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Obtaining Antibiotics without a Prescription (2002) (nejm.org)
79 points by wikiburner on Jan 15, 2014 | hide | past | web | favorite | 95 comments

ICU doctor here.

I frequently see complications of overuse of antibiotics. C diff colitis (1) is certainly the most obvious, but resistant pneumonias and urinary tract infections are becoming more common as well.

Many resistant organisms set up shop in chronically ill patients who see multiple rounds of antibiotics through their lives; however, in just my short 10 year history as a physician, the increasing amount of resistant staphylococcus (specifically MRSA) and VRE (2) found out in the community has changed how we treat many suspected infections.

Although some of this is due to overprescription by the healthcare profession, there are likely other selection components in our environment. Just as you can buy these antibiotics for animal use, so can people raising livestock. The FDA realizes this is a problem. (3)

Personally, the sad part to me is that our medical system is so expensive that treating routine, mild infections can cost hundreds of dollars. Thus, people search out these alternative riskier, but cheaper methods.




Curious: Do these problems exist in other countries where even strong antibiotics are sold OTC?

I would guess not as bad, the culture in the US is to medicate immediately at first sign of illness. When I get sick, I try to just let it run it's course.

When I was in India I got antibiotics OTC a few times for myself after I self diagnosed using the internet. Because my mum went to med-school I was always very aware about the need to complete the course. I am sure that not everybody is as careful: http://ibnlive.in.com/blogs/shalini/211/65030/anitbiotic-res...

In India there are lots of doctors running small individual practices, due to this for simple diagnosis and prescription they would charge a small fee in cash and be done with it. Infact, I know for a fact that the Ayurvedic doctor near our house used to charge less than the standard Doctor.

When I came to the US, I found things here to be more restrictive - but I guess in the interest of safety we have to accept these restrictions.

India has a serious problem with some antibiotic resistant illnesses because many people are too poor to buy a full course but are convinced of tbe efficacy of a few days of treatment.

But overuse of antibiotics for things like ear infections is also part of the problem too.

Yes. Multidrug resistance in TB is frequently related to the availability of antibiotics.

Or does it exist in places where medical care is cheap or free (Canada or the UK)?

The last I checked Canada didn't have near the problem with MRSA that the US has:

"Similarly the United States has major problems with methicillin-resistant S aureus, vancomycin-resistant enterococci, multidrug-resistant M tuberculosis and penicillin-resistant pneumococci, whereas in Canada there is very little resistance to any of these organisms." (1)

That being said, it's a very multifactorial issue so it's hard to know exactly why that is. Canada's health care is more available and more regulated. Is it that people have an easier way of getting checked, is it that not-for-profit systems have less pressure to over-prescribe antibiotics, or something else?

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327906/

Having recently been to an international Epidemiology conference, I can say that there's intense interest/concern from researchers in the UK and Europe about both MRSA and carbapenem-resistant Enterobacteriaceae.

For that matter, the current strain of C. difficile which is causing so many problems was first observed in the UK and Canada.

Was it first observed and reported in these countries because they have socialized healthcare?

Unlikely, as surveillance for C. difficile is pretty intensive in the U.S., and it was reported there shortly thereafter (which isn't particularly a surprise).

My wife the same. She is all over this issue with me and sees it just as well in her rounds.

Notice our friend was already in a world of hurt by the time he went for help. Not only had he likely made his infection worse by helping it build tolerance while misdosing random antibiotics, even if he hadn't, he made it worse by waiting to get professional care.

Antibiotics are a balancing game of just the right dose. I suppose vet medicine is better than nothing at all in dire straights but if its at all possible, see a people doctor. They're good at that sort of thing.

But on the other hand he skipped going to a doctor and maybe paying for the privilege.

I think he should have right to bet on it. Most times he will win.

I think that most limitations on sale of medications are bad for people and should be lifted.

I'm also not so sure that people doctors are so good.

I fail to understand how commanding people what to do with their own body is suddently okay when it comes to medicine.

I have successfully diagnosed and treated MRSA and upper respiratory infections in myself. I NEVER suggest anybody else to self medicate. Most people do not take it seriously enough or do enough research to self medicate.

All that being said, I think it is a shame that we live in a system where it is so expensive and inconvenient to see a real doctor that people resort to this kind of thing.

By what means did you self-diagnose MRSA? At a hospital, that would involve a Gram stain / culture/speciation / sensitivities and take a few days.

Gram stain, because it's very fast (minutes) and can tell you, e.g., that you have Gram positive cocci in clusters (thus, likely staphylococcus species).

Culture, then, to grow the bugs and see what nutritional requirements they have and what biochemical modifications they make. Catalase producing? Likely staph aureus.

Finally, sensitivities: resistant to oxacillin? MRSA.

One could imagine PCR-based tests, too, though at my institution such a test is not in use.

Getting back to my question, how did you successfully self-diagnose MRSA?

A really determined person could probably do almost all of those at home if they really wanted to, with the exception of the sensitivity test and PCR. A makeshift incubator wouldn't be that hard to fashion, TSA plates are cheap, gram stain kits are relatively cheap, and you can do a catalase test with hydrogen peroxide. I guess you'd need a decent microscope, but the hypothetical person that's gram staining their own cultures at home surely has one, right?

So the MRSA diagnosis is hard to swallow, but getting to staph aureus might be doable.

Totally agreed; I don't doubt that anyone on HN could do this in their own apartment with the right tools. Many HNers probably have done this in bio lab back in high school or college. I'm just doubtful of the actual claim of self-diagnosis of MRSA.

edit: misread your comment, nvm

'carbocation is too nice to say it, but I'm not nice at all, so I will: the point is that it's hard to diagnose MRSA even if you have expertise and a full lab, and so it's nearly certain that the commenter above didn't actually "self-diagnose MRSA".

Oh, definitely. I'm just saying listing the steps in the diagnosis isn't, in and of itself, convincing, since most of them aren't actually that hard (and like carbocation says, you end up doing most of them in a college bio class), so at least figuring out that you have a staph infection isn't completely implausible (though like I said, the "MR" part of MRSA is probably harder).

It's still unlikely, though, firstly because PCR is hard, and secondly, because what person willing to go to that much effort wouldn't just go to the doctor?

There are several signs that distinguish MRSA from a normal staph infection.

1. Intense pain that extends beyond the boundaries of the visible irritation. Pain that is much more intense than a normal pimple or ingrown hair.

2. Distinct rash (as far as I understand the rash is caused by the specific toxins MRSA generates)

3. Necrosis of the skin. MRSA will produce blackened dead skin which many people mistake for a scab.

That, and I had MRSA years ago and had it diagnosed by a doctor, so I was already familiar with the condition.

For those reading along at home, none of those distinguish MRSA from a normal staph infection.

The primary distinguishing feature of MRSA vs regular staph aureus ("MSSA") is MRSA's resistance to oxacillin/methicillin. While you can find research papers distinguishing MRSA from MSSA on clinical grounds, I'm not familiar with any clinical distinguishing feature that is used in practice (aside from sensitivity analysis or PCR, which are laboratory techniques, not clinical ones).

What you are describing could be necrotizing fasciitis, and although MRSA is a common cause there are many classes of pathogens responsible. Any of them can constitute a medical emergency, and if not diagnosed and treated quickly a surgeon may need to butcher you to save your life. I've been in the OR for a debridement and you do not want to be that patient.

If you have pain way out of proportion and darkening skin (or any rash for that matter), that's not the time to play House. Call your doctor if you have one, or just go directly to the ER.

Really, you successfully diagnosed yourself with MRSA as opposed to a methicillin-susceptible Staph infection? And how exactly did you do that? Non response to one antibiotic?

This is exactly the problem with people self treating. Without a proper workup, which in this case would have likely involved some sort of diagnostic microbiology, people end up over- or mistreating themselves.

I was able to recognize the symptoms based on my previous experience and some reading. I had it previously and the doctor was able to diagnose it on sight. No testing was required.

Active duty special forces is likely more worried about keeping a clean medical history than expense or inconvenience.

I doubt that is what drove this. I'm sure they teach them that sort of thing so they know how to treat themselves in a pinch if they are on there own and can't see a real doctor. The problem is that some of them are too self confident and a little dumb so they think it is a fine idea to give it a go during every day life even when there is a doctor available to them. Think, "I'm not lost and don't need to ask for directions I'll just follow the north star like they taught us."

I've got family who is ex elite forces, and I met a number of his comrades in arms at his wedding last year. Cocksure and self-confident? Certainly. A little dumb? I can say without qualification that they are not.

I have self-medicated with antibiotics in the past, when circumstances warranted. It is indeed an access problem (at least for me), but not caused by the cost (I have good healthcare insurance). Rather, it's caused primarily by the delay before one can see the doctor. And all evidence suggests that the results of the USA's current healthcare initiatives will exacerbate this waiting problem, and therefore also the self-medication issue as well.

I also think it's a pretty good idea to carry emergency medication when traveling abroad. You won't know where medical care will be available, and indeed how to avail yourself of that care. Having a Z-pack and a couple of other things handy can save a lot of trouble. This has been a big boon to me more than once in the past. One one occasion the wife got a UTI, which is easily treatable with the right meds. On another occasion I helped out a fellow traveler, a doctor as it happens, by giving him an Ace bandage for a sprained ankle.

I actually have some fish meds stored in case of emergency, but have never been desperate enough to use them. The extra stuff I have on hand I acquired while traveling abroad, in countries that have looser restrictions on pharmaceuticals (this used to be Mexico, but they recently tightened up their laws).

Obviously th need to be a bit careful with the meds and the country you're travelling to.

Some people are imprisoned for the anti anxiety pill in their bllodstream that they took before the flight.

Carrying prescription medications with unclear prescriptions is risky advice unless you're sure about the country you're travelling to.

Good point. I've never traveled with anything psycho-active, but I can see that some nations have tighter restrictions on such meds.

I hope it never gets to the point where I can get in trouble for my motion sickness pills.

> Some people are imprisoned for the anti anxiety pill in their bllodstream that they took before the flight.

OMG, where? I need to be sure to never go there, given my random (being treated) phobias and such.

Japan for example is strict about some drugs used to treat ADHD or anxiety in US and Europe, better travel with papers from a doctor.

The case I remember is a woman travelling to UAE with diazepam in her blood. I have no idea how they discovered that. I'm unable to find a reference. It was a long time ago, ten years or more.

http://wikitravel.org/en/United_Arab_Emirates has some relevant info.


A woman was arrested for some passport/visa irregularity and they then took a urine sample and found Codeine and Temazepam in it, which she had been given by a doctor in the UK. They gave her a four year sentence, but she was eventually acquitted, after two months.


> [...] imprisoned for the anti anxiety pill in their bloodstream [...]

Really? Which countries are now demanding blood samples at the border?

"Since these medications are not regulated for use in humans, there are no guarantees as to their quality or potency."

Also no regulation as to how they are used. Super-bugs are being bred by over-use, and a careless or ignorant individual can make his/her own infection hard to kill by using antibiotics in other than the approved way (e.g. not finishing the course).

It's not just that. Not all anti-biotics are suitable for all infections - treating a skin infection and a gut infection will tend to require different anti-biotics.

Self medication is possible and, with enough research, can be done successfully and responsibly, but for most people it's really not a good idea.

People don't properly use prescribed medication. I see no indication that the takers of fish-drugs are leading the charge on this one

The fact that so many people are looking to get drugs without a prescription makes me reflect on the accessibility to healthcare in this country....

The folks in the special forces community have access to doctors. They're in the military. There are doctors in the military too and their whole job is looking after soldiers.

If you really want to get right down to it, why are guys in special forces (arguably reasonably smart, also evidenced by their figuring out this antibiotics trick) NOT going to see an army doc right away?

If I was going to be a really snarky asshole I might suggest that perhaps because it's a single-payer system the quality of care isn't that great and blah blah blah. I don't really believe that but arguments can be made both ways.

Don't be a troll.

I think maxerickson over in another subthread hit it on the head, "Active duty special forces is likely more worried about keeping a clean medical history than expense or inconvenience." These people are by definition and filtering hyper-motivated.

More generally, what makes sense for your career sometimes negatively affects other areas, but we tend to protect our careers.

Another comment (https://news.ycombinator.com/item?id=7063539 ) seems to imply that special forces soldiers avoid seeing army docs because any recorded medical problem might hurt their career.

Here in Brazil, if you're friends with the pharmacist, this is easy.

Here in Brazil, I just read about this ophtalmologist who switched fields, and now regularly prescribes anabolic steroids to his clients. All you have to say is you feel weak and you'd like to gain more muscle. Apparently, according to the article, a bunch of other doctors do this.

So what you’re saying is that Brazilian pharmacists are more corrupt than others.

Well, as an American, I was going to say friends with the vet. There's lots of potent horse medicine out there as well :)

This actually might be good for my grandparents. They live pretty far out from the nearest town and during storms in the winter the roads can be blocked for a week or more. It seems like this would be something good to have in their first aid kit.

Are there antibiotics that keep well and are good for general infections? (Purely as a last resort if there's no way for them to get medical attention)

A very large percentage of infections are viral and antibiotics would be of no use. Hence the reason antibiotic abuse in humans is so common.

I suspect antibiotics in livestock/food supply are an even greater contributor to resistance, because they are used as preventative medicine in that sector, but really, neither is good.

So are his grandparents going to catch a cold from the trees? If they don't have contact due to blocked roads then I think they can rule out viral infections?

Or have I forgotten something.

Can't rule it out. You don't have to be showing symptoms to be a carrier, and you can be a carrier for extended periods. It's quite possible (in fact likely) that there are plenty of virus sources waiting to get you, including inside yourself.

July 18, 2002

Has anything changed?

Nope. I bought (fish) amoxicillin for my first-aid kit a couple of weeks ago. It says USP pharmaceutical grade, and the pills look exactly like Google image search says human amoxicillin looks. I suppose since it's unregulated they could be putting sugar or arsenic or something in the pills, but I'd imagine they'd be in hot water with some pissed off fish owners if that were the case.


The efficacy of those antibiotics, I'd wager.

Before I had health insurance/well-paying job, buying fishmox was the standby plan if I needed antibiotics. It occurs to me now that, even though I haven't taken many antibiotics in my life, it wouldn't matter - the bugs I would catch would be from other people and would have built up resistances to whatever I took.

Unfortunately, I told my mom about fishmox a long time ago (during same salad days) and now I sort of wish I hadn't. It's her standby plan and I'm not likely to be able to convince her otherwise.

"the bugs I would catch would be from other people and would have built up resistances to whatever I took"

This seems to imply an assumption that all bacteria are resistant, when it's my understanding that this is actually a small [in relative terms] but growing phenomenon.

True, but given my limited antibiotics exposure (I just haven't had to take them much), the chances of getting a resistant bug from someone else are much higher than my getting a resistant bug from nature (which I have limited exposure to now).

I probably could have phrased it better. Blame lack of coffee.

This "common knowledge amongst all branches of the american special forces" is going to be a breeding ground for resistant strains.

Yes... Also, you can get anything you like over the counter in Cambodia and presumably other less developed countries ... good luck to anyone trying to regulate that.

Cambodia? It's well-known that if you want something without having to see a doctor, you can just drive over the border to Mexico and pick it up from a pharmacy. Obviously you can't get serious narcotics but you can certainly get antibiotics, prescription-strength toothpaste, etc.

Nice try, but not a chance. You want to see where resistance comes from? Have a little look-see at this chart:


well, the biggest segment of the graph isn't identical to what the previous guy said, so you must be right! </casm>

Well plus also the animals get the antibiotics in a very low dose all the time. If a human takes antibiotics it's in large doses for a week or two. Which one of those situations sounds like a long-term incubator for resistance?

That's weird. I can easily buy erythromycin in the drugstore. I thought this drugstore was for humans, well, I have never checked...

The FDA only regulates drugs in the United States. Presumably you are located elsewhere, or if you are in the US you are likely referring to the same phenomenon described in this paper.

Why do special forces guys need to get medicine this way?

A guess would be that obtaining medication in an official way may affect them when it comes to selection relating to field readiness. I.e. if you are being prescribed anti-biotics it may be showing that you aren't in peak fitness so may get passed over for other fitter team members.

There are so many hidden penalties for seeking medical help. When I went through a bad breakup, I saw someone and he thought a mild antidepressant would help. I saw him twice and took the medication for 9 months.

Almost four years later, I'm trying to get a pilot license for recreational purposes and now I have to admit to having had a mental disorder, get written statements from all providers, and go through special review from the FAA. I can't imagine what a special ops guy or airline pilot would go through.

That's not even mentioning the hell I went through for pre-existing conditions as a result of this prior to the ACA.

There are very strong disincentives to seek treatment.

Bugs and Drugs gives good local info.


Or go to India, or Russia. Antibiotics are sold over the counter and (at least in case of India last time I checked) are dirt cheap.

A lot of antibiotics in the U.S. are basically free. For instance, Walmart has a $4 prescription program:


Lots of other places have similar programs/prices.

So the expensive part is getting the prescription.

The final uninsured cost being closer to $100 :(

Garlic, colloidal silver, MMS, etc...

I predict that the corporate media will run with this story and that as a consequence this source of medicine will soon disappear.

We cannot have the profits of our Most Holy Corporations drop. Cheap antibiotics will cause a drop in the Most Holy Profits of Our Sacred Corporations, and That Is Not Permissible.

You do realize that it's a Very Good Thing Indeed For Everybody if the reckless use of antibiotics is reined in as much as possible?

How much profit do you think is made on antibiotics?

How much profit is made by the misuse of antibiotics in animal rearing?

The linked paper is from 2002. Has anything changed with regards to regulation in the past 10 years?

If we assume for a moment your assumptions about corporate motivations are correct they would be just as well to let this continue and promote it so that even the most common infection can't be treated by cheap antibiotics any more due to resistance. At which point people are forced to run into the arms of the large drug companies and their patented expensive antibiotics which can't be bought w/o a prescription at the pet store.

>Cheap antibiotics will cause a drop in the Most Holy Profits of Our Sacred Corporations

The opposite is true: with bacteria resistant to ancient antibiotics that are out of patent and work in weeks, the only alternative will be treatment for months or years with heavily patented drugs of dubious effectiveness and long hospital stays.

Is that your preferred outcome?

Not to mention treatment for the side effects. Our last ditch antibiotics are not gentle drugs.

Increasing access to antibiotics is not necessarily a good thing.

Let people decide. If they want antibiotics: sell it to them.

No, because people are idiots and have no concept of how overuse of antibiotics reduces their utility.

People, as a whole and on average, are terrible at judging long-term costs and overuse.

Now, if the product was priced to properly reflect negative externalities of use and abuse, maybe. But, that's not going to happen.

Let's stop selling cars, PCs and alcohol to people.

Because, you know, people are idiots and you know better.

So make them consult a well-paid and often clueless bureocrat before buying anything listed above. No prescription - no bottle.

Do the phrases "Negative externalities" or "Tragedy of the Commons" mean anythign to you?

The harms from antibiotic overuse don't go to the people doing the overusing.

Then limit yourself! Or better, your mom.

You can try to limit animal antibiotics use but that industry can fight back.

People, you persuade. Nobody have to preserve your commons for you. If you want that field be green, what are you willing to spend?


When actions taken based on the perceived self-interest of individuals put the public health at harm, any public health program will probably be perceived as paternalistic.

The cavalier approach to antibiotic custodianship you are describing is exactly why we have limitations on antibiotic availability in this country.

Well that's too bad his post got deleted. While the following doesn't address all the issues [he has], depending on location int he U.S. many "express clinics" are popping up in convenient locations (like grocery and retail stores) that do not require an appointment, can diagnose common ailments (such as ear infections), write prescriptions (for such common ailments as ear infections), and are relatively inexpensive.


You're reading too much into my post. I'm neither advocating nor opposing the current model of who gets to prescribe antibiotics and how hard it is to see the gatekeepers (currently doctors). But I do endorse some sort of system in which there are (hopefully somewhat enlightened) gatekeepers. Plenty of miserable, painful infectious diseases are not bacterial in nature.

This is an issue that pits public health against the perceived (not actual) self interests of people who want antibiotics. Public health is not medicine, though it does guide medicine.

Also, "Fuck you doctor" is a greeting that I've never seen before. Hilarious.

I don't live in the US, so I can only tell from my country, that I think is even more what pisses you off.

I don't think, that every use of medicine should be regulated, but antibiotics I see different and I am really not amused hearing, that you can get them in fish stores ...

The problem of modern medicine today is, that more and more resistances occur. The reason is: Overuse or wrong use of antibiotics. That problem is already causing many, many deaths and extraneous diseases every year. The problem will grow.

Of course, the main reason is -- as much I know -- the use of antibiotics in meat production. But even then, when everybody would have free access to antibiotics, the problem would be worsen a lot, since most people even in western world are not ready to handle them right.

Ok, but the guy takes antibiotics, and the pain goes away. Seems pretty clear-cut, no? How long should he wait in pain?

I get sinus infections like that. They drag on for weeks at a time, I take some antibiotics, and bang, better in a day or two. Those weeks when I'm miserable have costs in terms of not being able to work as much, not being as much help around the house, not going out/seen friends, and generally getting less done.

Naturally, here in Italy I can pretty much see a doctor any day of the week, so of course I get them prescribed.

It is that notion in modern people "pain must go away, fast!" that makes things worse.

Because people think that way, many will go to hospital and get said: There is nothing we can do for you (anymore).

And wait some years, than the problem will widespread.

We are indeed really lucky: Only 100 years before, there was no cure for many diseases where we just throw a pill today. But we today just take it for granted and we gamble the advantage away. They day will come and has yet come, that nature is throwing back onto us.

You should try walking a mile in someone else's shoes before telling them what they should and should not think or how they should act.

I do. I also have pains sometimes, but I don't take pills every time. And when I have to take antibiotics, I go to a doctor. What is the problem with that.

Ok, in the US, the people oftentimes have no adequate healthcare, but that is an other problem in my opinion ... The US seems to be rich enough to handle it ....

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