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More nonsense from the medical mafia

Just to avoid any possible confusion, I should probably point out here that the Samizdata Illuminatus is a collective pseudonym used when any of the regular writers of this site wants to publish something anonymously. The author of this post is actually in London, not Massachusetts

Dale posted below about the idiotic rules he encountered when attempting to buy asprin in (I presume) Northern Ireland. I cannot answer the question as to whether the situation with asprin is really as absurd as his pharmacy said it was, but in answer to the question of whether it could be that absurd, I can assure him that the answer is very definitely yes. In this regard I have a little story of my own.

I have a hiatus hernia, which causes acid reflex in my oesophagus, which is intensely painful and uncomfortable, makes it difficult to eat certain kinds of food (anything at all acidic), and if untreated could lead to longer term problems that are even more serious (In the worst case cancer of the oesophagus). There is a class of drugs called proton-pump inhibitors that are used to treat this condition, and they are simply wonderful. You take one pill a day, and all your symptoms go away. They are really this good. The best known of these drugs is omeprazole, sold under the brand name “Losec” in Europe and “Prilosec” in the US. To get this drung, I could get a prescription from a doctor, but I would rather not have to deal with the NHS, as I find doing so to be too soul destroying.

However, the drug is available in the UK without a prescription, so no problem.

Well, not exactly. Omeprazole is a “behind the counter” drug in the UK, meaning that it is only available in pharmacies and you cannot simply pick it up off a shelf and then take it to the cashier and pay for it, but you have to actually walk up to the pharmacy counter and ask for it, supposedly so that you can receive proper advice. However, the nasty sting is that pharmacies tend not to display the price of such drugs in clear view, so you don’t usually find out the price until after you ask for the drug. They are relying on people being too embarassed to say that the drug is too expensive after having asked a pharmacist for it, so “behind the counter” drugs tend to be priced much higher then they would be if they were on the regular shelves.

To make things worse, the law states that the over the counter version of omeprazole must be sold in 10mg pills (the standard for the prescription version is 20mg) and in packets containing no more than 14 pills. There is nothing stopping you from buying a larger number of pills to obtain a larger dose, other than the fact that the way the drug is regulated and sold makes it expensive to do this. I am charged about £8 for such a pack of 14 pills, but as they are half dose pills, this is only a week’s supply. (This is almost entirely profit for the pharmacy, as the patent on the drug has expired).

So, although the drug is very effective for people with certain ailments, not prone to any kind of abuse, pretty much completely harmless, out of patent and very cheap to manufacture without any intellectual property issues, I cannot buy it without vast numbers of rent seekers in the medical and related professions profiteering from doing so (either by charging me directly or charging the government via the NHS) and the price being pushed up to a level I find annoying.

The US lacks this “behind the counter” racket, and omeprazole is also available over the counter in the US in large packets of proper 20mg pills, so there is nothing preventing me from buying it in large quantities at Wal-Mart when I am in the US, for about a quarter of what I pay for it in the UK. However, the Americans have lots of other rackets and the situation with this drug is sadly not typical, as American regulators (under pressure from doctors groups) are extremely reluctant to reclassify other prescription drugs as over the counter.

Sadly, though, I visit the US only once a year, if that, and my supplies seldom last until the next trip. Recently, I have found another solution, however, which is to buy the drug on eBay from people in Delhi. The price in this case is much less than I would pay even in the US, and less than a tenth what I would pay in the UK. It is possible to argue about the ethics of importing patented medicines from abroad, but in a situation in which the patent has expired, parallel imports are definitely something to be encouraged. It is probably not technically legal for me to conduct my own parallel imports from abroad, but I really do not care.

And there is something supremely ironic about using India to get arount the permit-Raj of the developed world medical bureaucracy.

24 comments to More nonsense from the medical mafia

  • Andrew Duffin

    It’s not that ironic.

    India has been a major centre for the production of generic drugs for a very long time.

    Some of the manufacturers are competent, serious, and worthy competitors to the big pharma companies.

    Except, of course, that they don’t invent anything, they just copy other peoples’ work.

  • Illuminatus

    No slight at all was meant to the Indians who make the drugs, or the Indians selling them to me. I wouldn’t buy and take the drugs if I thought there was likely to be a problem with their quality. There isn’t – they are just as effective as any bought locally. It was more just a comment that the world has changed: bureacracy in the developed world in some areas has now reached the point where I am using a country that was once famed for its stultifying bureaucracy to get round it.

    It’s kind of depressing that nobody ever seems to learn anything.

  • I’m just learning about various rackets since I was diagnosed with a chronic condition several months ago which will need continual medication for the rest of my life.

    I’ve already had to ask my GP to give me a repeat prescription twice – which he does without needing to examine me because I’m already visiting a hospital every two weeks for checks anyhow.

    Each time I get a repeat prescription , my GP claims the single piece of paper is in fact two prescriptions and each time he writes a prescription, it’s for only a month’s worth of drugs.

    On top of this, he’s just charged me £20 for a letter so that I can enter the States carrying the drugs I need.

    Bit of a money spinner for someone, this.

    Perhaps I should take up smoking and then ask for the £150 being offered to kick the habit; maybe I should use the facilities of the NHS-funded Royal London Homoeopathic Hospital, see if they can’t help me out with some of their very expensive water.

    Don’t get me started on the appalling out-of-hours service.

  • J

    Losec is AstraZeneca’s version of this drug, and the high price you are paying will be going to their pockets more than the pharmacy’s. The generic form of this drug is rather cheaper:

    Capsules: 20 mg, 28-cap pack = £2.03;
    Tablets: 20 mg, 28-tab pack = £9.94;

    The BNF does not quote an official price for the 14-pack of 10mg, but the 28-pack of Losec 10-mg capsules is 19.34, so your price does not seem especially inflated above the ‘list’ price. These are BNF ‘net’ prices and generally a fraction cheaper than you would expect to find on the private market.

    So, one might ask, why does the pharmacy not sell the generic form of the drug? Well, they might, you could try asking for it. But given how cheap it is, why would they stock it, if they are doing a % mark up either way?

    This is not (I think) a drug generally taken continuously, its over-the-counter use is more for periodic alleviation of symptoms, and since, as you say, it’s very effective most people will be prepared to pay for that. For those who need to use it more often, most will get it free on the NHS. You, alas, represent a tiny market of people, and so the system does not cater to you. One would hope the NHS prescribe the generic form, although that will be down to individual doctors.

    You may be able to buy the drug mail order.

    Finally, although I’m not qualified to talk about whether it should be over-the-counter or not, I note the drug has a few non-trivial contra-indications and interactions.

    For those unaware, the BNF is free to all people in Britain (we paid for it…) but requires registration. http://www.bnf.org

  • J

    Sorry, skimmed over the end of your post – I notice you are already buying the drug mail order, thus solving the problem.

    I believe it is entirely legal for individuals in the UK to buy such drugs mail order from anywhere. It is not a patent issue, because the existence of a generic form means the patent has expired in any case. It’s now a free-for-all to see who can make this chemical cheapest, basically.

    One thing you have discovered is that AZ are able to continue selling the drug at a high price even when the exact same thing is available far cheaper.
    absorbtion, taste, ease of swallowing etc. I don’t ascribe this to any complex dealings in the murky world of healthcare. It’s just branding and marketing, taken to extremes.

  • llamas

    J wrote:

    ‘One thing you have discovered is that AZ are able to continue selling the drug at a high price even when the exact same thing is available far cheaper. ‘

    This is often seen in mega-stores in the US, that can justify having popular off-patent and ‘generic’ OTC medicines packaged in their own-brand packaging.

    You’ll see a whole variety of OTC medications with brand-name versions and store-brand-packaged equivalents side-by-side. The store-brand packaging will often mimic the brand-name packaging, as close to the wind as they can sail and not attract a trade-dress infringement suit. The store-brand package may even proclaim ‘Compare with (brand-name product)!” and draw direct attention to the ingredient list – which is identical between the two. And the store brand is often 50% or more cheaper than the brand name.

    And yet people are still firmly-convinced to buy the brand-name product, in the belief that it is somehow ‘better’.

    And – apparently – the store can make a profit by stocking both. I sometimes wonder whether they stock the brand-name versions, not so much to sell them as to give the customer a direct comparison which will cause them to select the store brand – which may have a higher margin.

    llater,

    llamas

  • toolkien

    Unfortunately parts of the US do have “behind the counter” as well, as in my state Wisconsin. Granted there is abuse in the form of people using certain products along with a laundry list of other household products to make crystal meth. If you buy anything with ephedrine or pseudoephedrine (in many cold and allergy medicines) you have to sign your name and address in a book so the State can track if anyone is buying inordinate amounts to use in the cooking process to make crystal meth. The result is that the 99.99% of people who use such products are highly inconvenienced (I’ve waited upwards of 10 minutes while the pharamcist waited and other prescribed individuals) when they want to make a legitimate and legal purchase and very little is done to decrease the supply, the only winners in the whole deal are Mexicanos whose exports go up as people aren’t as readily able to make their own. Barrels full of meth come in every day.

    Is crystal meth a problem? Sure. But it is it so much a problem as to inconvenience the vast majority and make a small dent in the overall supply of drugs? People who want crystal meth will buy the imported stuff, or, econcomics being what it is, they will buy a replacement good. Meanwhile those with runny noses and itchy eyes can just rot in line signing the State’s little black book. A perfect case of killing a fly with a sledgehammer. And pure liberty takes another tiny cut in the “death by a thousand cuts” process.

  • Right.

    This sort of shite drives me up the fucking wall. I sometimes get sinus problems and usually Sinutab works but sometimes I need antibiotics to combat a possible secondary infection if it’s really bad. I know the name of the drug I need. The last three times I needed it the effing GP asked what it was. All he or she did was write a prescription to my specs. I once had to spell it for the doc. They make 100k pa for that!

    Again, just as the original poster said it’s not something the kiddies are gonna take at raves or anything.

    My wife is on a waiting list for a 24-hour blood pressure monitor. By which I mean something that logs her BP for a day and is then returned. The GP said their last machine broke and is being mended like two months ago. Heaven’s forfend that she might need an MRI scan or anything complicated.

    Here is another one. This is a beaut. The Implanon contraceptive implant is sporadically available on the NHS. It is an excellent contraceptive but does nothing to prevent STIs. So who do you think the NHS think is the primary customer? Women in stable, long-term, relationships, perhaps even married? Women who want effective, cheap, simple contraception and aren’t sleeping around? Nah. The National Elf have decided it’s roll-out of this product should be targeted at under 25s. Under 25s aren’t too keen so the roll-out has been limited.

    I’m probably preaching to the converted here but… Socialized healthcare is a Kafkan nightmare and if it takes root in the USA then we’re all fucked.

  • RRS

    “Acid Reflux” which is usually something more than “acid”, more often creates the risk of Bishop’s which is an erosion of the base of the esophagus, rather than cancer, when severe.

    Many of the medications are variations on “inhibitor” molecules, some are contra-indicated if other conditions exist (e.g., the molecule Regulans where there may be indicated Parkinsons syndrome at any stage).

    If you do not have knowledge of the molecule (proprietary or gentic) pharmacuetical advice may save your life, or at least a lot of agony.

    Amidist all the consternations about prices, distribution, etc – consider how these benefits came to be.

    They were all stimulated by both curiousity and the profit motive.

  • anon

    Just a heads-up that this is a bit of a grey area about prescription only (and the higher does tabs may be) medication being sent in the post:
    (Link)

  • Sam Duncan

    So, one might ask, why does the pharmacy not sell the generic form of the drug?

    They do. Boots sells its own brand. It costs £7 for 14 10mg capsules. I know because I’m in exactly the same position as Illuminatus, only when I snapped I gave in to the dead hand of the NHS.

  • RRS

    Nick M,

    You will not be surprised to learn that the “staffers” are already way ahead on the curve of the next healthcare “advance” at the federal level, which a Democrat majority, especially if not opposed at the Executive, fully intend to install, promptly, during the “honeymoon.”

    The basic plan will be stipulated “benefits” of 8 to 14 plans (duly A,B, C….); that will establish the beginnings of rationing, to “control” expansion of costs.

    To gain an idea of the format, look back at the structure created for “MediGap,” which effectively limited what risks one could provide for by insurance.

    “You ain’t seen nothin’ yet!

    Was it Hotspur who said: “First kill all the lawyers” ??

    Well, we need to remove all the staffers (esp. “legislative assistants”) who now provide us with government by the unelected.

    After over 26 years on the edge of the beltway, and having moved far away, the hours long calls still come from those concerned with what is transpiring and the effects on the “industries” impacted.

    Still, we are, as Paul Johnson noted, “The Almost Chosen People.”

  • J: I quoted the brandnames as I thought this was the best way for readers to know the drugs I was talking about. I am personally happy to buy generics, as I know they are exactly the same thing. The £8 I quoted is the approximate price for the Boots branded generic in Boots. This is what they generally try to sell you, although they also carry a branded AZ version (which does not carry the “Losec” name for the OTC version – I think they are trying do sell the “occasional” version as a different product to the “chronic” version) for about £10. Most independent pharmacies tend to sell the branded version for around the £10 mark.

    toolkein: In the UK you will usually find generic brands and store brands sitting next to the branded version for products that are available on the shelves for self-service versions. The branding and packaging is never as close as in the US. In a US pharmacy you will often find similar packaging, a similar name, and a sign that says “Compare the active ingrediencts of sudafed and Wal-fed” or something like that. In the UK you will have to figure it out for yourself, but it is there, and the generic is usually cheap. For the “behind the counter” products there are usually fewer choices and the pharmacist has much more chance to choose the brand for you, and you don’t often find what the brand is until he rings up the price, so prices are usually higher.

    Obviously the solution to the crystal meth problem is to legalise all drugs.

    I confess that I have never heard of “Bishops”. My gastrologists advice to me included the warning that the condition could lead to something called “Barrett’s”, which is considered a premalignant condition and can lead to cancer of the oesophagus.

    I am not advising anyone to take medication without medical advice (although, given the blog I am writing for, it is surely not a surprise I would defend the right of anyone who wishes to self-medicate to do so and I generally believe that people who do so will show good judgement). I have my condition checked out by a gastrologist every couple of years, but in truth there is not much a GP can do for me other than write the prescrition. I know what drugs I need, what they do, and when my symptoms occur I need to simply take them. The GP will then charge the government for what is basically a ticket clipping exercise. The pharmacy will then charge more for what is basically another ticket clipping exercise. If this is happening through the NHS my taxes will pay for both of these things.

  • Bod

    Just to go a bit off-topic, Nick M commented about his frustration with having to get a prescription for antibiotics.

    I’m going to show my ‘collectivist’ side for a moment and just comment that it’s probably a good idea to ensure that someone, somewhere has records on *your* antibiotic use, because of the widespread misuse (yes, even when prescribed by doctors). We’re running out of effective options for combatting some strains of bacteria, and some ‘centralized’ intelligence about outbreaks of MRSA (for example) sounds like a prudent course to me. Of course, collecting the information and using it responsibly (or at all) is a different issue.

    Disclosure: I make this statement despite being in the self-same situation regarding secondary infections of the sinuses. Much as I like the guy, I’m bored with the rigmarole of going to my primary care guy (GP to you benighted limeys) having my temperature and blood pressure checked, a swab taken, and having ‘the boys’ held for 5 seconds while I cough. The worst thing is when we look each other in the eye and say “ok, *this time* it’s a 5 day course of Zithromax”.

    P.S. Dear Prudence … I think the thing with ‘the boys’ is unneccessary. Should I confront him on this?

  • Daveon

    As I understood it the original limitation on sales of certain painkillers were to reduce the possibility of accidental overdose of paracetomol. Which has apparently happened. Depending on body mass the overdose rates start at 12 in 24 hours and it’s a pretty nasty way to die. Can’t for the life of me see the point with limits on Ibuprofen and Asprin.

    I had to sign a declaration and give ID and address when I bought some Sinutab in Texas last year due to the Crystal Meth thing. Apparently the restrictions on sale of certain items has been extremely effective at shutting down local labs and pushing prices up. Of course, I leave it to the reader to work out what happened next. Best anti-Meth activity seems to be showing pictures of Meth users and especially their teeth…

    Antibiotics: given the potential epidemiological problems of these drugs, there does need to be control, but surely there’s a serious need for something other than a doctor to prescribe these?

    Finally, NickM, 24 hour monitoring? Weird, the only delay when I did mine was fitting it in around my travel. The Doctor in West London had a cupboard full of them. Of course you could always pay privately for it. :)

    As it happens the things are useless at night, if you sleep normally, the cuff doesn’t inflate properly, so you’re probably best off setting times and doing it manually your self and taking the results to a Doctor. Portable BP equipment should be a standard item in any home where there is a risk of hyper tension and it’s pretty cheap these days.

  • abc

    What is this ten minute thing? I went to see my GP this morning about something and the consultation lasted about ten minutes and it couldn’t have been done any quicker. When I tried to bring up another problem I was told that I would have to make another appointment on another day because otherwise it will go over my ten minute allowance. The staff try to fit me in and I know they must be under some kind of pressure to meet targets but every time I go to the doctors these days I feel like I’m troubling them.

  • Commenter

    FWIW, the US does have a “behind the counter” system – if you have a stuffy nose and want to buy Sudafed (pseudoephederine) you have to get it from a behind the counter process (sign a log, bla, bla…)
    Of course this pertains to the Drug enforcement Nazis rather than the medical Nazis, but it amounts to the same thing. (For those who merely think that sudafed clears a stuffed up nose, apparently if you melt down a million of them, mix them with battery acid and a few other things, you get a pill that gives you a slightly better lift than a cup of coffee.)

  • Kevin B

    The Internet is affecting the way we are interacting with health professionals, and not just by buying drugs from e-bay.

    Sufferers of even quite obscure maladies can contact each other and swap treatment regimes and progress reports as well as keeping tabs on the latest research. I know someone who is generally much better informed on her illness(es) than most of the medical practitioners she has to deal with. This leads her to a certain uncompromising attitude towards some of her would be carers.

    In my own, more trivial, case, after my ten minutes of ‘consultation’ with my GP during which he pulled, pushed and twisted various bits until he could confirm, (by the nature and timing of my screams), that I did, indeed, have Sciatica, I was able to find a site which described the exercises he’d sketched out for me spelled out in far more detail, complete with diagrams.

    I was also able to swap mattress advice which has proved quite helpful.

    (The last time I had a new mattress, my keeper at the time had fallen for the ‘experts’ assertion that a hard mattress was neccesary to prevent back trouble. An opinion that seems to have arisen from the fact that some people with a bad back can sleep better with a plank under their mattress. A fact that the ‘experts’ took to mean that if everyone slept on a plank, back problems would cease. This has much the same logical foundation as the salt fallacy whereby since some people suffer from a form of hypertension caused by an inability of the body to remove excess salt from the bloodstream, then all of us must reduce our salt intake to the bare minimum necessary to keep us alive.)

    Of course our ability to diagnose and treat our ailments via the internet also gives us the ability to misdiagnose and mistreat ourselves. This is already provoking reaction among the pros. In an NHS style system, if a large number of would be patients can treat themselves without bothering the doctor, then this saves them lots of money. On the other hand, the thought of the proles managing their own affairs must be galling, (if not frightening).

    It will be interesting to see how this pans out over the next few decades, especially if some of the wilder prognostications of the anti-aging crowd are realised.

  • Citizen Unit 666

    Thanks to the Democrat junta here in Oregon, USA, one needs a doctor’s prescription to buy Sudafed. I can still drive north across the Columbia river to Washington and get it off the shelf. Don’t know for how long that will last though.

    All hail the Nanny State!

  • nick

    While the State is the medical provider of last resort, it make sense for them to limit access to medications like PPIs and antibiotics. PPIs are extraordinarily effective medications against reflux, but they also mask the signs of reflux due to gastric/duodenal ulcer and cancer. The risk of this occurring per person is low, but the cumulative population risk is significant.

    In Australia, I prescribe 6 month supplies of these medications for people at low risk. When re-prescribing, I have a checklist of signs and symptoms to look out for. In people at very low risk, I may provide a further 6 month prescription without an additional consultation.

    The problem in the UK is the socialised model of health care. Get rid of the ‘free at the point of entry’ component, allow a bit of private enterprise, and most, if not all, of these problems will go away.

  • Laird

    A bit off-topic, but I would like to express my disappointment at learning that “Samizdata Illluminatus” is a collective pseudonym. And Englishmen, no less! All this time I have been laboring under the happy delusion that this was some libertarian “Deep Throat” laboring in obscurity at Miskatonic University. What else don’t I know?

    No, don’t tell me. Let me keep at least some of my delusions!

  • Charlie

    Just a correction as someone wrote “Bishop’s” when I think he meant to write “Barrett’s” esophagus.

    I have a 40 mg prescription for that stuff. My apocatharist told me doctors sometimes give a prescription so they can monitor usage. A generic pill version costs me $10 per month. But it does seem silly that I need a prescription for a pill that I can’t get high off of, nor can overdose with.

  • No Bod,
    No.
    I know antibiotics are over used but I’m not part of the problem. The problem is that NHS GPs give ‘em out like smarties. It’s a symptom of the systemic failure of the NHS just like the whole crazy idea that we can all get a doctors appointment of 15 mins duration regardless of whether it’s over cancer or mild sniffles. We are conditioned into the idea that unless the doc gets his pad out we ain’t got money for our stamps.

  • Frederick Davies

    If you think pharmaceutical controls are nuts, just read this(Link). Behind-the-counter salt anyone?