns of PPI's, H-2 blockers, vaginal antifungals & many others over 30 years.

As McDoctor said - real problems will come see him in time. Yes, as pharmacists, we do indeed know when to tell that pt to go see her gyne after the second or third round of vag antifungals, or the pt who doesn't get relief after 14 days of Prilosec.

But....those patients who lie to us will ie to you as well (no dr - I've never had a vag yeast infection before!).

As for PSE - I can only hope a democrat wins the presidency. This stupid law was signed into effect as part of the republican homeland security law. I'm not sure a democrat will solve other problems, but at least it would get this monkey off my back!

The funny part about this whole discussion is - until about 10 years ago - you could buy codeine containing cough syrups "behind the counter" in 15 or so states......

Also, when I graduated (in 1977), you could only buy prophylatics "behind the counter" in CA - not sure about other states.

Goodness - I had no idea what "clinical" abilities I had at the time!!!
 

docB

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I don't really care about it either way. Stupid people will find a way to jack themselves up. Might as well let them self medicate with TCAs. They can buy booze, nailguns and propane down the block.

As for where they'll wind up when they have problems with the drugs they might not have ever needed in the first place, we all know the answer to that question. As I see all these folks in the ED I expect to have some funny conversations:
Me: Well you have myositis from your Mevacor. How bad was your high cholesterol?
Pt: I dunno. I started taking it because my uncle's ex wife had it and someone else told me it runs in families.
Me: Well how was your liver function panel when you started?
Pt: Liver whattion pimple?
 

Faebinder

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IT will cause such chaos.... now people will come to you taking 10 drugs and you will think they got 10 diseases when they might only have one that they are doing multiple meds for in a non-sensical fashion.

But either way, if people are too dumb to care about their own health then fine please dont let us stop you... take your OTC birth control pills and enjoy that liver adenocarcinoma you will have for several years before you finally see a doctor who will notice the hepato megaly you got.
 

brianmartin

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I think it's a good idea as long as it is implemented with integrity.

That means when a pt comes into the pharmacist for a "behind the counter" med, the pharmacist:

- must adhere to a physician's diagnosis, as pt's cannot diagnose themselves
- should write a note about discussion with pt
- should clearly state the reason for allowing the pt to take the medication
- within 24 hours, they should send this document to the pt's PCP to be incorporated into the medical record
- make sure to follow up with the pt in reasonable time to make sure there are no problems

Obviously the meds should be limited to those with minimal side effects and minimal potential for harm.
 

Faebinder

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I think it's a good idea as long as it is implemented with integrity.

That means when a pt comes into the pharmacist for a "behind the counter" med, the pharmacist:

- must adhere to a physician's diagnosis, as pt's cannot diagnose themselves
- should write a note about discussion with pt
- should clearly state the reason for allowing the pt to take the medication
- within 24 hours, they should send this document to the pt's PCP to be incorporated into the medical record
- make sure to follow up with the pt in reasonable time to make sure there are no problems

Obviously the meds should be limited to those with minimal side effects and minimal potential for harm.

If you are going to prescribe medications without a doctor's script then it's your responsibility. Don't expect the PMD to sit there and cover you. Essentially, you are not a mini PMD when you bypass the physician. Hope they dont call you at 12 midnight with a rash.
 

sdn1977

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I think it's a good idea as long as it is implemented with integrity.

That means when a pt comes into the pharmacist for a "behind the counter" med, the pharmacist:

- must adhere to a physician's diagnosis, as pt's cannot diagnose themselves
- should write a note about discussion with pt
- should clearly state the reason for allowing the pt to take the medication
- within 24 hours, they should send this document to the pt's PCP to be incorporated into the medical record
- make sure to follow up with the pt in reasonable time to make sure there are no problems

Obviously the meds should be limited to those with minimal side effects and minimal potential for harm.

Sorry - thats just silly!

They either have seen the physician & have an rx or don't.

Do you realize there are some states in which a pt can get limited amounts of codeine cough syrup without an rx - yet we have to document all PSE transactions for some ridiculous Homeland Security Bill???

Goodness! Think of all the potential lung ca, tb pts, COPD pts who might go untreated or have treatment delayed because they purchased guiafenesin ac? These same pts are going to delay tx or not.....and are probably still smoking, I might add!

I gotta tell you - I do indeed remember when benadryl was rx only. It didn't take an MD or rocket scientist to know when I had poison oak & needed it to get to sleep & stop me itchiing. It still doesn't.

Honestly - can you imagine all the notes which would be faxed to a physician for each & every benadryl package I recommend. Then, add to that - cimetidine (bad drug), ranitidine, famotidine, omeprazole, miconazole, Miralax & on and on & on - all of which were rx only.

The charts would be exploding!!!
 

brianmartin

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Good points. There would be increased paperwork and confusion.

I'm still not seeing the role for pharmacists here. Maybe I am missing something.
 

sdn1977

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Good points. There would be increased paperwork and confusion.

I'm still not seeing the role for pharmacists here. Maybe I am missing something.

This seems to be a continuing theme for you - perhaps you should find out what pharmacists actually do - you could visit the pharm forum to find out.

But, to stay on topic, the role of the pharmacist is to know when to say "sure, this fits the right OTC indication" & when it doesn't (ie - when the individual is just off base or when they need a doctor more than they need a drug at that moment).

With direct to patient marketing, many patients come in wanting a specific drug, not realizing it really doesn't work, nor is it indicated for that purpose. Additionally, we have patients who read all sorts of internet & "alternative" health info & actually use a variety of available herbal products, which can actually cause harm if combined with drugs or if it prevents them actually seeing a physician.

Some folks want statins behind the counter - personally, I don't. I've seen enough evidence there are significant enough liver issues which I don't have the capacity to follow or evaluate prior to initiation or to evaluate continuation of therapy.

However, there are other products - nasal antihistamines, ophthalamic antihistamines & decongestants, which are appropriate & will indeed either become OTC or behind the counter (this is largely economic rather than medical - its what will make the most money for the drug companies, truthfully).

But, we have lots of people who say they have a cold & have a runny nose & stuffy head & they want an antihistamine to fix it. Even when we explain an antihistamiine is for an allergic problem & might they have that? Nope - just a cold, but I want it to go away faster. When I took chlortrimeton last time it did go away fast - in 5 days (hmmmm.....viral infections will resolve in 5-7 days).....there is no convincing folks & if they can buy the product, they will. Even though a decongestant is really what they want.

But, again, the marketplace eventually "fixes" things - we've currently had a recall of infant decongestants because parents overdose their kids. It doesn't matter what the bottle says - just give 'em a bit more & they'll go to sleep......Well, after enough morbidity - it gets taken off the market.

So, some control of this with ultimate corresponding responsibility might allow these products to become OTC, have greater availability (& consequently less insurance coverage), but also safer usage. A pharmacist rather than a grocery clerk is willing to take on that responsibility - we do it daily.

Would you find it interesting that one of the major interests in favor of these products going "behind the counter" are the insurance companies? Again - economic. When it not rx, they don't have to pay.

You always need to wonder what the motivation is for a change. Personally, I don't particularly care. I'll dispense Astelin & Patanol as much as I ever did & with far less paperwork than if I have to dispense without an rx. But....think about who woud profit if it went off rx????? Not me, certainly not the prescriber........
 

genesis09

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The FDA meeting is going to be on Friday. From what I've been hearing, they are leaning towards implementing BTC. They want to approve it without having to go back to Congress.
 
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