PURCHASE PRESCRIPTION DRUGS FROM ABROAD? WHY NOT?

A few weeks ago drug company Turing Pharmaceuticals raised the price of a toxoplasmosis drug, Diatrim, from $13.50 to $750 per tablet, an increase of 5,000 percent. This medication is used with other medications to treat a serious parasitic infection of the body, brain, or eye or to prevent toxoplasmosis infection in people with HIV. Turiing's CEO Martin Shkreli explained that the company needed to make a profit on the drug. The price increase meant that the annual cost of treatment for people who need this medication will be anywhere from $336,000 to $635,000 depending on the patient's weight. The uproar this news caused has led to renewed concern about meteoric price increases in the pharmaceutical industry, generating an aggressive dialogue among political candidates, while resurfacing the question why Americans should not purchase their medications from abroad - especially Canada - since the price for medications in most developed countries is significantly lower than in ours.

It is not difficult to understand why many are tempted to purchase their medications elsewhere. We pay the highest prices in the world for our prescription drugs. Take for example the popular acid reflux drug Nexicum. An insurer in the U.S. pays on average $215 per customer. In the Netherlands the same prescription costs $23. A 30 tablet supply of Abilify costs $711 at Walgreens, but only $200 in Canada. A 10 capsule dose of Tamiflu sells for $112 in the U.S., and less than $50 in Canada. The IMS Institute for Healthcare Informatics, in a 2012 study, estimated that U.S. residents spend about $900 per year on prescription drugs, while the average Canadian spends $420, and Europeans spend on average $375.

During the 1990's travel agencies began organizing bus trips into Canada for seniors who wanted to purchase cheap brand-name drugs. These trips continue to be popular. It is technically illegal for individuals to importy drugs into the U.S. However, officials tend to use enforcement discretion and allow participants to bring in up to a 90-day supply of medication for personal use if they can provide documentation from their U.S. physician.

When I decided to research the viability of purchasing medications from abroad, I thought I would make the case for legalizing their importation. Given the vast differences of drug prices between us and the rest of the world this seemed logical. However, after digging into the subject matter it became clear to me that the issue is not that simple, and that falling in line with politicians who are shooting from the hip to effect legalization could generate troubling advice for people who react to cost alone. 

One reason for not allowing importation of prescription drugs is that the FDA won't be able to guarantee the safety of drugs coming in from a foreign country. This includes Canada. Drugs from foreign pharmacies are not subject to the agency's jurisdiction, could be mislabeled, counterfeit, or otherwise adulterated. Legality aside, bus tours taking passengers to brick and mortar pharmacies in Canada are pretty safe. However, these tours are only practical for residents of border states. The rest of us depend on web-based pharmacies, many of which are illegitimate, and often sell counterfeit drugs.In 2007 the FDA seized 9,600 websites and more than $41 million worth of illegal drugs worldwide. Many sites claimed to be Canadian. However, a sting operation discovered that only 15% of drugs claiming to be Canadian were actually from Canada. The remaining 85% came from 27 different countries. In 2011 the National Association of Boards of Pharmacy reviewed more than 8,300 online pharmacies. Just over 3 percent proved to be legitimate.

Anyone deciding to still take a chance on web-based pharmacies to save on the cost of prescriptions should access one of the following sites. They are designed to help insure that you are dealing with a legitimate online business:

VIPPS - the Verified Internet Pharmacy Practice Site.

CIPA - the Canadian International Pharmacy Association website.

PharmacyChecker

Any of these accredit online pharmacies, and PharmacyChecker also claims that their pharmacies offer drug prices that are up to 80% lower in price than those in U.S. pharmacies. In short, buyer beware. Know who you are dealing with.

Of course this still begs the question: Why do Americans pay two to six times more than the rest of the world for brand-name prescription drugs?

Other countries feature single payer nationalized healthcare systems. They contyrol pricing by negotiating as a single entity with pharmaceutical companies. Their governments essentially decide who can sell what at what price. In the U.S. companies negotiate with individual insurance companies, hospitals and private plans, resulting in an unregulated market driven pricing structure. Besides, by law the federal government-run Medicare system cannot negotiate with the pharmaceutical industry. If Medicare were allowed to negotiate directly, as one of the largest buyers of prescription drugs, it could potentially drive the prices of drugs down. The Veterans Administration has that ability, and within the V.A. system drug prices are 10% to 20% lower than elsewhere. Finally, pharmaceutical companies claim that the average cost of developing a new drug is about $1 billion. Since they are forced to sell at lower prices abroad, U.S. consumers pay higher prices to make up for reduced revenue from foreign sales.

Meanwhile all of us are well advised to do our homework, research the legitimacy of web-based pharmacies, recognize that there is a lot of fraud in the system and, perhaps, just contact several local pharmacies to find the best price.

"DEATH WITH DIGNITY" - What are we really talking about?

Last monday California Governor Jerry Brown signed Assembly Bill X2-15, the "End of Life Option Act", into law, ending a 23 year effort to provide what proponents euphemistically refer to as a "death with dignity" option for California residents diagnosed as having less than 6 months to live. The intent of this legislation made the headlines when Brittany Maynard, inflicted with brain cancer and only months to live, moved to Oregon specifically to be allowed to take advantage of that state's Death with Dignity  Act and take her life peacefully with barbiturates.

Attempting to commit suicide was once a criminal act. It has been decriminalized for many decades in most jurisdictions. Assisted suicide remains a criminal act throughout the country except in Oregon, Washington, Vermont, New Mexico, and by next year California. Although both in the U.S. and most of Europe upwards of 75% of people polled expressed being in favor of some form of assisted suicide, the issue remains controversial and emotional. The controversy centers on legal, social, ethical, moral and relikgious points of contention related to suicide and murder. The question is whether there is a legal right for a terminally ill person to end his or her suffering without interference by the state or the convictions of others. In 1997 the U.S. Siupreme Court ruled that state laws against assisting suicide are not unconstitutional. However, it also held that patients have a right to aggressive treatment of pain and other symptoms even if the treatment hastens death.

Advocatess on both sides of the discussion frequently and mistakenly misidentify substantive components of the argument to make their points. All of us may have different opinions on the subject. However, it could help to clarify some of the substantive elements of that discussion, especially those referring to the most emotionally charged terms referring to the methods used to provide the end of life option - euthanasia and physician-assisted suicide.

Euthanasia in Greek means "good death." This term normally implies an  intentional termination of life by an other at the explicit request of the person who wishes to die. The process distinguishes two forms of euthanasia - passive and active. Passive euthanasia is defined as hastening the death of a person by altering some form of support and letting nature take its course. This is generally performed on persons in a persistent vegetative state, terminally ill, or in a coma. Examples are turning off respirators, halting medications, or failure to resuscitate. This practice is often physician directed and, although technically illegal, quite common. Some people accept this approach because there is no need to articulate difficult moral choices. It has also been charged as hypocrisy since society is pretending to shun doctor-assisted suicide while condoning this form of euthanasia without safeguards.

Active euthanasia refers to causing the death of a person through a direct action in response to a request from that person. This method of suicide grabbed the headlines when Doctor Jack Kevorkian publically administered lethal medication to terminally ill Thomas Youk in Michiggan in 1998. Currently  this form of suicide is only legal in two countries: The Netherlands and Belgium. Belgium does not distinguish between passive and active forms of euthanasia.

Physician-assisted suicide, a term used by all states allowing this, is essentially a hybrid between passive and active euthanasia - also know as voluntary passive euthanasia. In this case a physician supplies information and/or the means of committing suicide to a person, allowing that individual to terminate his or her own life. This is a form of voluntary euthanasia, the preferred method authorized by the laws in place in this country. Physicians don't administer the drugs, and the laws mandate strict conditions to prevent abuse.

For critics of death with dignity laws the argument is moral and absolute. Deliberately ending a  human life is wrong, because life is sacred and the endurance of suffering confers its own dignity. For others, the legalization of doctor-assisted dying is the first step on a slippery slope where the vulnerable are threatened and where premature death becomes a cheap alternative to palliative care. These arguments resonate with a lot of people, and it is perhaps important to recognize that even in Europe only four countries allow the end of life option. Proponents argue however that suffering from a terminal illness with no hope of survival, and the prospect of increasingly intolerable agony, affects their quality of life and should allow them to terminate their lives gracefully.

Every year approximately 40,000 people commit suicide in our country, making suicide the nation's 10th leading cause of death. Each suicide costs society about $1 million in medical and lost work expenses and emotionally victimizes an average of 10 other people. Of all patients requesting information and medication allowing them to take advantage of assisted suicide laws 30% ultimately decide against it. One could argue that these laws could actually save some lives because their beneficiaries are forced to go through a more rational process.

Years ago two of my uncles committed suicide. One stepped in front of a train. The other straightened out a very windy road at 100 milers per hour. Their families were devastated. I also had an aunt who suffered from a horribly debilitating decease. She decided to end her life with her family present, allowing everyone to say their good-byes. She died with dignity.