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Comment by JumpCrisscross | Hacker News Reader

> maybe the minor hurdle of having to require a doc to check on the potential for side-effects really is justified?

Viagra is trivially available on the black market because many people don’t want to put up with that B.S. Antibiotics have a public interest in being gatekept; they harm everyone if abused. A similar argument can be made for addictive substances.

Merely-harmful drugs, on the other hand, can be disclaimed and, where the clinical and fatal doses are close, diluted. Beyond that, we’re manufacturing busywork.

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How, in your view, does dilution change the therapeutic index of a chemical? If a drug is effective at 20 milligrams, but at 60 milligrams has a steep rise in the incidence of hypotension, how does taking that same 60 milligrams in a larger volume of filler (e.g. water, or spread across more physical pills) change the fact that you've just taken 60 milligrams?

> how does taking that same 60 milligrams in a larger volume of filler (e.g. water, or spread across more physical pills) change the fact that you've just taken 60 milligrams?

It increases tolerance to mismeasurement and mistake. Same reason many pharmaceuticals require multiple pills for minimum dosing despite a concentrated form existing. A child eating a single pill, or you missing that you popped an extra pill into your hand, causes less damage.

That doesn't change the difference between effective and toxic doses, it changes the potential scale of off-by-one user error. If 20 milligrams is delivered in 1 tablet, then 3 tablets is the toxic dose. If 20 milligrams is delivered in 5 tablets, then 15 is the toxic dose. A single daily tablet is far superior to multiple daily tablets in terms of patient adherence and hence disease management.

Can you name specific examples where the number of pills/capsules/tablets has been increased to improve drug safety? Increased pill counts historically reduces patient adherence, which worses disease management. This is just the first example I found which measured it: https://pubmed.ncbi.nlm.nih.gov/31298592/ This review explicitly states it in the abstract even: https://pubmed.ncbi.nlm.nih.gov/30561486/

Idk what to say, this is established medicine [1]. When you have a small TI you dilute to make measurement tolerances wider in absolute terms. This is a motivating factor behind prescription-strength medicine.

> Increased pill counts historically reduces patient adherence

Of course. There are tradeoffs. You want to know what also increases burden? Requiring a prescription.

[1] https://en.m.wikipedia.org/wiki/Therapeutic_index

I don't see dilution anywhere on that page, and increasing volume of administration at a lower concentration to achieve the same effective dose does not alter the dose itself. You are not interpreting TI correctly.

Edit: further, to your comment about "prescription strength" nomenclature, look at section 14 of the Cialis/tadalafil prescribing information, IIRC, table of clinical studies, where they have the second two outcomes of the clinical studies broken down by dose. Efficacy increases pretty directly with increasing dose, and these are where the observed side effects show up. It seems like patients may well self-escalate. Maybe the OTC countries have public data on this?

NTI drugs, a/k/a critical dose drugs, can avoid titration requirements through dilution. It’s harder to fuck up a 500 mL difference than a 1 mL difference. Again, this is why most OTC versions of prescription drugs are different in only one way: concentration.

Everything is available on the black market, that doesn’t mean regulations are BS, it means people are willing to risk breaking the law to avoid being tracked. The demand for Viagra might have more to do with being embarassed about ED or other fears than with concern about the difficulty of getting it legally. (As another commenter pointed out, the bar is extremely low when using online remote clinics.)

What does “merely-harmful” mean? What do you mean it can be disclaimed? If it were over the counter, how will people know when and how to avoid fatal doses? Why do you assume it might be either effective or safe if diluted?

> What does “merely-harmful” mean?

Drugs that really only harm the person who takes them if abused. Alternatively, drugs which are unproblematically sold over the counter the world over.

> Everything is available on the black market

Available versus commonly procured.

> that doesn’t mean regulations are BS, it means people are willing to risk breaking the law to avoid being tracked

It means they’re willing to break regulations to get it. We can’t impute motivation.

> how will people know when and how to avoid fatal doses

Same way they do for e.g. Tylenol.

> Why do you assume it might be either effective or safe if diluted?

I don’t. Dilution is a common (and obvious) pharmaceutical tool for increasing the distance between the therapeutic and harmful dose.

> We can’t impute motivation.

Correct, you’re right, I was speculating on alternative reasons people might avoid the doctor. We also don’t have evidence that the cost or time of a doctors visit is the reason for the existence of the black market demand, contrary to your claim above.

Of course, a huge risk for black market purchases is that they turn out to be fake and/or have unlisted harmful ingredients. It’s already happening with black market Viagra. You get what you pay for, which is people who are breaking the law, are secretive and unaccountable, and putting anything they want in those pills. Good luck with that. A co-pay and a quick Zoom call with a doc seems like a safer choice to me…

> co-pay and a quick Zoom call with a doc seems like a better choice to me

Nobody is arguing it isn’t. The point is the forced choice is flawed. There wouldn’t be a market for the adultered stuff if the medicine were OTC.

> The point is the forced choice is flawed. There wouldn’t be a market for the adulterated stuff if the medicine were OTC.

You haven’t convinced me that there’s anything wrong with the regulation. There might be, but again, the existence of a black market is not a valid reason to relax the regulation. The black market exists for guns and heroine and antibiotics and certain types of illegal porn too, not to mention crazier things like bazookas. You wouldn’t argue any of those should be less regulated just because you can buy them on the black market right? What actual reasons justify deregulating Sildenafil?

> wouldn’t argue any of those should be less regulated just because you can buy them on the black market

I’d use that as evidence there is demand. Then I’d consider the harm of looser controls. The harm balance for Viagra seems minimal, particularly given so many people take it without bothering with a prescription. If you think Viagra is in the same harm bucket as guns and heroin, then yes, it makes sense to regulate it.

Demand is not a valid reason to deregulate, that’s exactly the same argument as the existence of a black market argument. And it doesn’t have to be in a severe harm bucket as heroine to deserve deregulation, it has to be relatively safe, and not have big contraindications with others commonly used medications.

Better reasons to deregulate would be that it’s shown as safe or safer than existing OTC products, that many other countries offer it OTC, or that Viagra provides a compelling health benefit when used safely. The benefit is there for some specific cases, but quite questionable broadly speaking, given that it often gets used casually and to help men who don’t truly need it, to party when they’re drunk or whatever. The safety has been reviewed and deemed worthy of a prescription gate, and it’s not a hard gate to get through at all, the top comment exaggerated it. Maybe it’ll change and get deregulated, but I guess I don’t really even see why deregulating Viagra would be a net positive for anything other than Pfizer’s pocketbook.

> What does “merely-harmful” mean? Drugs that really only harm the person who takes them if abused. Alternatively, drugs which are unproblematically sold over the counter the world over.

In the extreme case where someone ends up being injured or dead, friends and family are most definitely affected. There are few people this would not apply to.

Aside from that, the healthcare system takes a hit, employers do too and a thousand other little ripples spread out.

Some drugs are over-regulated and this is why I’m a fan of the middle line where some are sold at a pharmacy with no script needed and they can partially control the purchasing.

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