There are those who use drugs, and there are those who could, potentially, benefit from drugs. The two groups do not always coincide:
The blue circle represents those who could, potentially, benefit from drugs. The red circle represents those who actually use drugs. The intersection of the two, shown in purple, represents the sphere where drugs heal, the appropriate use of medications.
The two crescents represent millions of incidents of human suffering. The crescent on the left represents those who do not get the drugs that could, potentially, help them. It contains those without the resources or the skills needed to negotiate the medical system, articulate their needs, and get what they want, and those who simply refuse to seek help.
The crescent on the right represents the inappropriate use of medication: Ritalin or Adderall being used as study aids, or to boost exam performance; the use of antibiotics to treat viral infections; people taking anti-depressants when non-pharmaceutical treatments, such as exercise, diet, and vitamin D would work as well.
The crescents on the right and left are mutually exclusive in the picture, but are intimately related in reality. Those who become addicted to recreational drugs, such as alcohol, are often "self-medicating", trying to deal with underlying mental health issues. Overuse of some drugs is the flip side of underuse of others.
Anyone who has experienced the hurt created by the misuse of drugs just wants it to stop. The instinctive reaction is to use top-down methods of control. As a society, we use a variety of methods to shrink the red circle: we ban some drugs, tax others, and make accessing and consuming drugs more difficult by, for example, forbidding the consumption of alcohol in public places. Other policies attempt to both shrink the red circle, and move the blue and red circles closer together. Education is one such policy, but the more important one is gatekeeping. Physicians, pharmacists, other medical professionals, as well as governments and insurance companies, all limit and control access to medication.
For highly addictive and harmful drugs, such as crack cocaine, there is a case for intervention, possibly even prohibition. If I tried crack cocaine even just once I might get addicted, and that could ruin my life, so I'm happy that the sale and consumption of crack cocaine is banned.
But I'm not convinced that we're adopting the best gatekeeping strategy for prescription drugs, especially those used to treat mental illness. According to the recently released Mental Health Strategy for Canada, "only one in three people who experience a mental health problem or illness—and as few as one in four children or youth—report that they have sought and received services and treatment."
The undertreatment problem could be ameliorated by putting more money in the system: providing greater financial support for medications and counseling, for example. Yet the health system is already strained financially, and treatments such as one-on-one counselling are very expensive.
The patient model that characterizes much of health care - follow the doctor's orders - doesn't work for everyone. The Mental Health Strategy talks about giving patients more say, allowing people to be "empowered to make informed choices about the services, treatments and supports that best meet their needs." But how far can patient empowerment go? How about allowing people more say in choosing their own medications and prescriptions. For example, suppose that one could get a prescription for Prozac by going to the local local pharmacy and asking for one, instead of going to a doctor first.
The idea is not as off the wall as it might at first appear. Ontario's Drummond Report plays with it: "Suppose that pharmacists played a greater role in issuing prescriptions." Honestly, how often does a doctor, presented with a patient describing the symptoms of depression, do anything other than say "exercise - vitamin D - vegetables - sleep - here's a prescription"? Are there any circumstances when a pharmacist would issue a prescription that a doctor wouldn't? Any times when a doctor knows more about the potential side-effects of medication than a pharmacist? Indeed, if pharmacists could issue prescriptions, doctors might feel less pressure to do so, and be able to devote more time to, say, providing counselling for patients. If just one life was saved because someone was able to get anti-depressants when they needed them, instead of having to wait for a doctor's appointment, wouldn't it be worth it?
More radically, why not dispense with gatekeepers entirely, and make anti-depressant medications available over the counter? To an economist, making drugs available only through prescription - like any other policy that restricts people's choices - requires justification. Underpinning much of economics is the assumption that people are rational decision-makers, the best judges of their own well-being. People, in this framework, will only make the wrong decision in specific circumstances: when they fail to take account of the effects of their actions on others; when they lack information; when (drawing upon behavioural economics) their decision-making process are flawed. People succumb to temptation and peer pressure, for example, or do a poor job of estimating the risks inherent in their choices, or fail to plan for the future.
Thirty or forty years ago, one could reasonably assume that doctors knew more about the available prescription medications, their appropriate use and side-effects, than patients. This information asymmetry justified the system of medication-by-prescription that we have today. But does this assumption still hold? There are so many different medications on the market that the average busy family doctor cannot possibly know the ins and outs of all of them. The internet puts information in the hands of the patient, allowing him or her to make informed choices. The informational case for requiring prescriptions is weaker than it was.
There is an additional argument for the prescription system, however: equity. Prescription medications are covered by many health insurance plans, hence the cost of prescriptions are shared across the population. When drugs are sold over-the-counter, however, each person must pay for his or her own medication, and the amount of risk-sharing is diminished. The flaw in this logic is that many people do not have health insurance, so pay for their own pharmaceuticals directly. When people pay for their own medications, they are more concerned about the price, so making more treatments available over the counter could exhert downwards pressure on prices.
Honestly, I'm not sure about the wisdom of throwing open the medicine cabinet. But I am sure that too many people are falling through the cracks with our current system.