
U.S. to make More Drugs Easily Available, Cutting Role Doctors Play - mudil
https://www.bloombergquint.com/business/2018/07/17/u-s-to-make-more-drugs-easily-available-cutting-role-docs-play
======
Lanthanide
I live in a country where this scheme is already the norm (Saudi Arabia) and I
can say that while it's not necessarily ideal, I much prefer it to the
alternative. It plugs some seriously annoying holes in the healthcare
experience and frees up doctors' time for more patients.

As it is, the only medications that require a prescription to buy in Saudi are
psychotropic ones, narcotics, and most recently, antibiotics. Things like
insulin, birth control medications, hypertension medications, even
antidepressants and anti-psychotics- they are all OTC. And I think they should
remain so, because from what I've seen the damage from misusing those drugs
against pharmacists' advice is far less than the damage from going without
them due to the difficulties encountered in seeing a doctor.

The reason that this is the norm here is twofold; one, health insurance wasn't
much of a thing here until a few years ago. The second reason (and the reason
health insurance didn't factor in until recently) is that the socialized
healthcare system here was (and still is) stretched thin; seeing a doctor to
get prescriptions for every little thing becomes prohibitively difficult, with
appointments taking months.

It's asinine to expect someone suffering from, say, an acute athsma attack to
try to navigate ERs or try to see a doctor on short notice during a crisis,
when a pharmacist would be able to dispense the exact medication needed,
leaving the others free for more complex cases that need closer attention.

Edit: this actually created a bit of culture shock for an older friend of
mine. He was traveling to an EU country for the first time and didn't do his
homework- he thought he he could simply walk into any pharmacy and ask for a
pack of his cholesterol medication, as he usually does back home. I don't envy
the poor pharmacist that had to keep trying to explain the dispensing system
to him and to emphasize that yes, they are aware that it's Lipitor, not
morphine, it's just how the regulation is.

~~~
Engineering-MD
I’m not I agree. The first reason is that many medications carry significant
risks. For instance you mention insulin. For someone already prescribed
insulin, yes it should be easy to access in case they should be able to get
more (and that is the purpose of a repeat prescription). However, to provide
insulin over the counter to someone never previously prescribed it could be
incredibly dangerous, and indeed fatal. This is Similarly true for some
cardiac medication.

Second, i think such a system makes pharmacists de facto community doctors,
but without the time, training, or patient medical data to function correctly.
Community doctors can make better decisions when they see the same patient
multiple times, and have access to blood pressure readings, a list of other
medical conditions etc. Buying over the counter makes a lot of this difficult
and inefficient.

Third, I think it leads to a risk of encouraging patients to manage conditions
without valid medical advice. For instance, depression is often treated best
with psychotherapy. By buying antidepressives OTC, it prevents patients
getting the holistic care needed. Similarly, patients may follow quack medical
advice and do themselves significant injury by taking medications not needed
(in the short term or long term).

Ultimately doctors offer a lot of value more than just prescribing medication,
and often medicines need oversight to ensure the benefits outweigh the risk.

~~~
raverbashing
Read the article, it will have a questionnaire to determine if people should
be given the drug

I think allowing diabetics access to life saving medication is preferable,
even if there's some moron that's going to kill himself by injecting something
he has no idea about (and they do that already)

The proposal wouldn't allow the sale of controlled medication like
antidepressants

The rest just sounds like undue gatekeeping

~~~
IanCal
> I think allowing diabetics access to life saving medication is preferable,

I don't think anyone is arguing for diabetics to not have access.

My problem here is how someone knows they are diabetic.

But I saw little in the article actually describe what the process would be
for deciding what can be sold like this, I know diabetes is not mentioned.

~~~
raverbashing
> My problem here is how someone knows they are diabetic.

Again, I don't really see why this would be the problem of the person selling
it, unless you prefer living in a nanny state.

There are a multitude of OTC and other readily sellable stuff that if misused
can cause death. Complaining about selling insulin freely and the dangers of
it in a place where guns are sold like candy is a farce.

Make them sign a waiver and be done with it.

------
Communitivity
There are better ways to go about this. As others have noted, there must be a
mechanism for a continual prescription to be easily filled, e.g. insulin,
metformin, etc. I could see a long term prescription that has to be renewed
each year and is good at any pharmacy.

For the short term prescriptions though, cutting the doctor out of it makes
people much more susceptible to marketing (instead of 'ask your doctor if you
need X' we'll get 'You need X if you have any of a, b, and c...get it now
before it's too late'.

Also, the doctor is aware of your health history and can spot reasons you
specifically shouldn't take a drug, or better alternatives. Maybe you are
overweight and one diabetes drug would work for you, but this other one will
also help you lose weight. Maybe you have a loss of kidney function, and
shouldn't be taking metformin. Your pharmacist should catch drug interactions,
but they can't catch problems that would result from your past medical
history.

For me this is big pharma getting their way, at our cost, in more ways than
one.

~~~
gaius
_Also, the doctor is aware of your health history_

Your doctor skims your notes in the 20 seconds between the receptionist
calling your name and you entering her office, in handwriting she can barely
read herself, and has forgotten you before you’re even back in the waiting
room after spending 5 minutes talking to you while she’s really thinking about
the new Audi. That’s as far as the awareness goes.

~~~
aesclepius
Thanks for speaking for the entire medical profession. That is in fact what a
terrible physician does, and not what myself or other newly trained physicians
aspire to do.

~~~
phil21
You may not aspire to it, but you likely will have to do it if you want to
remain employed in many areas.

I have multiple friends who made it all the way through residency and have
since stopped practicing within years of "graduating. The OP describes the
profession much better than you do, as a whole.

Double booking patients, requiring certain revenue targets, massive amounts of
useless paperwork, etc. Considering the varying ranges of where they took up
residency I'd say this is endemic industry-wide. Also jives with my personal
experiences with the medical field.

~~~
adrr
They should start their own practice and set their own rules. Good
practices/doctors in my area are so in demand most aren't accepting new
patients.

~~~
u801e
Is it even possible to set up an individual practice these days? Most
individual practices were established decades ago. Most new physicians will
work with an established group practice on contract.

~~~
conanbatt
Its not because billing is so complicated that it takes up to 50% of the
doctors tie to manage his own practice.

Big companies have more people doing billing alone than doctors themselves.
Pretty clear cut case that regulation is the enemy of efficient markets.

~~~
adrr
Wouldn't this be a perfect opportunity for a startup to handle billing for
small doctor's offices?

~~~
conanbatt
There are several but its not as easy as it sounds. Its a very labor-intensive
task. Its kind of like saying that a startup should be going to peoples homes
and cook for them according to their liking.

The issue is that doctors work for insurance companies and that means you need
to do things a certain way they like while matching the way they practice and
document their medical decisions.

I could explain more since I am part of one of these startups :)

------
rdiddly
When you already know what drug you need and just need somebody to sign a
prescription, it's a very silly and awkward process to find a doctor, make the
appointment, wait for the appointment, show up to the appointment, fill out
the history forms and so on, meet with the doc, tell them you've got [disease]
and the drug for it is [drug], let them examine you until they agree with your
"diagnosis" of [disease], and let them recommend and prescribe [drug]. It
makes you feel sorry for the doctor almost.

~~~
LinuxBender
I agree with this. Many of the supplements I get online are just as risky as
anything a doctor can prescribe to me. I already know more about these
chemicals and drugs than any doctor I have met. What's more, I have yet to
meet a doctor that even cares about the supplements I take.

~~~
walshemj
Yes well I am sure that's what the guy next to me when I was in hospital last
year thought until he took supplements plus his prescribed meds and had 100%
kidney failure.

~~~
pkkm
Do you remember what supplements and meds he took?

~~~
walshemj
Large doses of Zinc some reaction with his other meds and the hadn't told his
GP about the zinc pills.

------
athenot
I have mixed feelings about this, especially considering the US is the only
first world country where direct-to-consumer marketing is allowed for
medications.

Bypassing the prescription requirement is of course of significant value to
drug companies, who expend quite a bit of resources to sway doctors with free
lunches, conferences and soft persuasion tactics.

Usually I welcome the freedom to chose but this doesn't increase availability:
the bottleneck is not with the doctors, it's with pricing. Drug prices aren't
going to go down with this measure, and will remain 3-5x the price of the
exact same meds sold in Europe.

~~~
nnm
One of my friends has type I diabetes, in more than one times, she needed
urgent visit/call to her doctors just to get the medicine she has being taken
for years.

~~~
veridies
I have type 1 diabetes, and this is a constant fear of mine. It’s absurd that
I should have to go through my insurance company to be able to get more
medicine if I need to.

~~~
srameshc
This is the most atrocious thing to do by not to letting people with Type 1
buy their Insulin medication. I just don't see a reason why this is so much
regulated. Like some meds which are partially regulated, where you can request
a Pharmacist and they can give you would be reasonable in this case.

~~~
15155
Insulin is regulated because you can very easily die from using it improperly.

~~~
maxerickson
Older versions are available OTC in at least parts of the US.

------
refurb
Similar to this idea, the province of Alberta in Canada allows pharmacists to
write prescriptions for patients with only the only limit that they can't
prescribe controlled substances.

~~~
csdreamer7
I like this, with the exception of anti-biotics because misuse would spread
immunity.

~~~
gehwartzen
You can already buy most standard antibiotics without a prescription if you
don’t mind taking fish medication ;) amoxicillin, ciprofloxacin, penicillin,
etc are all readily available through amazon and are identical to the human
version.

------
phil21
Beyond time. I find it pathetic that living in the "land of the free, home of
the brave" I need to travel out of the country to be able to pick up basic
medications without a permission slip from the authorities. I utterly refuse
to pay $100+ so I can get a signed hall slip from a doctor to get what I knew
I already needed.

This perhaps will save me some travel costs every few years when I go to
restock the personal pharmacy.

------
exabrial
My pharmacist friends have long bemoaned the 'go to the doctor for everything'
scheme. Some conditions are easily diagnosable and the side effects of the
drugs are minimal. They'd much rather see the doctor as an escalation if
treatment isn't responding or the patient has additional symptoms that could
indicate something more serious. The behind-the-counter system is a great
idea.

~~~
flukus
Yes, it's incredibly inefficient to have highly trained, expensive doctors
acting as tier-1 tech support. But they have a powerful union, so they can
keep being paid top dollar for their grunt work.

~~~
javadocmd
The kinds of doctors that work as "tier-1 tech support" \-- that is, primary
care -- are not being paid top dollar, believe me. After you account for the
cost of education, delay of entry to the workforce, hours worked per week, and
the fact that insurance compensation models are biased towards specialty care
and procedures, and it starts to look like bad financial planning.

------
jl2718
Bravo. The AMA/FDA/insurance cartel cannot die soon enough.

I don’t care if you want a free market, or you want socialized medicine, both
are preferable to government-enforced racketeering.

~~~
stochastic_monk
You mean the AMA and FDA should stop preventing patients from taking
contraindicated combinations or failing to understand the risks they’re taking
on by self-medicating? Pharmacology is complicated and dangerous. Letting
corporations go hog-wild will harm many people.

~~~
vibrio
...that and we'd better start inventing some new antibiotics now. As it is
now, physicans can barely prescribe them responsibly. If they are available as
cold medicine antibiotic resistance will surge even harder than it is now.
antibiotic resistance is a dramatically underappreciated problem.

~~~
mullingitover
Isn't human misuse of antibiotics a drop in the ocean compared to the
livestock feed? Pretty sure we could completely stop all human misuse and we'd
accomplish nearly nothing toward the goal of stopping antibiotic resistance.

~~~
vibrio
I very much agree that live stock antibiotic use is a major issue, even with
the recent regulatory advances, but I cannot agree that minimizing human
misuse is trivial. Ignoring either issue leaves a flank wide open for attack.

------
cassowary37
I'm always struck by the intensity with which some HN folks hate their doc -
reminded of this by the number of comments invoking conspiracy theories about
docs scheduling extra appointments to bill more or push more generic drugs.

Perhaps obvious but perhaps not: in the US and most EU countries I'm aware of,
you can choose a new doc. You can shop around. Despite the flaws in online
reviews, just as with Amazon, you can read between the lines. Choosing instead
to avoid healthcare completely seems self-defeating.

I'm sorry to read so many horror stories - going to the doctor even for docs
(especially for docs?) can be a frustrating experience. But while you're
burning down the FDA, at least shop around and find yourself a good primary
care doc.

~~~
PatentlyDC123
For me the issue is not exactly “burning down” the FDA, but rather changing
its purpose from regulatory to only advisory (and hopefully changing
associated statutes). The FDA provides a very valuable service by identifying
the risks associated with various food and drug. It is one thing to educate
the public and say “XYZ presents risk of ABC for this specific group of
consumers.” It is a very different thing to also add “therefore, consumers
cannot make the decision to take on the risks associated with XYZ because the
FDA (and associated governing bodies) have decided the general population
should not take these risks (regardless of the overall risk level and their
individual risk factors).”

~~~
microcolonel
This is more or less how I've felt. There are so many high-risk behaviors
which are perfectly legal, and when our right to take risks in those ways is
challenged, there is generally backlash; but in the case of drugs we are
legally prohibited from taking risks.

I think the FDA's prohibitive authority does more to protect the interests of
established pharmaceutical manufacturers, than the interests of consumers.

------
anoncoward111
Yikes, my girlfriend is applying to med school as we speak. The medical
industry is certainly a highly regulated, potentially overpriced service for
decades now.

When I see a headline like this, I have to seriously ask myself: "Is this when
the bubble finally pops, or will it be status quo for another generation?"

~~~
woolvalley
Does your GF really want to rubber stamp things epipen Rxs? Once you have the
allergy diagnosis, it generally doesn't go away.

It's kind of like low tech automation.

~~~
anoncoward111
I think these days, whether or not a doctor or physician assistant "wants" to
do something isn't really considered in the equation.

Basically, the schools jack up the medical practitioners with hundreds of
thousands in debt, and the practitioners will do absolutely whatever is
required to pay it off and eek out a living :(

~~~
medntech
I wouldn't do absolutely whatever is required to pay off my debt nor would my
peers. But we can relate to the concerns of hundreds of thousands in debt as
far as we can't "want" anything. We're just as trapped in the system as the
patients we treat. No wonder why there is a spike in suicides after medical
school.

------
pkaye
I think this is good. For many people a lot of the costs are the doctor
visits. Look at the Walmart 100 common generics for $4. I wouldn't be
surprised if 50% of the hospital visits can be solved by one of these generics
but then we add an expensive doctor visit to get a $4 medicine. There needs to
be a more affordable solution.

~~~
dragonwriter
> I wouldn't be surprised if 50% of the hospital visits can be solved by one
> of these generics but then we add an expensive doctor visit to get a $4
> medicine.

Its really not surprising that the expensive part isn't the drug but the
expertise to select the correct drug; it's true in lots of fields that the
equipment or consumables aren't nearly as expensive as the brain to choose
which of those to use and how.

Bits are a lot less expensive than the software engineers that arrange them.

------
jorblumesea
The true root of the problem is largely systemic: healthcare is a for-profit
system in this country and was poorly designed in the first place.

For example, employment based health insurance is largely a relic from WW2
because companies couldn't increase wages and offered it to entice workers.
This was logical at the time, but in the 21st century makes very little sense.

Until we can turn it into a true public service, little will change. We can
band aid the solution as much as we want but we will never be able to resolve
the true core problems.

------
paulie_a
Let me know when I can get Adderall without having to jump through endless
hoops...I can probably get cocaine delivered to my door with less effort.

------
lev99
> Patients could answer questions on a mobile-phone app to help determine
> whether they should be able to access a medication without a prescription.

The primary issue I am concerned with is self ownership of my body, and the
freedom to choose for myself which drugs I will consume. Transferring the
permission process from a human medical professional to an algorithmic
goverment agent does not give me anymore of what I want.

~~~
danso
A permission process seems inextricable from a system in which there are
regulations. But algorithmic agent would theoretically make approved drugs
more accessible. The expense and time of a doctor visit is enough friction to
stop people from getting drugs they may find beneficial.

~~~
wu-ikkyu
There are many systems in which production requires the following of
regulations but the purchasing and consumption does not, i.e. food.

~~~
danso
There is definitely more leeway with food. But the FDA, for instance, bans raw
milk from interstate sales:
[https://www.npr.org/sections/thesalt/2015/02/20/387558373/wh...](https://www.npr.org/sections/thesalt/2015/02/20/387558373/why-
some-states-want-to-legalize-raw-milk-sales)

Local governments can also regulate what food is purchaseable, more
specifically, who is legally allowed to sell food; restaurants have to agree
to pass health inspections, for instance. As another example: Peking Duck was
effectively illegal because of health regulations until legislators (of Asian
descent) were able to pass laws saying otherwise:
[https://www.nytimes.com/1982/03/31/us/around-the-nation-
cali...](https://www.nytimes.com/1982/03/31/us/around-the-nation-california-
panel-backs-a-chinese-duck-bill.html)

------
cm2012
This can't come soon enough. I hate going to the doctor in general, but
especially for basic shit I've been using for years.

------
seanmcdirmid
Nurse practitioners are already great for when you just have an infection and
need some anti-biotics. They have little clinics with them in many drugstores
these days.

~~~
athenot
NPs can already prescribe drugs (just not narcotics, iirc).

~~~
neurotech1
Nurse Practitioners can prescribe Class II narcotics in most states, if their
supervisor physician allows it.

~~~
athenot
Thanks for clarifying that.

------
toomanybeersies
Interesting that they mention Naloxone.

In Australia (VIC at least), Naloxone is available for free over the counter
at the pharmacy. Needles are also readily available (and I'm fairly sure
they're free).

It doesn't really make sense for Naloxone to be prescription. Smack users
aren't going to go to the doctor for a prescription. You can't get high off
the stuff, all it can do is take you off a high and keep you breathing until
an ambulance arrives.

On the other hand, if I want painkillers with opioids like panadeine (codeine
+ acetaminophen), I need to get a prescription. Same if I want cold medicine
containing psuedaephidrine, because I might make methamphetamine with it.

~~~
danieltillett
If you are in Australia you can get pseudoephedrine without a prescription -
you just give the pharmacist your drivers license and ask for the stuff that
works. How pharmaceutical companies can be allowed under our fair trading laws
to sell phenylephrine I don’t know.

------
Gatsky
Given the degree to which people waste time and money taking supplements that
do absolutely nothing, this doesn’t seem like a great idea. Sure, if you are
on HN and stay up late reading meta-analyses it would be fine, but then
governing the “Democratic Republic of HN” would be very easy in many ways.

If there was actually a proper system to enable evidence based and cost-
effective usage of pharmaceuticals without doctors it might improve things for
patients, but I don’t see that there is.

------
rjurney
This sounds like a bad idea until I remember that most countries have this
arrangement and I've made liberal use of it to great benefit... but mostly
that has to do with the lower cost of drugs everywhere but the United States.
I stock up every time I go to Europe, and I just made a run to Tijuana for
medication my insurance company doesn't cover.

The downside is that insurance wouldn't cover these often expensive
medications if they are OTC.

------
aaavl2821
looks like this is a draft guidance document, so it may not actually come into
effect for a while. something like this seems like it would be massively
controversial, and thered probably be a lot of debate on both sides. overall
though the idea is very interesting.

something like 20% of US health spend is on outpatient care. i dont know how
much of that relates to medication management, but id imagine a lot does. PCPs
get paid more when they manage a patients medication, and many psychiatrists
make nearly all their income from adjusting prescriptions. im sure other
specialties are similar. so this theoretically enables some of that work to be
done without the physician. this could significantly reduce cost of outpt
services, although it will depend very much on how hard it is for pharma
companies to demonstrate non rx use of their products is safe and effective.
it may be the case that only a few meds actually are eligible, or that many
are, once the guidance is finalized

i havent read the guidance doc yet so dont really know how this would play out
in terms of who decides what to rx if not a doc.

i personally am sort of disappointed to see doctors becoming even more
sidelined. doctors really do an important job of filtering info for patients,
advocating / negotiating with insurance companies, and looking out for them.
this could potentially be one less protection for patients as large companies
get more power to control info. id like to see cost taken out of the system by
reducing pricing power by breaking up large providers rather than
disintermediating doctors, but that isnt within fda's mandate, so i understand
why fda would go for something like this

this could be good for patients if it is implemented in a way that doesnt give
pharma too much power over patients. cost would decrease and access to meds
could increase. however there may be more patients taking medicines for
reasons other than the health benefits (ie marketing power / influence)

~~~
mullingitover
> i personally am sort of disappointed to see doctors becoming even more
> sidelined. doctors really do an important job of filtering info for
> patients, advocating / negotiating with insurance companies, and looking out
> for them

Tell that to my doctor, who on a routine checkup sent me to the lab for lab
work without clearing it with my insurance company. I got a nice $600 bill for
the lab work that the insurance company didn't agree was 'preventative.' After
calling the insurance company they ended up waiving it, but told me that in
the future I should clear every single thing the doctor orders with them,
because the doctors won't do it.

The supply of doctors in the US is artificially constrained, and physician
care costs more here than anywhere else in the world. Anything that removes
them from the equation, especially for basic things like prescriptions, is a
plus in my book.

------
chobytes
Exciting news. My only hope is they they would simultaneously dial back
medication advertisements.

------
baybal2
In China, you can't even buy loperamide. I think, they think that you can get
high on it if you eat a bucket load of it

------
Spooky23
Sounds like a way to mimic the success of over the counter medications like
ibuprofen, whose prices have been slowly creeping up for years.

Many of the major profitable blood pressure and statins are off patent, so the
drug companies need to make more money.

I’m sure this status will limit or eliminate insurance contributions, so now
you’ll pay more for generic because 50 million individuals lack the buying
power of CVS and the other PBMs.

~~~
mobilefriendly
Incorrect. 200 mg Ibuprofen is 2 cents a pill at Walmart.

[https://www.walmart.com/search/?query=ibuprofen%20200mg%2050...](https://www.walmart.com/search/?query=ibuprofen%20200mg%20500%20count&cat_id=0&typeahead=ibu)

~~~
vageli
Pointing at a single data point is not enough evidence to show that an upwards
trend does not exist.

~~~
pessimizer
The single data point is the exact same single data point mentioned in the
comment as the only evidence that an upwards trend existed in the first place.

------
nnm
Finally we come to common sense.

------
jrochkind1
This will be great for pharmaceutical profits, not so great for insurance
premiums.

~~~
ars
You have that 100% backwards.

Insurance premiums will go down since OTC drugs are not covered by insurance.
Pharmaceutical profits will also go down because people are much more price
sensitive for OTC drugs, so they can't charge as much.

~~~
darpa_escapee
I could be wrong, but I was under the impression that some plans will cover
OTC medication if a doctor "prescribes" them for you.

According to the article, these drugs won't be considered OTC, they still need
a pharmacists approval. I don't know how that will affect coverage, if at all.

~~~
ars
> I could be wrong, but I was under the impression that some plans will cover
> OTC medication if a doctor "prescribes" them for you.

Yes, that is correct. But the idea here is to have a person decide to take it
without having a Dr prescribe it, so insurance will not cover it.

------
cimmanom
How do they propose to deal with the potential dangers of drug interactions?

~~~
LinuxBender
Today you can research drug interactions online just like many doctors do. I
have to do this for the combination of supplements and the one prescription,
since most doctors are not trained in this area.

~~~
cimmanom
You're fortunate to have both the intelligence and the time to do that
effectively. Not everyone has the capability to assemble, decipher, and fully
understand that information.

~~~
LinuxBender
In my opinion, everyone should take the time to study the drugs that they are
prescribed, as well as the interactions to foods and supplements. I believe
this is more important that anything related to one's career or investments.
You only get one body.

~~~
cimmanom
It sounds to me as if you're failing to grasp just how difficult that is to do
for at least 80% of the population.

~~~
LinuxBender
I completely understand that a majority have a big learning curve ahead of
them. I am just not a fan of corporations and laws targeting the lowest common
denominator. I should have the ability to consent to making these decisions
myself, assuming I am willing to take the risks. I would even be fine with
getting a government issued certification that verifies I am educated enough
to make an informed decision.

------
rsynnott
> Patients could answer questions on a mobile-phone app to help determine
> whether they should be able to access a medication without a prescription.

Day 2: Websites showing the correct answers to get anything you want show up.

This is an absolutely bonkers idea.

~~~
xamuel
As opposed to the alternative where people buy said meds from a dude in an
alleyway?

~~~
matt4077
By that logic, I should already be able to buy medication from back-alley
dudes.

While I could quite easily get ahold of Marijuana and other illegal drugs on
the street or the dark side of the net, I have never seen an offer for non-
narcotic prescription drugs.

------
veryconfident
This is a good thing. Doctors, while good for some tasks, can have an adverse
effect on the flow of medical issue processing and patient care commodity
distribution. This initiative will lift the barriers to competition that
forces us to depend on the stodgy old-fashioned personal visits. Medical issue
processing should require no more than a few snapchats per conflict.

