The most vocal opposition to more flexible nonprescription drug regulation comes from the American Medical Association (AMA).
Doctors may be concerned about poor medication adherence, but insist that physician involvement in patient care and treatment
is vital, especially for patients with chronic diseases, said Sandra Fryhofer, chair-elect to the AMA Council on Science and
Public Health, at the FDA public hearing. Emergency pharmacy access to Epi-Pens might be appropriate, but "FDA has not offered
evidence that patients with hypertension, hyperlipidemia, asthma or migraine headaches can self-diagnose and mange those serious
chronic medical conditions safely on their own."
Fryhofer further warned that wider use of OTC drugs probably could raise out-of-pocket costs for individuals that have health
insurance, and that change alone could create "a new barrier to adherence." Although OTC medicines reduce overall healthcare
spending by $102 billion a year, according to the Consumer Healthcare Products Association (CHPA), individuals could end up
paying more because insurers, employers, and government healthcare programs seldom reimburse for nonprescription medicines.
That situation could change, however, if healthcare plans decide to cover third-class medicines in certain cases. In addition,
patient outlays for OTCs would be offset in part by eliminating the need for doctor visits.
Pharmaceutical manufacturers could benefit from increased sales of nonprescription products, but are keeping fairly quiet
about these prospects, particularly about the role of switches in retaining market share for a brand facing competition from
generic or other new therapies.
At the FDA meeting, CHPA President Scott Melville highlighted how OTC medicines save billions of dollars for the healthcare
system overall and provide relief to millions of Americans. Melville also urged retaining a "clear distinction" between prescription
and nonprescription drugs, and that FDA should approve OTCs under its proposed paradigm individually and based on scientific
data. Generic-drug makers support OTCs in general, but not necessarily switches that make it harder to enter a market; barriers
could emerge if FDA approves an OTC with safe-use provisions that apply to all similar products.
Drug distributors also are uneasy about OTCs with special conditions for safe use that limit product distribution to certain
pharmacies or retail outlets. The Healthcare Distribution Management Association urged FDA to adopt standardized processes
for requiring distributors to determine which pharmacies and customers may receive a particular nonprescription drug.
Pharmacists are most enthusiastic about FDA's new paradigm as a way to "optimize the important role pharmacists can play in
improving public health," said Thomas Menighan, CEO of the American Pharmacists Association. He and others cited pharmacists'
success in administering vaccines to millions of individuals and in forming collaborative practice agreements with local physicians
to check blood pressure and order tests related to specific medication management programs. They also point to "rescue medicines,"
such as asthma inhalers and epinephrine to block allergic reactions, as ready candidates for enhanced pharmacy access.
However, pharmacists emphasize that they will need additional compensation for providing extra clinical services as part of
safe use conditions. FDA is not likely to require specific payments, but Menighan advised that agency policies should not
preclude reimbursement by the patient, third parties, states, Medicare, or sponsors.
At the same time, retail pharmacists prefer to limit expanded access programs to bonafide pharmacies, as opposed to the thousands
of retail outlets that sell OTC medicines. And pharmacists working in hospitals and for healthcare systems have expressed
that they are well-positioned to participate in special safe-use programs
Not surprising, IT and research firms are eager to provide a range of technology to support these efforts. They are proposing
new ways to evaluate and ensure compliance with self-diagnostic tools, to devise collaborative programs that enhance care
management, and to coordinate follow-up and oversight in collaboration with physicians, payers, and patients. Manufacturers
also are exploring such systems, such as testing by GlaxoSmithKline Consumer Healthcare of an interactive drug facts kiosk
to help consumers self-determine the need for and suitability of using statins to reduce cholesterol. The program, explained
GSK Vice-President David Schifkovitz, could run on a home computer or smart phone and produce a personal recommendation regarding
An interesting side issue to the debate is whether enhanced access to medicines without a prescription could defuse the current
hostilities over contraception coverage. A number of women's health organizations applauded FDA's paradigm at the hearing
as a way to promote "reproductive freedom" for women by facilitating access to safe and effective birth control methods. Eleanor
Schwarz, director of the Center for Research on Health Care, described studies showing that women can use an IT kiosk to perform
self-screening for Chlamydia and for oral contraceptive. Given that most healthcare plans do not pay for nonprescription medicines,
access to OTC oral contraceptives makes moot the debate over whether religious-affiliated organizations should reimburse for
birth control pills. Of course, any move by FDA to authorize nonprescription contraceptives would launch a wave of objections
from physicians and family planning opponents—similar to what happened last December when FDA proposed to drop OTC limitations
for Plan B.
To move forward with this initiative, policymakers need to devise appropriate exclusivity arrangements and other incentives
for manufacturers to invest in innovative information and patient monitoring systems. In addition, methods for testing the
efficacy of patient self-selection programs need to be validated. Despite these and other obstacles, Woodcock and others appear
optimistic that this new approach not only could enhance medication use, but also identify drug–drug interactions and improve
pharmacovigilance tracking. Although efforts to expand nonprescription drug use in the past have failed, the advent of electronic
medical records and smart phones may create a more positive atmosphere for change.
Jill Wechsler is BioPharm International's Washington editor, Chevy Chase, MD, 301.656.4634, firstname.lastname@example.org