Asymmetrical Information

I understand the doctor's point, and have no doubt that he has asthmatics' best interests in mind, but I think he underestimates the ability of motivated people to manage their care, and fails to recognize that no regime works well with people who lack such motivation. Who isn't motivated to maintain their health? Well, go talk to people who work with folks to lose weight, or to stop smoking (sometimes with people who have been diagnosed with emphysema!), or change their lives in countless other ways, in order to decrease morbidity, and they will tell you that there is great variation among individuals as to how important it is to increase the likelihood of a longer life. Often, depression, in all it's variants, plays a great role in how motivated a person is to manage their lives more effectively, yet, ironically, depression is yet another condition in which the patient's motivation is the key factor in alleviating the condition. I've had a shrink with an outstanding reputation tell me that he has a tremendous success rate with depressives who work hard at thinking differently, but a lousy one with depressives that don't, and that he really can't say whether he has any success in moving those in the latter group into the former. Sure, information needs to be efficiently disseminated in order for people to manage their care well, but there many examples, like the decline in smoking rates, or seatbelt use, that suggest motivated people are capable of receiving that information and responding to it.

Megan, I'm so glad that you survived your asthma attack. I just wanted to post because I had to disagree with the idea that we have to require a prescription for lifesaving drugs because that's the best way to convince people to use the most efficacious drugs for their condition. No other consumer product is sold that way.

To use an asthma-related example: if you want to buy the best air filter to filter dust out of the air in your home, you don’t need to sit in a waiting room for an hour in order to have an air-quality specialist evaluate your home, recommend an air filter to you, and charge you just for the recommendation. For both air filters and asthma drugs, consumers can find out what they need to know more efficiently and more cheaply by harnessing the power of the printing press and it’s derivatives. Consumers can read the package inserts, go to a library, read articles on the internet, look at (regulated and honest) ads in newspapers. The printing press has been around a long time; from the patient’s point of view, medical care is still delivered as if Gutenberg had never existed.

In the case of asthma, there is a tremendous incentive on the part of the patient to manage the disease optimally, if only they didn’t have to go to a doctor every time they needed a new, or longer-acting drug. Who wants to wheeze and be short of breath? Who wants to puff on inhaler every four hours when once or twice a day might do? Given that incentive, it’s logical to assume that most people would WANT to manage their asthma well.

Putting information about optimal asthma control on the box, and making longer-acting drugs, including long-acting beta agonists (basically the same side effects as albuterol), leukotriene antagonists (side effects similar to placebo for short term use, unknown side effects with long-term use) and steroids (nasty side effects if overused, but overuse can occur now) available over the counter could make it easier, and thus more likely, for people to use the drugs that are best for them.

Further, what about the ~20% of asthmatics who DON’T need any drug other than occasional albuterol puff? Why make them pay for doctor visits that they don’t need?

The counter argument is, of course, that there will be people who won’t manage their asthma well if they aren’t told to by a doctor. What makes anyone believe that people, on average, respond better to being told what to do by a stranger in a white coat than by mass advertising? If mass advertising is so ineffective, then why aren’t soft drinks sold door-to-door by men in white coats?

Won’t letting people make their own choices disproportionately and negatively affect the health of the poor, who don’t have access to the same information sources that the rich do? Maybe, but the system as it is isn’t working out for the poor either. The poor are exactly the group that we would expect to benefit from any increase in efficiency of information transfer.

Note that your correspondent’s study looked at data from Chicago public aid databases. The patients behind those databases are probably getting short shrift from doctors now, who may be trying to see as many patients as possible each hour in order to make a living. How is that more conducive to good information exchange than letting the patients take the same amount of time that they would have spent going to the doctor, and digesting printed or internet-based information about the drugs available to them?

Who would pay for getting this information to potential consumers if asthma drugs were over the counter? Frankly, the answer is so self-evident that I’m tempted to delete this whole paragraph just to erase the evidence that I asked such a moronic question.

Again, glad you survived your asthma episode, and I look forward to reading other comments.

Sounds a bit like a "slippery slope" argument, doesn't it? Patients already aren't treating themselves properly, if we de-regulate the inhalers, it will only get much much worse.

Although this does fit a pattern: if your condition is potentially lethal, you'll probably needs a doctor's help to get treatment. I'd be interested in finding out more about the origins of modern prescription practice...

"I'd be interested in finding out more about the origins of modern prescription practice..."

While I also would like to research the history of the permission-slip requirements, it's pretty easy to figure out the philosophy behind it: human beings never actually grow up, and they need lifelong supervision to keep from putting dangerous things in their mouths.

Also in this particular case, the supply of rescue inhalers and controller is controlled by those permission slips handed out by doctors. Now we are told that patients are getting too much rescue inhaler and not enough controller. But the patients don't get to choose how much of either that they get; their doctors do. So essentially we are being told that because doctors are giving patients the wrong medicines, it is essential that we keep control of these medicines in the hands of doctors and firmly away from the patients. That doesn't make a whole lot of sense to me.

It's a complex question, and I'm sure arriving at the answer is no less complex. But if you look around the world for instances where US-prescription drugs are sold over-the-counter, I think you'll find they are generally abused. Antibiotics are of course the poster child of this issue, and it affects even the countries which do control them -- we're all suffering the effects of antibiotic resistance in infectious bacteria.

Despite my awareness of this phenomenon, I'm undecided on this issue. Part of that indecision comes from my own medical history: I'm also asthmatic, with serious hay-fever allergy problems on top of it, and my HMO-based care providers aren't doing a good job of managing my treatment. I'm sure I could do better myself, based on my successful treatment before I moved to an HMO region under a different office.

But as that example indicates, I'd probably be better served by doctors free of the constraints of the HMO, which is "managing" my care almost exclusively by denying coverage and providing endless procedural hoops for the doctors (not to mention me) to jump through. Given the ubiquity of HMOs and the common experience of their supression of treatment, I'm tempted to just say "legalize OTC sales of everything".

Could it be much worse then the present situation?

we are told that patients are getting too much rescue inhaler and not enough controller. But the patients don't get to choose how much of either that they get; their doctors do

While I agree with your philosophy, the reality behind the point above is a little more nuanced than it would seem. In my experience, what often happens is that asthmatics and COPDers ARE given prescriptions for both long-acting drugs, and for albuterol rescue inhalers. The long-acting drugs, though they last for a long time, also take a long time to have an effect.

Some patients then get their meds, go home and do nothing. They take no long acting drugs, they take no short acting drugs. They wait untill they wheeze, and then they take whatever drug they have that is closest to hand.

When they take the long-acting drugs, nothing happens right away. To a certain subset of people, "not right away" == "never." These people then take the short-acting drugs, and get (temporary) relief in a few minutes. The next doctor's visit, they then complain about how the long acting drugs don't work, how they don't want any more of those, and how they want more albuterol. To complete the picture, note that many of the "problem" "asthmatics" that we are talking about are smokers of -- well, of just about any smokeable substance you can name.

Anyway, I don't think the problem is one of getting the right prescriptions to people. I think it's one of convincing the greatest number of people to take, buy, and use the prescriptions already made. And, as per my post above, if you want to convince people to do something, the best way is likely to be some combination of (1) making it easy (2)making it cheap and (3) unleashing the power of advertising.

Regarding two of Jubal's earlier comments:

"What makes anyone believe that people, on average, respond better to being told what to do by a stranger in a white coat than by mass advertising?"

For starters, that stranger in the white coat has undergone a standardized certification procedure that included seven years of a most abusive education regimine, under the guidance of experts with their own previous training AND real-world experience. I know that *I* trust him more, and if he DOESN'T know more than the average mass advertiser, I'm getting ripped off in really big way.

"Won’t letting people make their own choices disproportionately and negatively affect the health of the poor, who don’t have access to the same information sources that the rich do? Maybe, but the system as it is isn’t working out for the poor either. The poor are exactly the group that we would expect to benefit from any increase in efficiency of information transfer."

You might try working around career low-income earners, as I did with my first job back in the high school days (fast-food industry). For starters, it's simply amazing how many of these people smoke, even the shoestring-budget single mothers. Right there you have a non-essential habit that taks money away from more critical resources such as food, rent, auto maintenance, and general child welfare. It also has long-term health effects these people cannot afford to deal with, ever.

But it's very typical of the pervasive mentality: short term solutions. Many of these people are simply not tuned to think about the long term; make this month's rent payment and pray that your job is still paying a living wage next month.

I at times saw the same attitude among such people in dealing with OTC drugs. Headache won't go away? Two Tylenol are good; four are even better.

I don't want to be guilty of painting the poor with a broad brush, I only want to suggest that they will NOT benefit from increased access.

I know that *I* trust him more, and if he DOESN'T know more than the average mass advertiser, I'm getting ripped off in really big way.

Good point, but lost, I believe, on large parts of the general public. I am VERY aware of the knowledge and experience doctors gain by going through the abusive education regime to which you refer, but many people just aren't so aware. It's my perception that a huge subset of the Chicago public aid recipients who were the subject of the study to which Megan's correspondent referred have NO IDEA that doctors are anything other than "the man." I am pretty familiar with that subset of people, having gone to medical school at the University of Chicago, (On the South Side of Chicago / the baddest part of town / if you go down there / you better just beware / of a cat named Leroy Brown. I've definetly met Leroy Brown a few times, and he DID NOT listen to me), and I have met people who pay much less attention to the advice of doctors than they pay to ads for Nike shoes. Why not look at what works, and try to get people to take the drugs they need using proven-effective means of communication rather than means which we already know don't really work?

Similarly, You might try working around career low-income earners. It's exactly because of a career partially spent working around, and on, those low-income earners that I am looking for another way to convince them to take the meds as they should be taken. One-on-one exhortations from some middle-aged, middle-class white man in an office just don't seem to be cutting it, in my opinion. Neither do one-on-one exhortations from young black male doctors, nor old asian female doctors, nor any other type of doctors. Based on the prevalence rates of asthma and COPD, and the use patterns of drugs for those diseases, I'm not the only one who is having that experience. Maybe people would listen more if drug companies spent more money pushing their wares with images of dancers, or sports stars, or powerful cars, or whatever they use to sell coffee and candy bars, and if asthma drugs were easier to buy.

I am VERY aware that I don't have all the answers, but I haven't yet seen a compelling argument that continuing to make life-enhancing drugs expensive and difficult to get is a good part of the solution. Therefore, I am led, inescapably, to the conclusion that these drugs should be available over the counter.

Hello, what a dramatic incident in the restaurant! Good thing that good samaritan was nearby. I'll bet he had asthma, too, and so recognized what was happening with you.

I also disagree with the opinion that you posted from the doctor. There's no logical reason that commonly used prescription drugs ought not be made accessible without a prescription.

Just think of having to pay for a doctor's appointment everytime you wanted to use Ibuprofen. Or got a yeast infection. Both those things used to be by prescription only and now are not, and thank goodness. The gateway mentality is good business for doctors.

This is all about control! So the doc says that I shouldn't be able to get albuterol because "the population" can't figure out how to use it? Please! We are individuals, not a cohort. I find it shocking that we are even discussing this. Doctors want control more than anything else. They can't envision that patient's might actually know what is best for themselves. The study be damned. I am not some test group. I am an individual!

I am a pharmacist from the Chicago area and I have to agree that albuterol would not be a good candidate for OTC status. Being one of the 20% of asthmatics who are controlled on albuterol alone, I understand the frustration that comes with having to wait hours for a 10 minute appointment just to get my "permission slip."

However, albuterol is not candy, it is a drug. And as such, it can be very harmful if used improperly. In excessive doses it can cause hypertension (high blood pressure), tachycardia (fast heart rate), angina (severe chest pain), and hypokalemia (low potassium); all of which can be deadly in a patient with cardiovascular problems.

Yes, a patient who has been on the medication for long time and is properly educated might be able to manage their medication, but if albuterol were to be made OTC, who is going to regulate the people who buy the medication simply because they "think they need it?" Many of these people may have underlying risks that they are unaware of, and these are exactly the people who should be monitored by a health care professional.

Of course, these are all examples of people who have realtively simple medical issues. The people I would be concerned about are people who have multiple issues and are on multiple medications. They may very well be able to monitor what drugs they take, but are they capable of monitoring their own drug interactions and disease progression?

If you're still having trouble with asthma, you might want to check out "Your Body's Many Cries for Water," by F. Batmanghelidj. He has a very interesting view of it you won't read anywhere else.

Also, since it probably won't be sold over-the-counter, could doctors at least give someone they trust unlimited refills?

albuterol is not candy, it is a drug ... it can be very harmful if used improperly ... it can cause hypertension, tachycardia, angina, and hypokalemia, all of which can be deadly

All of which can also be caused by coffee, in high doses (BTW, caffeine is also useful for asthma), and none of which is likely to be a health risk for the 13-to-24 year old age cohort which is most likely to have asthma. Further, the fact that albuterol is not candy, and is not a particularly common drug of addiction, makes the excessive albuterol use likely to cause death in a 24 year old even less likely. Yes, I know Jay didn't specifially mention death as a risk of albuterol overuse, but I think that's what he was leading up to, so I'm going to mention it here: excessive albuterol use CAN cause death, even in children. However, death is an extremely rare side effect in young people, and generally involves young chilren drinking relatively large amounts of the stuff. For young adults, albuterol is pretty safe.

To be fair, albuterol is also used for COPD, which generally affects people over 40 who are more likely to suffer from it's ill effects. On the other hand, a large proportion of COPDers are smokers, who have already accepted a certain amount of risk with thier habit. Further, it's even harder to make the argument that people over 40 are not yet adults, and should not yet be trusted to make their own health decisions.

That said, Jay makes an excellent implied point: that one legitimate use of keeping drugs off the OTC list is to REDUCE their use, so that people are less likely to harm themselves with said drug. That seems to be the opposite point made by Megan's original correspondent, who seemed to be saying that albuterol should be prescription-only because not enough people were taking the long-acting drugs that are supposed to be used with albuterol.

Based on the fact that asthma has it's highest prevalence rates among the young, who generally don't have "multiple issues (or) are on multiple medications," for whom the serious side effects (angina, heart attack) of albuterol overuse are vanishingly rare, and for whom the side effects of not being able to get enough albuterol when needed are most likely to be catastrophic (a suffocating death), I don't buy Jay's argument any more than the argument of Megan's original correspondent. Not that it really matters, since we are not making policy here, but that's my opinion.

"However, albuterol is not candy, it is a drug. And as such, it can be very harmful if used improperly."

So can lots of other things. So do human beings ever reach the stage where they don't have to be watched lest they put dangerous things into their mouths, or what?

"In excessive doses it can cause hypertension (high blood pressure), tachycardia (fast heart rate), angina (severe chest pain), and hypokalemia (low potassium); all of which can be deadly in a patient with cardiovascular problems. "

Then don't take excessive doses. I'm not really seeing a problem here. The correct dose is printed on the label.

"but if albuterol were to be made OTC, who is going to regulate the people who buy the medication simply because they "think they need it?" "

Jeez, you make it sound like they're a bunch of children. There's no need for anyone to "regulate" American citizens, and there's no reason why Americans should be reduced to saying "Mother May I" when they need medicine.

"Of course, these are all examples of people who have realtively simple medical issues. The people I would be concerned about are people who have multiple issues and are on multiple medications. They may very well be able to monitor what drugs they take, but are they capable of monitoring their own drug interactions and disease progression?"

Probably not. But that's what doctors are for - to give advice, not to give orders.

"This is all about control! So the doc says that I shouldn't be able to get albuterol because "the population" can't figure out how to use it?"

Now you're catching on. The busybodies have figured out that there are people who are prone to hurt themselves without adult supervision, and have decided that protecting grown-ups from themselves is one of society's highest duties.

"All of which can also be caused by coffee, in high doses"

Yeah, but even in the smallest possible volumetric quantity, we're talking multiple shots of espresso -- I think sixteen in a short time span is somewhere around the fatal dose of caffeine -- and it takes real effort to get all those together at once. Caffeine is also a diurinate and your body begins ridding itself of the intruder in a relatively short time span.

It's rather a false analogy when dealing with a drug that is far easier to abuse, and which has a far deeper physiological interaction with the host.

"So can lots of other things. So do human beings ever reach the stage where they don't have to be watched lest they put dangerous things into their mouths, or what?"

For that matter, there's a fatal dose of water. We had a sixteen-year-old in this state (Colorado) prove that while on an ecstasy high about a year ago. The point is not whether something CAN be dangerous in large enough quantities (anything can be), but as with my response above, HOW easy is it to obtain and abuse, and how likely?

'Now you're catching on. The busybodies have figured out that there are people who are prone to hurt themselves without adult supervision, and have decided that protecting grown-ups from themselves is one of society's highest duties.'

You know, the busybodies are right about medicine in general. One look at the exploding "dietary supplement" industry should convince you of this.

I am one of those 20% whose astma acts up only when triggered by an allergy. I agree that we shouldn't have to pay for a doctors visit to treat occasional attacks. I am 19, have no medical insurance, and I support my mother, sister, and myself. I was taken off medicade because I turned 19 and have no kids. I'm not going to have kids just to get back on medicade so that I can see a doctor for occasional attacks. In my case I not going to go to a doctor ,rack up a bill I cannot pay because I have to support the family. If I do have an attack I can just die because I not going to be in debt my whole life. I feel this way because I have been poor my whole life, probably will be for the rest of my life, and I dont need more debts I cannot pay.

The patients that post on this site have no idea what they are talking about. The comments made on this site are absurd and boarderlines on stupidity. It is my sincere hope that more asthmatic do not read the uneducated advice propetuated by this website. Asthma over a long peroid of time will and does cause eventual lung deformities and asthma has been known to progress into more serious symptoms. I would be surprised if asthmatic, in general, could even name the drug classification of albuterol. I would hate to think that there are people in this world that believe they have sufficient to self diagnois. Of course these are probably the same people that like to take there care to Wal-Mart to have the check out girl fix their car. The proposed thoughts on this site only prove and promote the complete ignorance that Americans possess.

Hi there im on albuterol right now and it feels good even though my heart is beating faster and im a little nervous, I feel almost euphoric. I only used to feel this way when I watched Hogan's Heros.

Anyone remember the model who died from using primatene mist (also OTC)? This product should definitely be discontinued from the market and albuterol should never be made OTC. Any asthmatic and any person should see their doctor at least once a year for a general check-up, at which time they can get their year long prescription if the doctor believes that is what they need.

Has anyone ever thought they were addicted to albuterol ? I have tried Advair with out any real diffrence. I use about one inhalor a week and really do have shortness of breath, however I knowI am using it to much. I have also been to several DR's and don't think they know or care about anything?

Has anyone ever thought they were addicted to albuterol ? I have tried Advair with out any real diffrence. I use about one inhalor a week and really do have shortness of breath, however I knowI am using it to much. I have also been to several DR's and don't think they know or care about anything?

Has anyone ever thought they were addicted to albuterol ? I have tried Advair with out any real diffrence. I use about one inhalor a week and really do have shortness of breath, however I knowI am using it to much. I have also been to several DR's and don't think they know or care about anything?

Has anyone ever thought they were addicted to albuterol ? I have tried Advair with out any real diffrence. I use about one inhalor a week and really do have shortness of breath, however I knowI am using it to much. I have also been to several DR's and don't think they know or care about anything?

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