My impression is that they don’t make some drugs over the counter because those drugs lend themselves to abuse (like painkillers). But why isn’t albuterol OTC? It’s fairly harmless to my knowledge and I don’t see how it can be abused (outside of perhaps being used as an inhalant, but you don’t need a prescription to buy spray paint…)
No idea, as I’ve asked myself this many times. This remains prescription only, while Primatine Mist was OTC for decades (until recently, as far as I’m aware), and PM was terrible stuff.
There are hundreds (thousands?) of prescription medications that do not have any potential for abuse that are not made OTC. Why should albuterol be different?
Also, it is not harmless.
They all have other reasons for not being OTC, however. Like antibiotics and resistance. There’s always some issue of possible abuse.
Exactly. I don’t think you can become resistant to albuterol.
I’m glad you expounded on how it is not harmless, now I’m more well-informed thanks to your well-thought out and detailed post.
It’s prescription only here too, known as Salbutamol. I believe that it is still possible to persuade a pharmacist to sell you some OTC if you can persuade him that you are normally prescribed it. I did this once when I went on holiday and left my medication at home.
You can, or at least it becomes less effective. That can happen with almost any drug, really. But that doesn’t answer the question, since you can also become resistant to paracetamol or other over-the-counter painkillers.
When I, as a youth, ran out of my asthma medication and couldn’t get a new prescription in time due to being homeless, the pharmacist told me that salbutamol was sometimes used by users of other drugs to increase their high, hence the limited availability.
This may not be the whole answer, but asthma is a condition that, ideally, should be regularly monitored by a health professional. Making albuterol prescription only compels the patient to see a doc regularly just to be able to obtain the med(s).
Similarly, insulin or glucophage, also not likely abused, require regular physician visits for diabetics.
mmm
I think this is mostly it.
But albuterol is indeed not without risks and side effects. It acts much like a stimulant, and raises the heart rate and blood pressure. If a person has high blood pressure and breathing problems (a common combo) and they use albuterol, they could potentially give themselves a stroke or heart attack.
Also, albuterol doesn’t fix all breathing problems. It only (temporarily) fixes bronchoconstriction. If you use it for congestion or coughing without bronchoconstriction, you’re not using the most effective medication, and exposing yourself to those risks for no benefit.
Finally, it has potential interactions with quite a few drugs. To be honest, I see a lot of people on diuretics and beta blockers as well as albuterol without ill effect. (I even did a paper about the supposed interaction between albuterol and beta-blockers in nursing school, and the research I could find revealed only a theoretical risk, not actual case studies of harm. So I’m not sold on that interaction, personally.) But the warnings are still there.
Oh, my bad. You said it was harmless without substantiating that claim, so I figured you didn’t need more details. WhyNot, as always, has done a good job of summarizing the medication’s complex side effect profile as well as it’s known and theoretical interaction concerns.
Short-Term beta-agonists like albuterol are intended for occasional use only.
Examples of appropriate use are for people with mild asthma who have symptoms less than once a week, or for people with specific triggers such as exercise or animal exposure, or for breakthrough symptoms in people who take maintenance medications such as inhaled steroids to control symptoms on a day-to-day basis.
Over-reliance on short-term meds like albuterol leads to a phenomenon known as tachyphylaxis, where the body stops responding as well, or in some cases at all, to the same medication. The death rate from asthma hasn’t changed in 50 years. However the proportion of deaths in which the person took albuterol within an hour of dying has steadily increased.
Making albuterol available without a prescription would serve to increase the likelihood of people taking it on a frequent basis (several times a day) instead of seeing a doctor, and getting on the kind of regimen intended to prevent, rather than treat, symptoms. This shift could potentially lead to more deaths from asthma. If someone has to see a doctor to get a script for albuterol, first of all the doc will know if they’re taking it more often than intended, and second, the doc can get the patient on an appropriate suppressive regimen.
Hope this helps.
You’d think so.
But insulin has been around a long time. So long that it was grandfathered when the FDA started regulating medications and started requiring a prescription for certain medications. This is the same reason aspirin is available OTC.
This is true only for older insulins (“R”/regular, and “N”/NPH), and not for the modified insulin analogs such as Lantus/glargine, Levemir/detemir, Humalog/lispro, Novolog/aspart, or Apidra/glulisine, which do require a prescription. And while the older insulins can be purchased without a prescription, insurers require a prescription for reimbursement, which is mostly a moot point since the reason people need to buy it without a prescription is because they don’t have insurance and can’t afford to see a physician.
*Allowing insulin to remain available OTC was not without controversy. But insulin is truly a life-saving medication, and it was felt the the risk of death from restricting the sale of insulin outweighed the benefit of protecting people from unsafe use.
I’d had concerns about removing primatene (yes, it was an awful med, but it was a rescue med for those in desperate need) from the OTC market. But it’s true that most asthmatics who depend upon rescue meds only, instead of getting on maintenance meds to deal with the underlying inflammation which causes asthma exacerbations, are putting themselves at extreme risk for bad outcomes. So now when they get seen to get a rescue inhaler prescription, they can also be put on appropriate maintenance meds for their particular asthma situation.
And since then, the death rate in the US for acute asthma attacks has gone down significantly. We used to lose over 5000 asthmatics every year to acute attacks. Now that number is around 3000, even as the prevalence of asthma has continued to slowly rise.
So it appears that keeping asthma rescue medications as a prescription only med has been associated with a decrease in overall asthma deaths. Which is good news to me.
This really deserves emphaisis.
The background includes many articles like this one:
There are many meds that I give multiple refills on. Albuterol rescue inhalers? No. I want to know how often it is being used and asking for refills too often is the big flag that we need to get them in and re-evaluate their preventative care plan. If asthma is treated appropriately the rescue inhlaer should be rarely used (other than before sports for exercise-induced). Using an albuterol inhaler frequently is a good marker for someone at risk of minimally soon to be in need of an ED visit and/or hospitalization, if not of death, from their asthma. Getting those people on appropriate preventative meds lowers risk of death substantially. I don’t need to see them for a refill (an annual is fine) but I do need to see when their last fill was.
I know beans about asthma, so please don’t interpret my follow-on questions as intending to debate the expert information you’ve provided …
There must be a reason/some reasons asthmatics with a deteriorating condition would choose to overuse their Albuteral in preference to getting better maintenance meds.
Other than laziness, ignorance, or uninsured cost what might some of those reasons be? Not that they’re *good *reasons medically speaking, but at least they ought to make some surface-level sense when viewed from the lay patient perspective.
Or is uninsured cost the real driver for many / most patients?
It’s uninsured cost combined with the inherent difficulty in taking the medication on a consistent, daily basis when you are asymptomatic.
Well, that’s the big three right there. You’ve asked a question that’s kind of like, “Other than the taste, convenience and cheap price, why do people like fast food?” 
There is one reason you don’t mention: they don’t think they need them. People get used to using their albuterol inhaler, and they slowly need to use it more and more, but they don’t realize how often they’re really using it. If I have a patient and a spouse in front of me, and I ask how often they’re using their inhaler, the patient’s answer is generally half or less than what the spouse tells me. “I use it three or four times a week.” “Um, he uses it at least twice a day, more if he’s doing yardwork.” I’ve even been the spouse in this situation - my husband underestimates his rescue inhaler use by nearly 2/3. So they don’t have an accurate idea of how often they’re using them, and they don’t know what the doctor knows about how often is too often. As a result, it’s very difficult to convince someone that they need a maintenance inhaler.
But you’re largely right in your reasons. I’ll try to expound in a way that might make your three “exceptions” make more sense.
Mostly what I find is that patients have absolutely no idea why their doctor gave them another inhaler. This is related to my first reason. They’ve been using the albuterol for a while, and to them it’s working just fine. Now the doctor gave them “this other one,” but they don’t know why. Sometimes they think they’re supposed to use it instead of albuterol, but they don’t really want to give up what they know works. Sometimes they think the doctor must have bought some stock in the company that makes the new inhaler (seriously) and they’re trying to trick them into switching so they - the doctor - makes more money. Sometimes (very often) they think they’re supposed to take it “in the moment” when they’re having trouble breathing, and then it doesn’t work, so they decide this one doesn’t work as well as the old one.
A huge part of my job is teaching them the difference between the two, and reinforcing that This One has to be used once (or twice) a day whether they feel like they need it or not, and That One is only to be used when they have an attack, and please let me know if they need it more than a couple of times a week.
So, ignorance (in the most non-judgemental use of the word) is primary. Next is money. If you can only afford one inhaler, are you going to buy the one that you take whether you feel like you need it or not, but that you can’t use when you’re having an asthma attack, or the one that helps you breathe when you need it? I know which one I’d pick, and it’s not the one that would make the doctors happy.
Convenience is a distant third. Mostly what happens there is that when people are out of the house, they don’t bring their maintenance inhaler any more than they bring their whole pillbox. They assume they’re going to be home later, and they’ll take it then, and then they forget all about it.
It’d be nice if they made them look a little more different, by the way. I’ve taken a Sharpie to inhalers more than once to mark them “EVERY DAY” and “ATTACK”. :rolleyes:
I haven’t seen a study, but if I were a bettin’ gal, I’d bet that people use Advair and Spiriva - which come in funny looking disc thingies that you have to put a capsule into - more than they use the “puffer” style maintenance inhalers.
The final reason is a little weird: people don’t think of it as medicine, so they think it’s optional.
One of my jobs is to make a list of all the medications that people are taking at home. When I call them before my first appointment, I always say, “If you would please get all of your medications together so I can see them when I get there, it will save us some time. I need all your medicines. Everything you take, prescription and over the counter. All your pills, inhalers, lotions, potions, teas, tinctures, creams, salves…anything that goes in or on your body that isn’t food!”
They NEVER remember to give me their inhalers. Never. People just don’t register “inhalers” in the same spot in their brain they store “medicine”. And so they don’t place the same importance on using their maintenance inhaler that they do, say, their statin pill.
Rescue inhalers provide an immediate feeling of relief; preventative ones? I feel exactly the same as I did before.
“Ignorance” also has such a demeaning connotation but many people just don’t know and would have no reason to unless a health professional explained it to them.
“Steroids” also have a scary connotation and many people don’t want to consider themsleves as being someone who needs to on any regular mediciation let alone something that scares them.
If what you have experienced is that you take care of your asthma by using albuterol as needed, you percieve albuterol as “fairly harmless”, and you think that a visit to the ED every so often is what is you should expect as your norm (rather than being on a care plan that makes ED visits a rare to never event) then the idea of better control will never cross your mind.
Honestly I think cost is the least of it; one ED visit offset a whole mess of preventative inhalers.
Thanks all. Makes sense.
I was originally thinking more along the lines of the maintenance meds having obvious adverse side effects, or huge cost, or maybe scary long-term consequences, e.g. they eat your kidneys. As such perhaps the patient could rationalize that the emergency inhaler was an approach which had them using the weakest medicine with the least frequency & therefore the greatest safety.
Between having good insurance, a well-organized life, and fairly stable maintenance med needs, I don’t find managing my or my wife’s meds while having 99.5% compliance any challenge at all. From all these various medical situation threads I gather we’re a lot less typical in that than I naively thought just a few years ago.