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Prescription Economics

07/10/2020

I am not economist, but my economics 101 professor in college gave me a decent grade, probably at least a C. He also correctly predicted the failure of restrictive drug policy we have seen for many years, attributing that failure to the very predictable growth of a black market. 

We have come to take for granted the fact that in order to obtain most drugs legally one must obtain a prescription from a medical provider. We have also come to take for granted that adults can readily obtain -- without a prescription -- the two drugs that cause by far the most sickness and death, with no medical indication: nicotine and alcohol.

When a medical provider prescribes a drug, they incur liability and responsibility. Failure to adhere to standards of care in prescribing can lead to loss of license, civil suit, and even criminal prosecution. Associated costs include those of education, training, record keeping and malpractice insurance. In addition the historical requirement of at least one in-person encounter adds the cost of office space. Pharmacies who store and dispense drugs add further to the overall cost. Government regulates the companies that manufacture drugs legally. Initially, these companies incur enormous cost to research and develop drugs and obtain approval for marketing them for specific indications. In contrast, store clerks who dispense tobacco and alcohol have no responsibility other verifying age, and, in the case of alcohol, perhaps taking measures to prevent drunk driving.

In order to maintain the appearance of adherence to standards, prescribers require periodic encounters with those patients who use a drug for extended periods. Often, these include laboratory tests, but many of these often perfunctory encounters add little or no benefit to the patient but add substantially to the overall cost. No such cost attends the use of tobacco or alcohol.

Regulation drives a wedge between patient and provider. Forcing this gate-keeper role upon physicians, especially in the case of controlled substances, makes them feel more like cops than helpers. They must view patients as liars and cheats who will take every opportunity to divert these drugs or misuse them. Patients suffer from this suspicion of their motives. Store clerks who sell tobacco and alcohol feel no such burden.

Imagine if competent adults could obtain drugs without a prescription. I hasten to remind that many drugs are readily available on the black market with no prescription or other involvement of any medical provider. First, the black market would shrink, along with the criminal enterprises it supports. Costs associated with law enforcement and the criminal justice system would shrink proportionally. Prisons would empty. Harm associated with prosecution and conviction for drug crimes would disappear. We could obtain pharmaceutical quality drugs without many of the added costs noted above. Medical providers could relax into a role of providing advice about which drugs might help -- or hurt. A glut of such providers would soon develop, leading to reduced cost. Would medical professions attract fewer qualified applicants with less promise of a lucrative practice? Patients would waste less time one perfunctory encounters with medical providers.

Pharmacists could assume the role of gatekeeper, but they could also expand their current role of educating patients about the drugs they plan to use -- or untrained clerks could sell drugs just as they do tobacco and alcohol.

What would happen to the cost of drugs? With removal of many barriers to obtaining them, increased demand might lead to increase in prices. But patients would spend less obtaining medical advice. 

With patients able to avoid the unregulated black market, they would have more reliable information about dosing and purity. They would not have to resort to sharing needles and other dangerous practices or to using in secrecy for fear of arrest and prosecution. 

Many tend to assume, but we do not know, that such changes would lead to huge increases in illness and death related to ill-advised use of drugs. We assume, but we do not know, that restrictive drug policy prevents this. Legalization of marijuana in some states has given us a glimpse of how things could play out, but it could take years or even decades for the dust to settle after implementing such changes.

We need to come to terms with the fact that current restrictive drug policy causes more more than good and start changing it.

Berry Edwards, MD