1. Online Medication Farrokh Alemi, PhD Based on Grahame-Smith, D. G. CBE lecture

2. Confusion on What Works Self medication is allowed in some societies Self medication is allowed in some societies Medication requires physician prescription Medication requires physician prescription Non-physicians can prescribe Non-physicians can prescribe

3. What shape will wider access take? 1. Extension of OTC categories. 2. Nurse & pharmacist prescribing. 3. Other professional health care staff prescribing, e.g. optometrists, chiropodists, health visitors, paramedics. 4. The influence of the internet. 5. Patient self-management. 6. Response of the pharmaceutical industry. 7. The special case of ‘life-style drugs. Objective data is needed

4. Why are we so restrictive about prescribing? 1. Professional restrictive practice? 2. Powerful drugs potentially dangerous to patients and others. 3. Dangerous in disease, e.g. anticoagulants. 4. Controlled drugs (addiction). 5. Erroneous self-diagnosis and therefore wrong medicine

5. Why now? The need to save money. The need to save money. Patient convenience. Patient convenience. Perceptions of Doctors' ignorance. Perceptions of Doctors' ignorance. Promotion of medical ‘team’ activity. Promotion of medical ‘team’ activity. The factor of patient power. The factor of patient power. Change in culture Change in culture Improved patient care -- genetics. Improved patient care -- genetics.

6. Nurse Prescribing Virginia does not allow but Maryland does for mental illness Virginia does not allow but Maryland does for mental illness England & Canada are allowing more nurse practices England & Canada are allowing more nurse practices

7. Nurses attitudes towards prescribing Prescribing is complicated and nurses recognize that. Prescribing is complicated and nurses recognize that. The clinical risks are considerable in many cases. The clinical risks are considerable in many cases. Safety is a major concern. Safety is a major concern. Linked to safety is the risk of litigation if things go wrong. Linked to safety is the risk of litigation if things go wrong. Responsibilities and workload increase. Responsibilities and workload increase. Less close nurse-patient contact ensues because of the distraction of prescribing. Less close nurse-patient contact ensues because of the distraction of prescribing. Added to all this, nurses do not get paid more for doing it! Plainly a mug's game! Added to all this, nurses do not get paid more for doing it! Plainly a mug's game! 30% actually doing it

8. Safety Truly independent prescribing could be dangerous Truly independent prescribing could be dangerous Doctors make mistake too Doctors make mistake too Pharmacists could act as a gatekeeper and advisor Pharmacists could act as a gatekeeper and advisor Law suits can reduce errors Law suits can reduce errors

9. Medication on Internet Illegal drugs on Internet Illegal drugs on Internet Legal drugs Legal drugs Medical prescribing over the internet. Medical prescribing over the internet. The obtaining of medicines over the internet by patients themselves. The obtaining of medicines over the internet by patients themselves. The supply of information. The supply of information.

10. Medical Prescribing Over Internet Questionnaire assessments without physical exam Questionnaire assessments without physical exam Assessments via telemedicine Assessments via telemedicine Second opinions Second opinions Lack of follow up Lack of follow up Across visit information Across visit information

11. Patients getting medicines over the Internet Life style medicine pushed Life style medicine pushed Medication available at lower cost Medication available at lower cost Medication available at lower quality Medication available at lower quality

12. Supply of Information Growth in medical information Growth in medical information Who is better informed, the patient or the MD? Who is better informed, the patient or the MD? Misleading information Misleading information

13. Life Style Drugs Industry pushed Industry pushed Changing norms Changing norms Based on patient preferences not medical needs Based on patient preferences not medical needs

14. What is needed from the industry? Simplification of prescribing Presentation of information Implications for advertising Clarification of safety issues of OTC drugs

15. FDA’s role Restricted from OTC drugs Restricted from OTC drugs Cumbersome data collection and communication means Cumbersome data collection and communication means Bureaucracies are naturally absorbed by industries they regulate Bureaucracies are naturally absorbed by industries they regulate Work after government jobs Work after government jobs Who is willing to listen and engage me Who is willing to listen and engage me

16. Your Opinion What changes you like to see?