There is no national regulatory agency governing pharmacy technicians and the duty falls to the individual state boards of pharmacies in the US. A  high school diploma  (or its  equivalent ) is typically required in all states but certification and licensing requirements vary by state. Some states require training from board-approved schools, national certification, on-the-job training or no requirements at all. A technician can become nationally certified by taking an NCAA-accredited examination administered by either the Pharmacy Technician Certification Board (PTCB) or the  National Healthcareer Association  (NHA). [ 22 ] [ 23 ] [ 24 ]


Beginning in January 2020, the PTCB enacted a requirement that prior to examination, an applicant for certification must complete an  American Society of Health-System Pharmacists -accredited pharmacy technician education program, a PTCB-recognized training program, or 500 hours of training [ 25 ]  however, the NHA had similar requirements prior to the PTCB enacting the 2020 requirements. Upon completion of the certification exam, a pharmacy technician earns the certified or CPhT credential.  Continuing education  after national certification is required for certification renewal every two years.


According to the  Bureau of Labor Statistics , in 2011 about 75% of pharmacy technicians in the US work in a retail setting, [ 2 ]  such as an independently owned  drugstore , a mass retailer chain, or a mail-order or  online pharmacy . An additional 16% of pharmacy technician jobs were in hospitals, [ 2 ]  while others worked for nursing homes, pharmaceutical wholesalers, or the  federal government . As of 2016, the nationwide average hourly pay for pharmacy technicians working in retail or independent pharmacies is $12.26 [ 26 ] [ 27 ]  and for pharmacy technicians working in hospital setting is $14.57. [ 28 ]  American pharmacy technicians work under the supervision of a pharmacist, often following a  pharmacist-to-pharmacy technician ratio  if required by the state that the pharmacy is located in. The National Pharmacy Technician Association and American Association of Pharmacy Technicians are professional organizations of pharmacy technicians in the US.


The states Delaware, Hawaii, Pennsylvania, and Wisconsin do not require licensing or certification but may require some form of training or registration.


Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Idaho, Illinois, Iowa, Kansas, Maryland, Massachusetts, Mississippi, Montana, New Mexico, North Dakota, Oregon, Utah, Virginia, Washington, West Virginia, Wyoming, and Washington, D.C. require both certification and licensing or registration, though some states may have a training period before these requirements.


California, Florida, Georgia, Indiana, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas (with exceptions), and Vermont require only a license. [ 29 ] [ 30 ]


Pharmacy technicians are trained at  Harare Polytechnic . Students graduate with a diploma after three years of training. The program is run by the  Ministry of Health and Child Welfare of Zimbabwe . Yearly intake is about 35 students. [ citation needed ]


Medication costs , also known as  drug costs  are a common  health care cost  for many people and health care systems.  Prescription costs  are the costs to the end consumer. Medication costs are influenced by multiple factors such as patents, stakeholder influence, and marketing expenses. A number of countries including Canada, parts of Europe, and Brazil use  external reference pricing  as a means to compare drug prices and to determine a base price for a particular medication. [ citation needed ]  Other countries use  pharmacoeconomics , which looks at the cost/benefit of a product in terms of  quality of life , alternative treatments (drug and non-drug), and cost reduction or avoidance in other parts of the health care system (for example, a drug may reduce the need for a surgical intervention, thereby saving money). Structures like the UK's  National Institute for Health and Clinical Excellence  and to a lesser extent Canada's Common Drug Review (a division of the  Canadian Agency for Drugs and Technologies in Health ) evaluate products in this way.


Medication costs can be listed in a number of ways including cost per  defined daily dose , cost per specific period of time, cost per  prescribed daily dose , and cost proportional to  gross national product . [ 1 ]


A November 2020 study found that more than 1.1 million  senior citizens  in the U.S.  Medicare  program are expected to die prematurely over the next decade because they will be unable to afford their prescription medications, requiring an additional $17.7 billion to be spent annually on avoidable medical costs due to health complications. [ 2 ]


Medication costs can be the selling price from the manufacturer,  that price together with shipping , the wholesale price, the retail price, and the dispensed price. [ 3 ]


The dispensed price or prescription cost is defined as a cost which the patient has to pay to get medicines or treatments which are written as directions on prescription by a prescribers. [ 4 ]  The cost is generally influenced by a financial relationship between pharmaceutical manufacturers, wholesale distributors and pharmacies. [ 5 ]  In addition to the financial relationship, each nation has different systems to control the cost of prescriptions. In the United States, a pharmacy benefit manager, a third-party organization, such as private insurances or government-run health insurances will implement cost containment programs, such as establishing a formulary, to contain the cost. [ 5 ] [ 6 ]   In the United Kingdom, the government negotiates an overall cap on drugs bill growth with the pharmaceutical industry. In addition a government agency, the National Institute of Health and Care Excellence (NICE) assesses cost effectiveness of individual prescription drugs pricing. [ 7 ]  The National Health Service also may negotiate direct with individual pharmaceutical companies for certain specialised medicines, as well as running competitive procurements for generic drugs and for patented medicines where there is more than one drug available for a condition. [ 8 ]  Prescription costs are a regular health care cost for the sick and may mean economic hardship for the underprivileged. [ 9 ]
With healthcare insurance, the patient in the U.S. pays a co-pay (the amount the patient must pay for each drug or medical visit), a deductible (the amount the patient has to pay before the insurance starts sharing the cost) and co-insurance (the amount the patient has to pay after deductible) for prescription costs. After reaching the out of pocket maximum, the insurance company will pay 100% of the prescription cost. The amount the patient has to pay depends on the healthcare insurance plan the patient has.


As of 2017, prescription costs range from just more than 15% in high income countries to 25% in lower-middle income countries and low income countries. [ 10 ] : 418


Pricing any pharmaceutical drug for sale to the general public is daunting. Per Forbes, setting a high ceiling price for a new drug could be problematic as physicians could shy away from prescribing the drug, because the cost could be too great for the benefit. [ 12 ]  Setting too low of a price could imply inferiority, that the drug is too "weak" for the market. [ 12 ]  There are many different pricing strategies and factors that go into the research and evaluation of a future drug's price with whole departments within US pharmaceutical companies like  Pfizer  devoted to cost analysis.


This chart shows discrepancies in drug pricing in different countries.


A study has placed the amount spent on drug marketing at 2-19 times that on drug research. [ 13 ]


Much research, needed to create drugs is done by the  public sector . [ 14 ] [ 15 ]  In addition, pharmaceutical companies also do much research prior to producing medications. The table shows research and development statistics for pharmaceutical companies as of 2013 per Astra Zeneca. [ 16 ] [ page needed ]


Severin Schwan , the CEO of the Swiss company Roche, reported in 2012 that Roche's research and development costs in 2014 amounted to $8.4 billion, a quarter of the entire  National Institutes of Health  budget. [ 12 ]  Given the profit-driven nature of pharmaceutical companies and their research and development expenses, companies use their research and development expenses as a starting point to determine appropriate yet profitable prices. [ 17 ]


Pharmaceutical companies spend a large amount on research and development before a drug is released to the market and costs can be further divided into three major fields: the discovery into the drug's specific medical field, clinical trials, and failed drugs. [ 18 ]


The process of drug discovery can involve scientists determining the germs, viruses, and bacteria that cause a specific disease or illness. [ 19 ]  The time frame can range from 3–20 years and costs can range between several million to tens of millions of dollars. Research teams attempt to break down disease components to find abnormal events/processes taking place in the body. [ 19 ]  Only then do scientists work on developing chemical compounds to treat these abnormalities with the aid of computer models. [ 19 ]


After "discovery" and a creation of a chemical compound, pharmaceutical companies move forward with the Investigational New Drug (IND) Application from the  FDA . [ 19 ]  After the investigation into the drug and given approval, pharmaceutical companies can move into pre-clinical trials and clinical trials. [ 19 ]


Drug development  and pre-clinical trials focus on non-human subjects and work on animals such as rats.


The  Food and Drug Administration  requires at least 3 phases of clinical trials that assess the side effects and the effectiveness of the drug. An analysis of trial costs of approved drugs by the FDA from 2015 to 2016 found that out of 138 clinical trials, 59 new therapeutic agents were approved by the FDA. These trials have a median estimated cost of $19 million US dollars. [ 20 ]


Of these phases, the phase 3 is the most costly process of drug development. [ 22 ]  A single phase 3 trial can cost upwards of $100 million. [ 23 ]  It accounts for about 90 percent of the cost to pharmaceutical companies to develop a medication. [ 24 ]


The processes of "discovery" and clinical trials amounts to approximately 12 years from research lab to the patient, in which about 10% of all drugs that start pre-clinical trials ever make it to actual human testing. [ 19 ]  Each pharmaceutical company (who have hundreds of drugs moving in and out of these phases) will never recuperate the costs of "failed drugs". Thus, profits made from one drug need to cover the costs of previous "failed drugs". The cost of failure in R&D constitutes about 60% of all development costs. It emphasizes the importance of success rates as a key driver of R&D productivity. The average costs for studies are estimated at $30 million, $70 million, and $310 million for Phase I, II, and III, respectively. [ 25 ]


Overall, research and development expenses relating to a pharmaceutical drug amount to the billions. For example, it was reported that  AstraZeneca  spent upwards on average of $11 billion per drug for research and developmental purposes. [ 23 ]  The average of $11 billion only comprises the "discovery" costs, pre-clinical and clinical trial costs, and other expenses. [ citation needed ]  With the addition of "failed drug" costs, the $11 billion easily amounts to over $20 billion in expenses. [ citation needed ]  Therefore, an appropriate figure like $60 billion would be approximate sales figure that a pharmaceutical company like  AstraZeneca  would aim to generate to cover these costs and make a profit at the same time. [ citation needed ]


Total research and development costs provide pharmaceutical companies a ballpark estimation of total expenses. This is important in setting projected profit goals for a particular drug and thus, is one of the most necessary steps pharmaceutical companies take in pricing a particular drug. [ citation needed ]


A 2022 study invalidated the common  argument   as is  for high medication costs that research and development investments are reflected in and necessitate the treatment costs, finding no correlation for  investments in drugs  (for cases where transparency was sufficient) and their costs. [ 27 ] [ 26 ]


Patients and doctors can also have some input in pricing, though indirectly. Customers in the United States have been protesting the high prices for recent "miracle" drugs like  Daraprim  and  Harvoni , both of which attempt to cure or treat major diseases (HIV/AIDS and  hepatitis C ). [ 28 ]  Public outcry has worked in many cases to control and even decide the pricing for some drugs. For example, there was severe backlash over Daraprim, a drug that treats toxoplasmosis. [ 29 ]   Turing Pharmaceuticals  under the leadership of  Martin Shkreli  raised the price of the drug 5,500% from $13.50 to $750 per pill. [ 29 ]  After denouncement from 2016 presidential candidates  Hillary Clinton  and  Bernie Sanders , Martin Shkreli said he would reduce the price but later decided not to. [ 29 ]


With the recent trend of price gouging, legislators have introduced reform to curb these hikes, effectively controlling the pricing of drugs in the United States. Hillary Clinton announced a proposal to help patients with chronic and severe health conditions by placing a nationwide monthly cap of $250 on prescription out-of-pocket drugs. [ 29 ]


Research for a drug that is curing something no one has ever cured before will cost much more than research for the medicine of a very common disease that has known treatments. [ citation needed ]  Also, there would be more patients for a more common ailment so that prices would be lower. [ citation needed ]   Soliris  only treats two extremely rare diseases, so the number of consumers is low, making it an  orphan drug . Soliris still makes money because of its high price of over $400,000 per year per patient. [ 12 ]  The benefit of this drug is immense because it cures very rare diseases that would cost much more money to treat otherwise, which saves insurance companies and health agencies millions of dollars. Hence, insurance companies and health agencies are willing to pay these prices. [ citation needed ]


Policy makers in some countries have placed controls on the amount pharmaceutical companies can raise the price of drugs. In 2017, Democratic party leaders proposed the creation of a new federal agency to investigate and perhaps fine drug manufacturers who make unjustified price increases. Pharmaceutical companies would be required to submit a justification for a drug with a “significant price increase” within at least 30 days of implementation. Under the terms of the proposal, Mylan's well-publicized price increase for its EpiPen product would fall below the criteria for a significant price increase, while the 5000% overnight increase of Turing Pharmaceuticals Daraprim (pyrimethamine) would be subject to regulatory action. [ 30 ]


One of the most important factors that determine the cost of a drug is the availability of competing drugs and treatments.  Having two or more manufacturers producing drugs for the same disease tends to reduce costs. [ 12 ]


Patent  laws give pharmaceutical companies the exclusive right to market a drug for a period of time, allowing them to extract a high  monopoly price . [ 31 ]  For example,  U.S. patent law  grants a monopoly for 20 years after filing.  After that period, the same product from different manufacturers - known as  generic drugs  - can be sold, usually resulting in a substantial price reduction and possible shift in market share. Two patents that are commonly used are  process patents  and drug  product patents . [ 32 ]  Process patents only provide developers intellectual claim to the methods in which the product was manufactured, so a competitor can make the same drug by a different method without violating the patent.


In some cases, a new treatment is more effective than an older treatment, or a given drug may work better than competitors for only some patients.  The availability of an imperfect substitution erodes prices to a lesser degree than would a perfect substitute.


Some countries grant additional protections from competition for a limited period, such as  test data exclusivity  or  supplementary protection certificates .  Additional incentives are available in some jurisdictions for manufacturers of  orphan drugs  for rare diseases, including extended monopoly protection, tax credits, waived fees, and relaxed approval processes due to the small number of affected patients.


The process of creating drugs to testing them to selling them is a long process. [ 33 ]  Aside from the costs for research and trials, many consumers are unaware of the process of the  drug supply chain . There are many middlemen and companies that buy and sell the drugs. This includes "drug manufacturers, drug wholesalers, pharmacies, and payers." [ 33 ]   Big Pharma 's influence in the policies and regulations regarding drug patents and prescription costs, protects pharmaceutical companies from having to be transparent about where the money goes and who those high prices benefit, including Pharmacy Benefit Managers. [ 34 ]   Transparency between drug manufacturers and sellers increases accountability between producers and consumers and allows for patients to know more about what they are paying for. Prescription Drug Price Locators allow for patients to learn of more cost-effective sellers and find discounts that will benefit them.


In an effort by the U.S. Department of Health and Human Services ( HHS ) to regulate drug price transparency in television advertising in 2019, the HHS saw a resistance to change against legislation. [ 35 ]  Although what the HHS sought to change was a step in the right direction for drug price transparency, Federal Judge Amit P. Mehta ruled in favor of the pharmaceutical industry. The ruling was based on the inability to give the HHS such power to enact such legislations. [ 35 ]  Policymakers have a lot to take into account when regarding the issue of transparency, as there are many middlemen involved in the selling and buying of prescription drugs.


When the price of medicine goes up the  quality of life  of consumers who need the medicine decreases. [ 36 ] [ 37 ]  Consumers who have increased costs for medicine are more likely to change their lifestyle to spend less money on groceries, entertainment, and routine family needs. [ 36 ]  They are more likely to go into debt or postpone paying their existing debts. [ 36 ]  High drug prices can prevent people from saving for retirement. [ 36 ]  It is not uncommon for typical people to have challenges paying medical bills. [ 36 ]  Some people fail to get the medical care they need due to lack of money to pay for it. [ 36 ]  In low and middle income countries up to 90% of people pay for medications out of pocket. [ 38 ]  A November 2020 study by the  West Health  Policy Center stated that more than 1.1 million  senior citizens  in the U.S.  Medicare  program are expected to die prematurely over the next decade because they will be unable to afford their prescription medications, requiring an additional $17.7 billion to be spent annually on avoidable medical costs due to health complications. [ 2 ]


The effects of high prescription costs on consumers also affects their long-term health and overall life expectancy. When properly used, a medication can benefit a patient and cure their disease. When a patient cannot afford to pay for their medication, they lose out on the optimal benefits of proper and adequate dosages. [ 39 ]  High prescription costs don't just affect patients in the short run, but also deteriorates their overall quality of life, as they are exposed to chronic illnesses that could have been prevented by that first prescription. [ 39 ]  Evidence from studies indicates that  insulin  therapy as a treatment for patients with high glucose levels that are not yet diabetic, leads to a decrease in  insulin resistance , which benefits patients. [ 40 ]


Consumers commonly respond to high or increasing drug prices by doing what they can to save drug costs. The most commonly recommended course of action for consumers who seek to lower their drug costs is for them to tell their own doctor and pharmacist that they need to save money and then ask for advice. [ 41 ]  Doctors and pharmacists are professionals who know their fields and are the most likely source of information about options for reducing cost. [ 41 ]


Depending on the country and health policies implemented, there are also options to search for the most convenient and affordable health insurance plans without having to consult a healthcare provider or obtain insurance through the employer. However, those who seek to purchase insurance individually through the individual market are most likely to be underinsured and therefore could potentially have a higher prescription cost. [ 42 ]


There can be significant variation of prices for drugs in different pharmacies, even within a single geographical area. [ 43 ]  Because of this, some people check prices at multiple pharmacies to seek lower prices. [ 43 ]   Online pharmacies  can offer low prices but many consumers using online services have experienced  Internet fraud  and other problems, [ 44 ]  such as long shipping times from overseas and a higher  insecurity  regarding  quality , genuineness and safety of the ordered products.


Some consumers lower costs by asking their doctor for  generic drugs  when available. [ 45 ]  Because pharmaceutical companies often set prices by pills rather than by dose, consumers can sometimes buy double-dose pills,  split the pills  themselves with their doctor's permission, and save money in the process. [ 46 ]


In countries without universal healthcare, there can be unaffordable  out-of-pocket  costs for needed medications. Approximately 25% of Americans find it difficult to afford prescription drugs. [ 47 ]  In the case of expensive  anti-obesity medications  it has been noted that many people "who could most benefit from weight loss may be unable to afford such expensive drugs". [ 48 ]  This may be of higher concern for conditions that are more risky or detrimental to health and/or which, unlike obesity, don't have additional treatment options that are both widely known and effective – like further improvements in diet and physical activity in the case of obesity. A study found that among U.S. Medicare beneficiaries without subsidies, 30% of  prescriptions  written for anticancer drugs, 22% for hepatitis C, and more than 50% for disease-modifying therapies for either immune system disorders or hypercholesterolemia were not filled by patients. [ 49 ]


The  right to science and culture  is one of the rights in the  Universal Declaration of Human Rights  according to which "Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits." [ 50 ]


While some have concluded that " drug development  is likely to remain an expensive and resource-intensive process", [ 51 ]  a study found that wide range of medicines in the  WHO Model List of Essential Medicines  can be profitably  manufactured at very low cost  by  pharmaceutical industries  and that "Most EML medicines are sold in the UK and South Africa at prices significantly higher than those estimated from  production  costs". [ 52 ]


Global spending on prescription drugs in 2020 may have been ~$1.3 trillion and "The high cost of prescription drugs threatens healthcare budgets, and limits funding available for other areas in which  public investment  is needed". [ 47 ]


Prescription drug prices in the United States have been among the highest in the world. The high cost of prescription drugs became a major topic of discussion in the new millennium, leading up to the  U.S. health care reform  debate of 2009, and received renewed attention in 2015. High prices have been attributed to monopolies given to manufacturers by the government and a lack of ability for organizations to negotiate prices. [ 54 ]


Individuals are able to enroll in health insurance plans, which often include prescription medication coverage. However, insurance companies decide which drugs they will cover by creating a  formulary . If a medication is not on this list, the insurance company may require people to pay more money out-of-pocket compared to other medications that are on the formulary. There are also often tiers within this approved drug list, as the insurance company may be willing to cover a portion of one drug but prefer and completely cover a cheaper alternative. [ 55 ]


Medicare Part D  is a branch of Medicare that helps to cover costs of prescription medications for patients aged 65 and up. From 2010 to 2018, the Part D plan "nearly quadrupled" its spending on the catastrophic coverage phase. [ 56 ]  This increase in spending is attributed to the rising pricing of prescription medications.


It varies by region in the  United Kingdom . In Wales, Scotland and Northern Ireland prescription costs have been completely abolished, however in England the current prescription cost for adults as of 1 April 2024 is £9.90 per item dispensed. [ 57 ]  There are subsidised costs for those claiming  Universal Credit .


To provide context for the medication costs in Canada, the country is a member of the  OECD , an international organization that consists of 38 countries which includes countries like the United States, Australia, Germany, and more. Among these 38 countries, Canada ranks number three in medication costs in the OECD. [ 58 ]  The Government of Canada found that during the 2020-2021 year, the country had spent 12.3 billion dollars on medication costs. [ 59 ]  In Canada, each province and territory publicly funds their own insurance plan rather than a national insurance plan. [ 60 ]  With differing insurance plans, the medication costs the public varies from area to area. [ 61 ]


In Canada, the medication pricing is overseen by the  Patented Medicine Prices Review Board  (PMPRB), which monitors the prices set for patented drugs. [ 62 ]  One way the PMPRB evaluates whether drug pricing by patentees is excessive by considering international drug pricing. [ 63 ]  The PMPRB also compares the price of the drug to a similar market. [ 64 ]  However, the patentees do not need approval of drug pricing with the PMPRB before listing drugs for sale. [ 65 ]


In  developing countries  medications make up between 25 and 70% of health care costs. [ 38 ]  Many medications are beyond the reach of the majority of the population. [ 66 ]  There have been attempts both by international agreements and by  pharmaceutical companies  to provide drugs at low cost, either supplied by manufacturers who own the drugs, [ 67 ]  or manufactured locally as  generic versions of drugs  which are elsewhere protected by  patent . [ 68 ]  Countries without manufacturing capability may import such generics.


The legal framework regarding generic versions of patented drugs is formalised in the  Doha Declaration  on  Trade-Related Aspects of Intellectual Property Rights  and later agreements. [ citation needed ]


A  prescription drug  (also  prescription medication ,  prescription medicine  or  prescription-only medication ) is a  pharmaceutical drug  that is permitted to be dispensed only to those with a  medical prescription . In contrast,  over-the-counter drugs  can be obtained without a prescription. The reason for this difference in  substance control  is the potential scope of misuse, from  drug abuse  to  practicing medicine without a license  and without sufficient education. Different jurisdictions have different definitions of what constitutes a prescription drug.


In North America,  ℞ , usually printed as "Rx", is used as an abbreviation of the word "prescription". It is a contraction of the Latin word " recipe " (an imperative form of "recipere") meaning "take". [ 1 ]  Prescription drugs are often dispensed together with a  monograph  (in Europe, a Patient Information Leaflet or PIL) that gives detailed information about the drug.


The use of prescription drugs has been increasing since the 1960s.


In  Australia , the  Standard for the Uniform Scheduling of Medicines and Poisons  (SUSMP) governs the manufacture and supply of drugs with several categories: [ 2 ]


As in other developed countries, the person requiring a prescription drug attends the clinic of a qualified  health practitioner , such as a  physician , who may write the prescription for the required drug.


Many prescriptions issued by health practitioners in Australia are covered by the  Pharmaceutical Benefits Scheme , a scheme that provides subsidised prescription drugs to residents of Australia to ensure that all Australians have affordable and reliable access to a wide range of necessary medicines. When purchasing a drug under the PBS, the consumer pays no more than the patient co-payment contribution, which, as of January 1, 2022, is  A$ 42.50 for general patients. Those covered by government entitlements (low-income earners, welfare recipients, Health Care Card holders, etc.) and or under the  Repatriation Pharmaceutical Benefits Scheme  (RPBS) have a reduced co-payment, which is  A$ 6.80 in 2022. [ 3 ]  The co-payments are compulsory and can be discounted by pharmacies up to a maximum of  A$ 1.00 at cost to the pharmacy.


In the  United Kingdom , the  Medicines Act 1968  and the  Prescription Only Medicines (Human Use) Order 1997  contain regulations that cover the supply of sale, use, prescribing and production of medicines. There are three categories of medicine: [ 4 ]


The simple possession of a prescription-only medicine without a prescription is legal unless it is covered by the  Misuse of Drugs Act 1971 . [ 5 ]


A patient visits a  medical practitioner  or  dentist , who may prescribe drugs and certain other medical items, such as blood glucose-testing equipment for  diabetics . Also, qualified and experienced nurses, paramedics and pharmacists may be independent prescribers. Both may prescribe all POMs (including controlled drugs), but may not prescribe Schedule 1 controlled drugs, and 3 listed controlled drugs for the treatment of addiction; which is similar to doctors, who require a special licence from the Home Office to prescribe schedule 1 drugs. Schedule 1 drugs have little or no medical benefit, hence their limitations on prescribing.  District nurses  and  health visitors  have had limited prescribing rights since the mid-1990s; until then, prescriptions for dressings and simple medicines had to be signed by a doctor. Once issued, a prescription is taken by the patient to a pharmacy, which dispenses the medicine.


Most prescriptions are  NHS prescriptions , subject to a standard charge that is unrelated to what is dispensed. The  NHS  prescription fee was increased to £9.90 for each item in  England  in May 2024; [ 6 ]  prescriptions are free of charge if prescribed and dispensed in  Scotland , [ 7 ]   Wales  and  Northern Ireland , [ 8 ]  and for some patients in England, such as inpatients, children, those over 60s or with certain medical conditions, and claimants of certain benefits. [ 9 ]  The pharmacy charges the NHS the actual cost of the medicine, which may vary from a few pence to hundreds of pounds. [ 10 ] [ 11 ]  A patient can consolidate prescription charges by using a prescription payment certificate (informally a "season ticket"), effectively capping costs at £31.25 a quarter or £111.60 for a year. [ 9 ]


Outside the NHS,  private prescriptions  are issued by private medical practitioner and sometimes under the NHS for medicines that are not covered by the NHS. [ 10 ] [ 11 ]  A patient pays the pharmacy the normal price for medicine prescribed outside the NHS.


Survey results published by  Ipsos MORI  in 2008 found that around 800,000 people in England were not collecting prescriptions or getting them dispensed because of the cost, the same as in 2001. [ 12 ]


In the United States, the  Federal Food, Drug, and Cosmetic Act  defines what substances, known as legend drugs, require a prescription for them to be dispensed by a pharmacy. The federal government authorizes physicians (of any specialty),  physician assistants ,  nurse practitioners  and other  advanced practice nurses , veterinarians, dentists, and optometrists to prescribe any controlled substance. They are issued unique  DEA numbers . [ 13 ]  Many other mental and physical health technicians, including basic-level  registered nurses ,  medical assistants , emergency medical technicians, most psychologists, and social workers, are not authorized to prescribe legend drugs. [ 14 ]


The federal  Controlled Substances Act  (CSA) was enacted in 1970. It regulates manufacture, importation, possession, use, and distribution of  controlled  substances, which are drugs with potential for abuse or addiction. The legislation classifies these drugs into five schedules, with varying qualifications for each schedule. The schedules are designated  schedule I ,  schedule II ,  schedule III ,  schedule IV , and  schedule V . Many drugs other than controlled substances require a prescription.


The safety and the effectiveness of prescription drugs in the US are regulated by the 1987  Prescription Drug Marketing Act  (PDMA). The  Food and Drug Administration  (FDA) is charged with implementing the law.


As a general rule,  over-the-counter drugs  (OTC) are used to treat a condition that does not need care from a healthcare professional if have been proven to meet higher safety standards for self-medication by patients. Often, a lower strength of a drug will be approved for OTC use, but higher strengths require a prescription to be obtained; a notable case is  ibuprofen , which has been widely available as an OTC  pain killer  since the mid-1980s, but it is available by prescription in doses up to four times the OTC dose for severe pain that is not adequately controlled by the OTC strength.


Herbal preparations ,  amino acids ,  vitamins ,  minerals , and other  food supplements  are regulated by the FDA as  dietary supplements . Because specific health claims cannot be made, the consumer must make informed decisions when purchasing such products. [ 15 ]


By law, American pharmacies operated by "membership clubs" such as  Costco  and  Sam's Club  must allow non-members to use their pharmacy services and may not charge more for these services than they charge as their members. [ citation needed ]


Physicians may legally prescribe drugs for uses other than those specified in the FDA approval, known as  off-label use . [ citation needed ]  Drug companies, however, are prohibited from marketing their drugs for off-label uses. [ citation needed ]


Some prescription drugs are commonly abused, particularly those marketed as  analgesics , including  fentanyl  (Duragesic),  hydrocodone  (Vicodin),  oxycodone  (OxyContin),  oxymorphone  (Opana),  propoxyphene  (Darvon),  hydromorphone  (Dilaudid),  meperidine  (Demerol), and  diphenoxylate  (Lomotil). [ 16 ]


Some prescription painkillers have been found to be addictive, and unintentional poisoning deaths in the United States have skyrocketed since the 1990s according to the  National Safety Council . [ 17 ]  Prescriber education guidelines as well as patient education,  prescription drug monitoring programs  and regulation of pain clinics are regulatory tactics which have been used to curtail opioid use and misuse. [ 18 ]


The expiration date, required in several countries, specifies the date up to which the manufacturer guarantees the full potency and safety of a drug. In the United States, expiration dates are determined by regulations established by the FDA. [ 19 ]  The FDA advises consumers not to use products after their expiration dates. [ 20 ]


A study conducted by the U.S. Food and Drug Administration covered over 100 drugs, prescription and over-the-counter. The results showed that about 90% of them were safe and effective far past their original expiration date. At least one drug worked 15 years after its expiration date. [ 21 ]  Joel Davis, a former FDA expiration-date compliance chief, said that with a handful of exceptions—notably  nitroglycerin ,  insulin , and some liquid antibiotics (outdated  tetracyclines  can cause  Fanconi syndrome )—most expired drugs are probably effective. [ 22 ]


The  American Medical Association  issued a report and statement on Pharmaceutical Expiration Dates. [ 23 ]  The  Harvard Medical School  Family Health Guide notes that, with rare exceptions, "it's true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a decade after the expiration date". [ 24 ]


The expiration date is the final day that the manufacturer guarantees the full potency and safety of a medication. Drug expiration dates exist on most medication labels, including prescription, over-the-counter and dietary supplements. U.S. pharmaceutical manufacturers are required by law to place expiration dates on prescription products prior to marketing. For legal and liability reasons, manufacturers will not make recommendations about the stability of drugs past the original expiration date. [ 25 ]


Prices of prescription drugs  vary widely around the world.  Prescription costs  for  biosimilar  and  generic drugs  are usually less than brand names, but the cost is different from one pharmacy to another.


To lower prescription drug costs, some  U.S.  states have sought federal approval to buy drugs in  Canada , as of 2022. [ 26 ]


Generics undergo strict scrutiny to meet the equal efficacy, safety, dosage, strength, stability, and quality of brand name drugs. [ 27 ]  Generics are developed after the brand name has already been established, and so generic drug approval in many aspects has a shortened approval process because it replicates the brand name drug. [ 27 ]


Brand name drugs cost more due to time, money, and resources that drug companies invest in them to conduct development, including clinical trials that the FDA requires for the drug to be marketed. [ 28 ]  Because drug companies have to invest more in research costs to do this, brand name drug prices are much higher when sold to consumers. [ 28 ]


When the patent expires for a brand name drug, generic versions of that drug are produced by other companies and are sold for lower price. By switching to generic prescription drugs, patients can save significant amounts of money: e.g. one study by the  FDA  showed an example with more than 52% savings of a consumer's overall costs of their prescription drugs. [ 29 ]


In the United States there are many resources available to patients to lower the costs of medication. These include copayments, coinsurance, and deductibles. [ neutrality  is  disputed ]  The  Medicaid Drug Rebate Program  is another example. [ 30 ]


Generic drug programs lower the amount of money patients have to pay when picking up their prescription at the pharmacy. As their name implies, they only cover generic drugs. [ 31 ]


Co-pay assistance programs are programs that help patients lower the costs of specialty medications; i.e., medications that are on restricted formularies, have limited distribution, and/or have no generic version available. These medications can include drugs for HIV, hepatitis C, and multiple sclerosis. Patient Assistance Program Center ( RxAssist ) has a list of foundations that provide co-pay assistance programs. Co-pay assistance programs are for under-insured patients. Patients without insurance are not eligible for this resource; however, they may be eligible for patient assistance programs.


Patient assistance programs are funded by the manufacturer of the medication. Patients can often apply to these programs through the manufacturer's website. This type of assistance program is one of the few options available to uninsured patients.


The out-of-pocket cost for patients enrolled in co-pay assistance or patient assistance programs is $0. It is a major resource to help lower costs of medications—however, many providers and patients are not aware of these resources.


Traces of prescription drugs—including  antibiotics ,  anti-convulsants ,  mood stabilizers  and  sex hormones —have been detected in drinking water. [ 32 ] [ 33 ]  Pharmaceutically active compounds (PhACs) discarded from human therapy and their metabolites may not be eliminated entirely by sewage treatment plants and have been detected at low concentrations in surface waters downstream from those plants. [ 34 ]  The continuous discarding of incompletely treated water may interact with other environmental chemicals and lead to uncertain ecological effects. [ 35 ]  Due to most pharmaceuticals being highly soluble, fish and other aquatic organisms are susceptible to their effects. [ 34 ]  The long-term effects of pharmaceuticals in the environment may affect survival and reproduction of such organisms. [ 34 ]  However, levels of medical drug waste in the water is at a low enough level that it is not a direct concern to human health. However, processes, such as  biomagnification , are potential human health concerns. [ 36 ]


On the other hand, there is clear evidence of harm to aquatic animals and fauna. Recent advancements in technology have allowed scientists to detect smaller, trace quantities of pharmaceuticals in the ng/ml range. [ 37 ]  Despite being found at low concentrations, female hormonal contraceptives may cause feminizing effects on male vertebrate species, such as fish, frogs and crocodiles. [ 37 ]


The FDA established guidelines in 2007 to inform consumers should dispose of prescription drugs. [ 38 ]  When medications do not include specific disposal instructions, patients should not flush medications in the toilet, but instead use medication take-back programs to reduce the amount of pharmaceutical waste in sewage and landfills. [ 39 ]  If no take-back programs are available, prescription drugs can be discarded in household trash after they are crushed or dissolved and then mixed in a separate container or sealable bag with undesirable substances like cat litter or other unappealing material (to discourage consumption). [ 39 ]


Psychiatric pharmacy , also known as  mental health pharmacy , is the area of  clinical pharmacy  specializing in the treatment of people with  psychiatric illnesses  through the use of  psychotropic medications . It is a branch of  neuropsychiatric pharmacy , which includes  neurologic pharmacy . [ 1 ]  Areas where psychiatric pharmacists are found most abundantly are in chemical dependency, developmental disabilities, long-term care facilities, adherence clinics, mental health clinics, and within the prison system. [ 2 ]  However, psychiatry and neurology are not the only areas where psychiatric pharmacists require comprehensive knowledge. They must also be proficient in clinical problem solving, interprofessionalism, and communication with understanding and empathy for the patient population they serve, as they are a sensitive group. [ 3 ]


Psychiatric pharmacy was introduced in the late 1960s. The first time a psychiatric pharmacist was able to practice in a psychiatric unit was in 1971, as assigned by the US Public Health Service. This became the setting for the first published case where the role of a psychiatric pharmacist was elaborated upon. [ 4 ]  Psychiatric pharmacists were working not only in psychiatric inpatient and outpatient settings, but in methadone and disulfiram clinics, along with centers for mentally disabled people. During this time, the University of Tennessee created contracts which allowed for pharmacy dispensing and clinical services for local psychiatric facilities. This treatment paradigm involved some of the collaborative drug therapy management and medication therapy management (MTM) systems in which psychiatric pharmacists employ today. [ 5 ]


The  College of Psychiatric and Neurologic Pharmacists  (CPNP) is a  professional organization  that represents psychiatric pharmacists within the United States. CPNP credits two key  pharmacists  with developing clinical psychiatric pharmacy as a specialty: Dr. Glen Stimmel, PharmD, BCPP and Dr. R. Lee Evans, PharmD, FASHP, BCPP. [ 1 ] [ 6 ]  Dr. Stimmel would later become a founding member of CPNP, as well as serve as its president. [ 7 ]  Dr. Matthew Fuller PharmD, BCPP, FASHP, CPNP Foundation President 2006–2007, has recognized Dr. Stimmel as the "Father of Psychiatric Pharmacy." [ 7 ] [ 8 ]  The specialty of psychiatric pharmacy was recognized by the  Board of Pharmacy Specialties  (BPS) in 1992. [ 1 ]


Psychiatric pharmacy is practiced by psychiatric (also called "neuropsychiatric")  pharmacists . Psychiatric pharmacists tend to have a board certification in the specialty of psychiatric pharmacy, granting the title of Board Certified Psychiatric Pharmacist (BCPP) by the  Board of Pharmacy Specialties  (BPS), and attach the post-nominals after their professional degrees. [ 9 ]  Because the BPS does not have a separate certification for neurologic pharmacists, neurologic pharmacists may be classified as BCPP's as well (indeed, there is a significant amount of overlap between the two subspecialties). It is not uncommon for psychiatric pharmacists to be residency trained through a specialized  residency  (post-graduate year 2, abbreviated "PGY2") program in psychiatric pharmacy. [ 10 ]  The BCPP program validates that the pharmacist being certified has the progressive knowledge and experience to improve outcomes and recovery for patients with mental or neurological disabilities by designing, implementing, monitoring, and modifying treatment plans for patients as needed. It also ensures that the pharmacist being certified will educate patients, health care professionals, and other stakeholders. [ 11 ]


Psychiatric pharmacists work in both the  inpatient  and  outpatient  settings.


Psychiatric pharmacists working for the  Veterans Health Administration  can have salaries between $112,268-145,955. [ 12 ]


Psychiatric pharmacy is practiced by specialist mental health pharmacists. Specialist mental health pharmacists tend to work in the  inpatient  setting, within mental health hospitals. [ 13 ]  Credentialing is performed through the  College of Mental Health Pharmacy  (CMHP), which assesses the experience and aptitude of pharmacists working in the field of mental health (psychiatric) pharmacy. Credentialed members are granted the title of Member of the College of Mental Health Pharmacy (MCMHP), and attach the post-nominals after their professional degrees. [ 14 ]  Notable psychiatric pharmacists include  Professor David Taylor , foundation president of the college of mental health pharmacy.


As experts in pharmacotherapy, psychiatric pharmacists are trained to assure that patients with mental illness are treated with the most appropriate medications for their conditions. They provide a variety of services aimed at making sure that patients are treated safely, that side effects are minimized (if not eliminated), and that pharmacologic treatments are efficacious at controlling or halting disease progression.


Psychiatric pharmacists provide a service called comprehensive medication management (CMM), which involves a thorough assessment of a patient's present and past medication history, laboratory work-up and exam findings, and treatment goals. During CMM, psychiatric pharmacists look for drug related problems (DRPs) related to their patients' pharmacotherapy and correct them in collaboration with  psychiatrists ,  social workers , and other members of the interdisciplinary healthcare team, collaborating closely with the patient and their family. [ 15 ] [ 16 ]


Psychiatric pharmacists provide  therapeutic drug monitoring , which involves ordering laboratory tests that will measure the concentration of a medication in the blood. This is especially useful in the area of psychiatric pharmacy because a lot of drugs used to treat psychiatric illnesses (for example,  lithium citrate  and  clozapine ) have a narrow  therapeutic window . There is a lot of potential for severe adverse reactions when using certain psychiatric medications, making therapeutic drug monitoring a useful tool for preventing harmful outcomes. The National Council for Behavioral Health, a collaborative that represents the interests of psychiatric professional organizations, offers recommendations for targeted, interdisciplinary interventions by psychiatric pharmacists, including pharmacist-lead  clozapine  clinics and providing long-acting injectable  antipsychotic  administration services. [ 17 ]


Psychiatric pharmacists are sometimes involved in  collaborative practice agreements  which physicians, which allows pharmacists to add or remove medications from a patient's drug regimen, change the strengths/dose or frequencies of medications, the duration of treatment, and the route of administration. [ 18 ]  Combined with therapeutic drug monitoring, this allows psychiatric pharmacists to directly make changes to a patient's drug regimen based on the results from laboratory tests.


Regenerative Medicine Advanced Therapy (RMAT)  is a designation given by the  Food and Drug Administration  to  drug candidates  intended to treat serious or life-threatening conditions under the  21st Century Cures Act . [ 1 ]  A RMAT designation allows for accelerated approval based surrogate or intermediate  endpoints . [ 2 ]


RMAT goes beyond  breakthrough therapy  features by allowing for accelerated  approval  of drugs based on  surrogate endpoints . A surrogate endpoint is a  biomarker  that substitutes for a direct endpoint, such as clinical benefit. [ 3 ]


Section 3033 of the  21st Century Cures Act  introduces section 506(g) of the  Federal Food, Drug, and Cosmetic Act (FD&C Act)  that allows for the designation of certain therapies as a 'regenerative medicine advanced therapy' (RMAT) ( 21 U.S.C.   § 356 ).


In order to qualify for RMAT status, a treatment must


A regenerative medicine therapy is defined in section 506(g)(8) of the  FD&C Act  to include  cell therapies ,  therapeutic tissue engineering , human cell and tissue products. Under the FDA's interpretation,  gene therapies  and genetically modified cells that have a lasting effect, such as  CAR-T  antitumor therapies, may also qualify as regenerative medicine therapies.


A RMAT designation includes all benefits of the  Fast Track  and  breakthrough therapy  designations. In addition, it opens up early interactions between the  FDA  and sponsors to facilitate accelerated approval. In this context, accelerated approval means approval based on


The ability to use 'Real World Evidence' (RWE), i.e. post-market evidence of safety and effectiveness, is particularly useful in the context of  orphan diseases , where recruiting a sufficiently large cohort for pre-marketing  clinical trials  may not be feasible. [ 5 ]  RWE may include data from patient registries, clinical records and case studies. [ 6 ]


Where a RMAT's sponsor fails to comply with the requirements for accelerated approval, the RMAT designation and the benefits conferred by it can be withdrawn ( 21 CFR   601.43 ).


Viralym-M [ 11 ]


(Roctavian,


Valrox)


(Lentiglobin) [ 15 ]


(Breyanzi)


(Ologo) [ 16 ]


Vertex Pharmaceuticals


Transfusion-dependent  beta thalassemia


Castle Creek Biosciences


St. Jude Children's Research Hospital


In 2020, the FDA received 34 requests for RMAT status, of which 12 (35.3%) were granted. RMAT designated drugs include the novel  CAR-T  therapy  Kymriah  and  betibeglogene autotemcel  for  beta thalassemia . [ 34 ]  As of 31 March 2021, 62 requests for RMAT status have been granted. [ 35 ]


More than half of the RMAT applications received by March 2019 involved  autologous  or  allogeneic   cell therapy  products, including  CAR-T  therapies. [ 6 ]


Resinous glaze  is an  alcohol -based solution of various types of food-grade  shellac . The shellac is derived from the raw material  sticklac , which is a resin scraped from the branches of trees left from when the small insect,  Kerria lacca  (also known as  Laccifer lacca ), creates a hard, waterproof cocoon. [ 1 ]   When used in food and  confections , it is also known as  confectioner's glaze ,  pure food glaze ,  natural glaze , [ 2 ] [ 3 ]  or  confectioner's resin . [ 4 ]  When used on medicines, it is sometimes called  pharmaceutical glaze . [ 5 ]


Pharmaceutical glaze may contain 20–51% shellac in solution in  ethyl alcohol  (grain alcohol) that has not been denatured ( denatured alcohol  is poisonous), [ 5 ]  waxes, and titanium dioxide as an opacifying agent. Confectioner’s glaze used for candy contains roughly 35% shellac, while the remaining components are  volatile organic compounds  that evaporate after the glaze is applied. [ 6 ]


Pharmaceutical glaze is used by the drug and  nutritional supplement  industry as a coating material for tablets and capsules. It serves to improve the product's appearance, extend  shelf life  and protect it from moisture, as well as provide a solid finishing film for pre-print coatings. It also serves to mask unpleasant odors and aid in the swallowing of the tablet. [ citation needed ]


The shellac coating is insoluble in stomach acid and may make the tablet difficult for the body to break down or assimilate. For this reason, it can also be used as an ingredient in time-released, sustained or delayed-action pills. The product is listed on the U.S.  Food and Drug Administration 's (FDA) inactive ingredient list. [ 7 ]


Shellac is labeled as GRAS ( generally recognized as safe ) by the US FDA and is used as glaze for several types of foods, including some fruit, coffee beans, chewing gum, and candy. Examples of candies containing shellac include  candy corn ,  Hershey's   Whoppers  and  Milk Duds ,  Nestlé 's  Raisinets  and  Goobers ,  Tootsie Roll Industries 's  Junior Mints  and  Sugar Babies ,  Jelly Belly 's  jelly beans  and Mint Cremes,  Russell Stover 's jelly beans, and several candies by  Godiva Chocolatier  and  Gertrude Hawk .  M&M's  do not contain shellac. [ 6 ]


A competing non-animal-based product is  zein , a corn protein. [ 8 ]  It is preferred by some vegans [ 1 ]  because shellac production can kill many insects. [ 6 ]


Self-medication , sometime called  do-it-yourself  ( DIY )  medicine,  is a  human behavior  in which an individual uses a substance or any exogenous influence to self-administer treatment for physical or psychological conditions, for example  headaches  or  fatigue .


The substances most widely used in self-medication are  over-the-counter  drugs and dietary supplements, which are used to treat common health issues at home. These do not require a  doctor's   prescription  to obtain and, in some countries, are available in supermarkets and convenience stores. [ 1 ]


The field of  psychology  surrounding the use of  psychoactive drugs  is often specifically in relation to the use of  recreational drugs ,  alcohol ,  comfort food , and other forms of behavior to alleviate symptoms of  mental distress ,  stress  and  anxiety , [ 2 ]  including  mental illnesses  or  psychological trauma . [ 3 ] [ 4 ]  Such treatment may cause serious detriment to  physical  and  mental health  if motivated by  addictive mechanisms . [ 5 ]  In postsecondary (university and college) students, self-medication with " study drugs " such as Adderall, Ritalin, and Concerta has been widely reported and discussed in literature. [ 5 ]


Products are marketed by manufacturers as useful for self-medication, sometimes on the basis of questionable evidence. Claims that  nicotine  has medicinal value have been used to  market cigarettes  as self-administered medicines. These claims have been criticized as inaccurate by independent researchers. [ 6 ] [ 7 ]  Unverified and unregulated third-party health claims are used to market dietary supplements. [ 8 ]


Self-medication is often seen as gaining personal independence from established medicine, [ 9 ]  and it can be seen as a  human right , implicit in, or closely related to the right to refuse professional medical treatment. [ 10 ]  Self-medication can cause unintentional self-harm. [ 11 ]  Self-medication with antibiotics has been identified as one of the primary reasons for the evolution of  antimicrobial resistance . [ 12 ]


Sometimes self-medication or DIY medicine occurs because patients disagree with a doctor's interpretation of their condition, [ 13 ]  to access experimental therapies that are not available to the public, [ 14 ] [ 15 ]  or because of legal bans on healthcare, as in the case of some transgender people [ 16 ]  or women seeking  self-induced abortion . [ 17 ]  Other reasons for relying on DIY medical care is to avoid  health care prices in the United States [ 18 ]  and  anarchist  beliefs. [ 19 ]


Generally speaking, self-medication is defined as "the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms". [ 20 ] [ 21 ]


Self-medication can be defined as the use of drugs to treat an illness or symptom when the user is not a medically qualified professional. The term is also used to include the use of drugs outside their license or off-label.


As different drugs have different effects, they may be used for different reasons. According to the self-medication hypothesis (SMH), the individuals' choice of a particular drug is not accidental or coincidental, but instead, a result of the individuals' psychological condition, as the drug of choice provides relief to the user specific to his or her condition. Specifically,  addiction  is hypothesized to function as a compensatory means to modulate effects and treat distressful psychological states, whereby individuals choose the drug that will most appropriately manage their specific type of psychiatric distress and help them achieve emotional stability. [ 22 ] [ 23 ]


The self-medication hypothesis (SMH) originated in papers by  Edward Khantzian , Mack and Schatzberg, [ 24 ]   David F. Duncan , [ 25 ]  and a response to Khantzian by Duncan. [ 26 ]  The SMH initially focused on  heroin  use, but a follow-up paper added  cocaine . [ 27 ]  The SMH was later expanded to include alcohol, [ 28 ]  and finally all drugs of addiction. [ 22 ] [ 29 ] [ 5 ]


According to Khantzian's view of addiction, drug users compensate for deficient ego function [ 24 ]  by using a drug as an "ego solvent", which acts on parts of the self that are cut off from consciousness by  defense mechanisms . [ 22 ]  According to Khantzian, [ 27 ]  drug dependent individuals generally experience more psychiatric distress than non-drug dependent individuals, and the development of drug dependence involves the gradual incorporation of the drug effects and the need to sustain these effects into the defensive structure-building activity of the ego itself. The addict's choice of drug is a result of the interaction between the psychopharmacologic properties of the drug and the affective states from which the addict was seeking relief. The drug's effects substitute for defective or non-existent ego mechanisms of defense. The addict's drug of choice, therefore, is not random.


While Khantzian takes a psychodynamic approach to self-medication, Duncan's model focuses on behavioral factors. Duncan described the nature of  positive reinforcement  (e.g., the "high feeling", approval from peers), negative reinforcement (e.g. reduction of negative affect) and avoidance of withdrawal symptoms, all of which are seen in those who develop problematic drug use, but are not all found in all recreational drug users. [ 25 ]  While earlier behavioral formulations of drug dependence using operant conditioning maintained that positive and negative reinforcement were necessary for drug dependence, Duncan maintained that drug dependence was not maintained by positive reinforcement, but rather by negative reinforcement. Duncan applied a public health model to drug dependence, where the agent (the drug of choice) infects the host (the drug user) through a vector (e.g., peers), while the environment supports the disease process, through stressors and lack of support. [ 25 ] [ 30 ]


Khantzian revisited the SMH, suggesting there is more evidence that psychiatric symptoms, rather than personality styles, lie at the heart of drug use disorders. [ 22 ]  Khantzian specified that the two crucial aspects of the SMH were that (1) drugs of abuse produce a relief from psychological suffering and (2) the individual's preference for a particular drug is based on its psychopharmacological properties. [ 22 ]  The individual's drug of choice is determined through experimentation, whereby the interaction of the main effects of the drug, the individual's inner psychological turmoil, and underlying personality traits identify the drug that produces the desired effects. [ 22 ]


Meanwhile, Duncan's work focuses on the difference between recreational and problematic drug use. [ 31 ]  Data obtained in the Epidemiologic Catchment Area Study demonstrated that only 20% of drug users ever experience an episode of drug abuse (Anthony & Helzer, 1991), while data obtained from the National Comorbidity Study demonstrated that only 15% of alcohol users and 15% of illicit drug users ever become dependent. [ 32 ]  A crucial determinant of whether a drug user develops drug abuse is the presence or absence of negative reinforcement, which is experienced by problematic users, but not by recreational users. [ 33 ]  According to Duncan, drug dependence is an avoidance behavior, where an individual finds a drug that produces a temporary escape from a problem, and taking the drug is reinforced as an operant behavior. [ 25 ]


Some people who have a  mental illness  attempt to correct their illnesses by using certain drugs.  Depression  is often self-medicated by the use of  alcohol ,  tobacco ,  cannabis , or other mind-altering drugs. [ 34 ]  While this may provide immediate relief of some symptoms such as  anxiety , it may evoke and/or exacerbate some symptoms of several kinds of mental illnesses that are already latently present, [ 35 ]  and may lead to addiction or physical dependency, among other side effects of long-term use of the drug. This does not differ significantly from the potential effects of drugs provided by physicians, which are equally capable of producing dependency and/or addiction and also have side effects arising from long-term use.


People with  post-traumatic stress disorder  have been known to self-medicate, as well as many individuals without this diagnosis who have experienced psychological trauma. [ 36 ]


Due to the different effects of the different classes of drugs, the SMH postulates that the appeal of a specific class of drugs differs from person to person. In fact, some drugs may be aversive for individuals for whom the effects could worsen affective deficits. [ 22 ]


Alcohol  and  sedative / hypnotic  drugs, such as  barbiturates  and  benzodiazepines , are  central nervous system  (CNS)  depressants  that lower inhibitions via  anxiolysis . Depressants produce feelings of relaxation and sedation, while relieving feelings of depression and anxiety. Though they are generally ineffective antidepressants, as most are short-acting, the rapid onset of alcohol and sedative/hypnotics softens rigid defenses and, in low to moderate doses, provides relief from depressive affect and anxiety. [ 22 ] [ 23 ]  As alcohol also lowers inhibitions, alcohol is also hypothesized to be used by those who normally constrain emotions by attenuating intense emotions in high or obliterating doses, which allows them to express feelings of affection, aggression and closeness. [ 23 ] [ 29 ]  Most patients that have been hospitalized for substance use or alcohol dependence reported using drugs in response to depressive symptoms. This type of misuse is more likely in men than in women. This makes diagnosing a psychiatric disorder very difficult in substance abusers, because of self medicating. [ 37 ]


People with  social anxiety disorder  commonly use alcohol to overcome their highly set inhibitions. [ 38 ]


Psychostimulants , such as  cocaine ,  amphetamines ,  methylphenidate ,  caffeine , and  nicotine , produce improvements in physical and mental functioning, including increased energy and alertness.  Stimulants tend to be most widely used by people with  attention deficit hyperactivity disorder  (ADHD), which can either be diagnosed or undiagnosed. Because a significant portion of people with ADHD have not been diagnosed they are more prone to using stimulants like  caffeine ,  nicotine  or  pseudoephedrine  to mitigate their symptoms.  Unawareness  concerning the effects of illicit substances such as  cocaine ,  methamphetamine  or  mephedrone   can result in self-medication with these drugs by individuals affected with ADHD symptoms. This self medication can effectively prevent them from  getting diagnosed  with ADHD and receiving treatment with stimulants like  methylphenidate  and  amphetamines .


Stimulants also can be beneficial for individuals who experience  depression , to reduce  anhedonia [ 23 ]  and increase  self-esteem , [ 28 ]  however in some cases depression may occur as a  comorbid condition  originating from the prolonged presence of negative symptoms of undiagnosed ADHD, which can impair  executive functions , resulting in lack of  motivation ,  focus  and contentment with one's life, so stimulants may be useful for treating  treatment-resistant depression , especially in individuals thought to have ADHD. The SMH also hypothesizes that hyperactive and  hypomanic  individuals use stimulants to maintain their restlessness and heighten euphoria. [ 23 ] [ 27 ] [ 28 ]  Additionally, stimulants are useful to individuals with  social anxiety  by helping individuals break through their inhibitions. [ 23 ]  Some reviews suggest that students use psychostimulants to self medicate for underlying conditions, such as ADHD, depression or anxiety. [ 5 ]


Opiates , such as  heroin  and  morphine , function as an  analgesic  by binding to  opioid receptors  in the brain and  gastrointestinal tract . This binding reduces the perception of and reaction to  pain , while also increasing  pain tolerance . Opiates are hypothesized to be used as self-medication for  aggression  and  rage . [ 27 ] [ 29 ]  Opiates are effective  anxiolytics ,  mood stabilizers , and anti-depressants, however, people tend to self-medicate anxiety and depression with depressants and stimulants respectively, though this is by no means an absolute analysis. [ 23 ] [ 39 ] [ 40 ]


Modern research into novel antidepressants targeting opioid receptors suggests that endogenous opioid dysregulation may play a role in medical conditions including  anxiety disorders ,  clinical depression , and  borderline personality disorder . [ 41 ] [ 42 ] [ 43 ]  BPD is typically characterized by sensitivity to rejection, isolation, and perceived failure, all of which are forms of  psychological pain . [ 44 ]  As research suggests that psychological pain and physiological pain both share the same underlying mechanism, it is likely that under the self-medication hypothesis some or most recreational opioid users are attempting to alleviate psychological pain with opioids in the same way opioids are used to treat physiological pain. [ 45 ] [ 46 ] [ 47 ] [ 48 ]


Cannabis  is  paradoxical  in that it simultaneously produces stimulating, sedating and mildly psychedelic properties and both  anxiolytic  or  anxiogenic  properties, depending on the individual and  circumstances of use . Depressant properties are more obvious in occasional users, and stimulating properties are more common in chronic users. Khantzian noted that research had not sufficiently addressed a theoretical mechanism for cannabis, and therefore did not include it in the SMH. [ 23 ]


Self-medicating excessively for prolonged periods of time with  benzodiazepines  or  alcohol  often makes the symptoms of anxiety or depression worse. This is believed to occur as a result of the changes in brain chemistry from long-term use. [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ]  Of those who seek help from mental health services for conditions including  anxiety disorders  such as  panic disorder  or  social phobia , approximately half have  alcohol  or  benzodiazepine dependence  issues. [ 54 ]


Sometimes anxiety precedes alcohol or benzodiazepine dependence but the alcohol or benzodiazepine dependence acts to keep the anxiety disorders going, often progressively making them worse. However, some people addicted to alcohol or benzodiazepines, when it is explained to them that they have a choice between ongoing poor mental health or quitting and recovering from their symptoms, decide on quitting alcohol or benzodiazepines or both. It has been noted that every individual has an individual sensitivity level to alcohol or sedative hypnotic drugs, and what one person can tolerate without ill health, may cause another to experience very ill health, and even moderate drinking can cause rebound anxiety syndrome and sleep disorders. A person experiencing the toxic effects of alcohol will not benefit from other therapies or medications, as these do not address the root cause of the symptoms. [ 54 ]


Nicotine addiction seems to worsen mental health problems. Nicotine withdrawal depresses mood, increases anxiety and stress, and disrupts sleep. Although nicotine products temporarily relieve their  nicotine withdrawal  symptoms, an addiction causes stress and mood to be worse on average, due to mild withdrawal symptoms between hits. Nicotine addicts need the nicotine to temporarily feel normal. [ 7 ] [ 55 ]   Nicotine industry marketing  has claimed that nicotine is both less harmful and therapeutic for people with mental illness, and is a form of self-medication. This claim has been criticised by independent researchers. [ 6 ]


Self medicating is a very common precursor to full addictions and the habitual use of any addictive drug has been demonstrated to greatly increase the risk of addiction to additional substances due to long-term neuronal changes. [ citation needed ]  Addiction to any/every  drug of abuse  tested so far has been correlated with an enduring reduction in the expression of GLT1 ( EAAT2 ) in the  nucleus accumbens  and is implicated in the drug-seeking behavior expressed nearly universally across all documented addiction syndromes. This long-term dysregulation of glutamate transmission is associated with an increase in vulnerability to both relapse-events after re-exposure to drug-use triggers as well as an overall increase in the likelihood of developing addiction to other reinforcing drugs. Drugs which help to re-stabilize the glutamate system such as  N-acetylcysteine  have been proposed for the treatment of addiction to  cocaine ,  nicotine , and alcohol. [ 56 ]


In 89% of countries, antibiotics can be prescribed only by a doctor and supplied only by a pharmacy. [ 57 ]  Self-medication with antibiotics is defined as "the taking of medicines on one's own initiative or on another person's suggestion, who is not a certified medical professional". It has been identified as one of the primary reasons for the evolution of  antimicrobial resistance . [ 12 ]


Self-medication with antibiotics is an unsuitable way of using them but a common practice in  developing countries . [ 58 ]  Many people resort to that out of necessity when access to a physician is unavailable because of lockdowns and GP surgery closures, or when the patients have a limited amount of time or money to see a prescribing doctor.  [ 59 ]  While being cited as an important alternative to a formal  healthcare system  where it may be lacking, self-medication can pose a risk to both the patient and community as a whole. The reasons behind self-medication are unique to each region and can relate to health system, societal, economic, health factors, gender, and age. Risks include allergies, lack of cure, and even death. [ 60 ]


Besides developing countries, self-medication with  antibiotics  is also a problem for higher-income countries. In the European Union the average prevalence was 7% in 2016 with the highest rates in southern countries. There are high rates of self-medication with antibiotics in Russia (83%), Central America (19%) and Latin America (14-26%) too. [ 61 ]


Two significant issues with self-medication are the lack of knowledge of the public on, firstly, the dangerous effects of certain antimicrobials (for example,  ciprofloxacin , which can cause  tendonitis ,  tendon rupture  and  aortic dissection ) [ 62 ] [ 63 ]  and, secondly, broad microbial resistance and when to seek medical care if the infection is not clearing. [ 64 ]


Also inappropriate use of over-the-counter  ibuprofen  or other  nonsteroidal anti-inflammatory drugs  during  winter   influenza   outbreaks  can lead to  death , e.g. due to  haemorrhagic   duodenitis  induced by ibuprofen, or the consequences of exceeding the recommended doses of paracetamol by combining doses of the generic product with proprietary flu-remedies and Tylex (paracetamol and  codeine ). [ 65 ]


In a questionnaire designed to evaluate self-medication rates amongst the population of  Khartoum ,  Sudan , 48.1% of respondents reported self-medicating with antibiotics within the past 30 days, whereas 43.4% reported self-medicating with  antimalarials , and 17.5% reported self-medicating with both. Overall, the total prevalence of reported self-medication with one or both classes of anti-infective agents within the past month was 73.9%. [ 21 ]  Furthermore, according to the associated study, data indicated that self-medication "varies significantly with a number of socio-economic characteristics" and the "main reason that was indicated for the self-medication was financial constraints". [ 21 ]


Similarly, in a survey of university students in  southern China , 47.8% of respondents reported self-medicating with antibiotics. [ 66 ]


One area of DIY medicine is self-administered pharmaceutical drugs that are obtained without a prescription, as in the case of  DIY transgender hormone therapy  which is common among trans people. [ 67 ]  Prescription-only  lifestyle drugs  such as those to treat  erectile dysfunction ,  male pattern baldness , and obesity are often purchased online by people who have no diagnosis or prescription. [ 68 ] [ 69 ]  In 2017, the United Kingdom legalized the sale of  sildenafil  (Viagra) over the counter in part to cut down on the number of men buying it online from unlicensed pharmacies. [ 70 ]


Self-managed abortion  with medication is safe and effective, but is illegal in some jurisdictions. [ 71 ] [ 72 ]  Before the current medication had been developed and in places where abortion is illegal, people may resort to unsafe methods of self-managed abortion. [ 73 ] [ 74 ]


Another area is the creation of  medical devices , such as  PPE  for protection against  COVID-19 [ 75 ]  and  epinephrine  injectors. [ 76 ]  Some people with insulin-dependent diabetes have created their own  automated insulin delivery systems . [ 77 ] [ 78 ]  One review found that "the quality of glucose control achieved with DIY AID systems is impressively good". [ 79 ]  With DIY brain stimulation, individuals with depression create their own devices to access an  experimental treatment . [ 80 ] [ 81 ]  Other people self-administer  fecal transplant  as a treatment for various diseases. [ 82 ]


In a survey of  West Bengal ,  India   undergraduate   medical school  students, 57% reported self-medicating. The type of drugs most frequently used for self-medication were antibiotics (31%),  analgesics  (23%),  antipyretics  (18%), antiulcerics (9%),  cough suppressants  (8%),  multivitamins  (6%), and  anthelmintics  (4%). [ 83 ]


Another study indicated that 53% of physicians in  Karnataka ,  India  reported self-administration of antibiotics. [ 84 ]


A study of  Luo  children in western Kenya found that 19% reported engaging in self-treatment with either  herbal  or  pharmaceutical  medicine. Proportionally, boys were much more likely to self-medicate using conventional medicine than herbal medicine as compared with girls, a phenomenon which was theorized to be influenced by their relative earning potential. [ 85 ]


Self-medication is highly regulated in much of the world and many  classes of drugs  are available for administration only upon  prescription  by licensed medical personnel.  Safety ,  social order ,  commercialization , and  religion  have historically been among the prevailing factors that lead to such  prohibition .


People trying to buy pharmaceutical drugs online without a prescription may be the victim of  fraud ,  phishing , or receive counterfeit medication. [ 86 ]  Selling prescription drugs to people without a valid prescription is illegal in many jurisdictions and can be considered an example of  transnational organized crime . [ 87 ]  In a 2021 article, Jack E. Fincham argues that unlicensed sales of prescription drugs online are a significant public health threat. It is also possible to obtain  controlled substances  such as  amphetamine ,  benzodiazepines , and  Z-drugs  online without a prescription. [ 88 ]


Separation of prescribing and dispensing , also called  dispensing separation , is a practice in  medicine  and  pharmacy  in which the  physician  who provides a  medical prescription  is independent from the   pharmacist  who provides the  prescription drug .


In the  Western world  there are centuries of tradition for separating pharmacists from physicians. In Asian countries it is traditional for physicians to also provide drugs.


Contemporary research indicates that separation of prescribing and dispensing lowers expenditure on drugs, [ 1 ] [ 2 ]  which is explained by the fact physician-prescribing gives doctors an incentive to over-prescribe. This is an example of a  conflict of interest in the healthcare industry  leading to  unnecessary health care .


In many Western jurisdictions such as the  United States ,  pharmacists  are regulated separately from  physicians .  These jurisdictions also usually specify that  only  pharmacists may supply scheduled  pharmaceuticals  to the public, and that pharmacists cannot form business  partnerships  with physicians or give them "kickback" payments.  In other words, the diagnosing physicians' role is supposed to extend only as far as providing proper prescriptions to patients, who are then entitled to purchase the prescribed drugs at the pharmacies of their choice. [ 3 ]


However, the  American Medical Association  (AMA) Code of Ethics provides that physicians may dispense drugs within their office practices as long as there is no patient exploitation and patients have the right to a written prescription that can be filled elsewhere. [ 4 ]  7 to 10 percent of American physicians practices reportedly dispense drugs on their own. [ 5 ]


In some rural areas in the United Kingdom, there are dispensing physicians [ 6 ]  who are allowed to both prescribe and dispense prescription-only medicines to their patients from within their practices. The law requires that the GP practice be located in a designated rural area and that there is also a specified, minimum distance (currently 1 mile; 1.6 kilometres) between a patient's home and the nearest retail pharmacy. See  Dispensing Doctors' Association .


This law also exists in  Austria  for general physicians if the nearest pharmacy is more than 4 kilometers ( 2 + 1 ⁄ 2  miles) away, or where none is registered in the city.  Switzerland  also allows dispensing physicians in several Kantons. [ 7 ]


In other  jurisdictions  (particularly in  Asian  countries such as  China ,   Malaysia , and  Singapore ),  doctors  are allowed to dispense  drugs  themselves and the practice of pharmacy is sometimes integrated with that of the  physician , particularly in traditional  Chinese medicine .


In Canada it is common for a medical clinic and a pharmacy to be located together and for the ownership in both enterprises to be common, but licensed separately.


The reason for the majority rule is the high risk of a conflict of interest and/or the avoidance of absolute powers. Otherwise, the physician has a financial self-interest in "diagnosing" as many conditions as possible, and in exaggerating their seriousness, because he or she can then sell more medications to the patient. Such self-interest directly conflicts with the patient's interest in obtaining cost-effective medication and avoiding the unnecessary use of medication that may have  side-effects .  This system reflects much similarity to the checks and balances system of the U.S. and many other governments. [ citation needed ]


A campaign for separation has begun in many countries and has already been successful (as in  Korea ). As many of the remaining nations move towards separation, resistance and lobbying from dispensing doctors who have pecuniary interests may prove a major stumbling block (e.g. in  Malaysia ). [ citation needed ]


In many Asian countries there is not a traditional separation between physician and pharmacist. [ 8 ]  In  Taiwan , a plan initiated in March 1997 experimented with separating doctors who prescribe from pharmacists who fulfill prescriptions on the theory that this would reduce  unnecessary health care . [ 8 ]  The plan had mixed results. [ 8 ]  The  South Korean  government passed a law in 2000 which separated drug prescribing from dispensing. [ 9 ]  The passing of the law achieved some of its intentions and also caused problems in unexpected ways. [ 9 ]   Japan  also is experimenting with separation of prescribing and dispensing. In  Malaysia , as of 2016 [update] , separation of prescribing and dispensing only occurs in government hospitals. [ 10 ]


Trap, B (1997).  "Practices of dispensing doctors - drug use and health economics" .  archives.who.int . World Health Organization . Retrieved  14 February  2017 . [ dead link  ]


A  show globe  is a glass vessel of various shapes and sizes containing a colorful liquid. [ 1 ]  It has been a symbol of  pharmacy  from the 17th century  England  to the early 20th century in the  United States . It marked the drugstore or  apothecary  in much the same way as the  barber's pole  marked tonsorial establishments in some countries. People who were  illiterate  needed such symbols to locate these medical practitioners.


Show globes were displayed almost exclusively in English-speaking countries, contrasting with the wider use of the  mortar and pestle  as a pharmaceutical symbol.


The most dramatic story of their origin goes back to the time of  Julius Caesar  100–44 BC. When the  Romans  invaded  England , according to this report, Caesar's forces found an ideal landing site opposite a pharmacy window which displayed large containers of colored liquids.  Julius Caesar 's forces guaranteed the pharmacist that he would be safe from the invading forces as long as he kept lighted lanterns in his windows which would serve as a beacon for the landing forces. As a token of his appreciation, Caesar "decreed that henceforth all apothecaries would be permitted to exhibit containers of colored liquids in their windows as a symbol of their calling." [ 2 ]


The main problem with this theory is that this would have occurred at least twelve centuries before there was any recognizable profession of pharmacy. [ 2 ]   This story was reported in  The Pharmaceutical Journal  (the journal of the Royal Pharmaceutical Society of Great Britain) in 1931. As the columnist wrote, "Surely further research is needed." [ 3 ]


Another theory says that show globes had their origins in the  Middle East  during the period of  Islamic  domination. Shops were outdoors and pharmacists may have placed their material in elaborate jars or containers which could be the forerunners of show globes. Travelers from  Western Europe  admired these urns and took the idea back home.  There are two reasons why this is probably false; there is no evidence that show globes were popular as a symbol in the Middle East, and instead of show globes appearing throughout Europe they are almost exclusively  Anglo-American .


Another hypothesis says that show globes may have been  maceration  vessels, which were used to steep organic material in sunlight. The trouble with this explanation is that "England is not famous for its sunny days." [ 4 ]


Another theory makes the show globe a kind of  first aid  beacon. Apothecary shops in coastal regions filled vessels with red and green liquids to show sailors where to obtain medical attention.


Apothecaries in England had been competing with physicians since an act passed in 1542 permitted them to practice medicine along with anyone else. [ 5 ]  According to another theory which puts pharmacists in a good light, during the  Great Plague of London  (1665–66), while many physicians were fleeing the city, apothecaries placed containers of colored liquids in their windows "to assure the threatened citizenry that they were still there ready to provide needed help." [ 2 ]   Apothecaries may have seen this as a chance to expand their medical activities, as well as acting altruistically.


George Griffenhagen , pharmacist and acting curator of the  Smithsonian Institution , did extensive research into the evolution of the show globe and laid to rest many of the more unusual stories about its origin. [ 6 ]   He thought that the show globe appeared when the apothecaries and  alchemists  merged their professions during the mid 16th to mid 17th century. In England in the mid 1550s, just as  physicians  competed against apothecaries, the apothecaries, who delivered  surgical services  along with compounding and dispensing  herbal medicines , competed with chemists and druggists. Druggists bought drugs in bulk and sold them as merchants (not as medical practitioners like the apothecaries); while chemists, who were derived from alchemists, prepared and sold chemical preparations used for medicinal purposes, like  mercurials . [ 7 ]
To attract attention to themselves and to symbolize the mystery and art of their profession these chemists displayed show globes with solutions of colored chemicals. Apothecaries and physicians were usually considered more conservative in their practice before the 18th century and often restricted themselves to non-chemical drugs using material of largely botanical origins. Most historians today feel the show globe began as a symbol of the  chemist 's shop. Eventually the apothecaries began to use chemical remedies, and also adopted the globe as their symbol.


For a largely illiterate public the show globe was a welcoming symbol.  Charles Dickens  once declared they were the only "bright and cheery spot in a London street on a dark and wet night." [ 8 ]


According to Charles Richardson, a collector of pharmaceutical artifacts, two apothecaries arrived in  Jamestown, Virginia  (1607) shortly after it was founded, and the colonists asked the  Virginia Company  to send more physicians and apothecaries to the colony. [ 5 ]   In the early American settlements there was a shortage of health professionals; public officials, religious leaders, educators and household heads served as health advisors. Herbs and Indian remedies were used and apothecary shops were set up in large population centers. During the Revolutionary War medicine and pharmacy emerged as separate professions, and the first American Pharmacopoeia was printed in 1778. [ 9 ]   By the 19th century, pharmacists had stopped practicing medicine and even the name apothecary faded away. Pharmacies developed the warmth and comfort of country stores and were displaying show globes, which by 1789 were being exported to America. [ 10 ]   According to one writer, the only way pharmacies distinguished themselves from other stores was this unique sign. " Bakeries  and  hardware stores  did not differ greatly from pharmacies in their façades." [ 11 ]   It was in the United States 19th century that the show globes started to develop their elaborate design and diverse forms. Although the show globe became a pharmacy symbol of mainly English-speaking countries, it did appear in a few other countries notably France. [ 12 ]


Next to their origins, the greatest debate about show globes is what, if anything, the colors of the liquids symbolized.  Red and blue may have indicated  arterial  and  venous blood . One belief was that if the globe was filled with red liquid there was a plague in town, but if it was filled with green all was well. Pharmacists could create vibrant colors with chemicals in their shops, often following a recipe book. [ 4 ]


Most globes were plain glass, but sometimes they were punty cut or etched glass. Some had multiple stoppers, each stopper smaller than the one below, tapering to a small finial at the top. They could be freestanding or wall-mounted. If they were freestanding, they hung from a brass chain; the most elaborate had multiple tiers, each chamber containing a different color of water. It was not so much the pharmacists who were responsible for the evolution of show globes to works of arts, but American glass manufacturers. Pharmaceutical catalogs during the 1870s advertised numerous styles of show globes with each glass manufacturer developing his own design. A U.S. patent was granted in 1869 to Henry Whitney of  Cambridge, Massachusetts , for a show globe with a colored glass body with a neck and base of transparent uncolored glass. The purpose of this design was to eliminate the need to use colored liquids, which could leave a residue inside the bottle. [ 13 ]
Though oil could be used to illuminate the colored glass panes in windows, gas lighting in the early 19th century led to the general use of show globes. They could be lit from the interior or placed in front of a gas jet.  In the United States, globes were usually illuminated by a light placed behind them.


Despite many attempts to revive show globes, they have disappeared from American pharmacies. By the early 20th century, new stores shunned them, and they were disappearing from many older pharmacies.  Renewed support for the globes in the 1930s moved the  Owens-Illinois Glass Company  to introduce a new style with an electric bulb inside to illuminate the globe. [ 4 ]   However, a 1935 American news article notes "rarely is a show globe ever seen in a modern druggist's emporium". [ 14 ]   Through the 1950s,  American Druggist  urged pharmacists to bring back the show globe, terming it "the greatest trademark ever invented."


Tablet hardness testing  is a  laboratory technique  used by the  pharmaceutical  industry to determine the breaking point and structural integrity of a  tablet  and find out how it changes "under conditions of storage, transportation, packaging and handling before usage" [ 1 ]
The breaking point of a tablet is based on its shape. [ 2 ]  It is similar to  friability  testing, [ 1 ]  but they are not the same thing.


Tablet hardness testers first appeared in the 1930s. [ 3 ]  In the 1950s, the Strong-Cobb tester was introduced. It was patented by Robert Albrecht on July 21, 1953. [ 4 ]  and used an air pump. The tablet breaking force was based on arbitrary units referred to as Strong-Cobbs. [ 3 ]  The new one gave readings that were inconsistent to those given by the older testers. [ 3 ]  Later, electro-mechanical testing machines were introduced. They often include mechanisms like motor drives, and the ability to send measurements to a computer or printer. [ 3 ]


There are 2 main processes to test tablet hardness: compression testing and 3 point bend testing. For compression testing, the analyst generally aligns the tablet in a repeatable way, [ 2 ]  and the tablet is squeezed between a fixed and a moving jaw. The first machines continually applied force with a spring and screw thread until the tablet started to break. [ 3 ]  When the tablet fractured, the hardness was read with a sliding scale. [ 3 ]


There are several devices used to perform this task:


According to the  International System of Units , the  units of measurement  of tablet hardness mostly follow standards used in materials testing.


Tall man lettering  ( tall-man lettering  or  tallman lettering ) is the practice of writing part of a  drug 's name in  upper case  letters to help distinguish sound-alike, look-alike drugs from one another in order to avoid medication errors. [ 1 ] [ 2 ]   For example, in tall man lettering, " prednisone " and " prednisolone " should be written "predniSONE" and "predniSOLONE", respectively. The Office of Generic Drugs of the US  Food and Drug Administration  (FDA) encourages  manufacturers  to use tall man lettering labels to visually differentiate their drugs' names, [ 1 ]  and a number of hospitals, clinics, and health care systems use tall man lettering in their computerized order entry, automated dispensing machines, medication admission records, prescription labels, and drug product labels. [ 3 ]


Wrong-drug errors have been found to occur at a rate of about one per thousand orders filled or dispensed. [ 4 ]   Evidence regarding the effect of Tall Man lettering on error rates is mixed.


A 2004  eye-tracking  study found that Tall Man lettering resulted in fewer errors when selecting a target drug from an array of choices. [ 5 ]   Other laboratory-based studies of Tall Man lettering show a mixture of positive and  null results , which may be further complicated due to  demand characteristics  of some of the studies. [ 4 ]


A 2016  time-series analysis  of data from 42 children's hospitals over a 9-year period found no significant difference before and after a 2007 recommendation for hospitals to adopt Tall Man lettering. [ 6 ]   However, this study has been criticized due to methodological limitations, such as not recording when and how Tall Man lettering was adopted, if at all, at each of the hospitals studied. [ 4 ]


The FDA published a list [ 7 ] : Table 1   of recommended Tall-Man Letters for look-alike drugs which includes, but is not limited to:


The  Institute for Safe Medication Practices  (ISMP) has a supplemental list covering pairs not recommended by the FDA, but considered necessary by the ISMP. [ 7 ] : Table 2   ISMP Canada also offers additional recommendations. [ 8 ]


Telepharmacy  is the delivery of  pharmaceutical care  via  telecommunications  to patients in locations where they may not have direct contact with a  pharmacist . It is an instance of the wider phenomenon of  telemedicine , as implemented in the field of  pharmacy . Telepharmacy services include  drug therapy  monitoring, patient counseling, prior authorization and refill authorization for  prescription drugs , and monitoring of  formulary  compliance with the aid of  teleconferencing  or  videoconferencing .  Remote dispensing  of medications by automated packaging and labeling systems can also be thought of as an instance of telepharmacy. Telepharmacy services can be delivered at retail pharmacy sites or through hospitals, nursing homes, or other medical care facilities.


The term can also refer to the use of videoconferencing in pharmacy for other purposes, such as providing education, training, and management services to pharmacists and pharmacy staff remotely. [ 1 ]


A primary appeal of telepharmacy is its potential to expand access to pharmacy care in smaller rural communities, some of which cannot support a full-time pharmacist or cannot easily recruit a pharmacist to reside in their region. Telepharmacy can potentially give patients in remote locations access to professional pharmacy care that could not be received locally, which can lower costs and improve patient safety through better patient counseling, drug administration monitoring, [ 2 ]  and compliance monitoring. Sharing of pharmacists between sites can also decrease costs in existing facilities, which might no longer need to employ a full-time pharmacist.


The potential costs of telepharmacy are broadly the same as those associated with all forms of  telemedicine : potentially decreased human interaction between medical professionals and patients, an increased risk of error when medical services are delivered in the absence of a registered professional, [ 3 ]  and an increased risk that  protected health information  may be compromised through electronic information storage and transmission. [ 4 ] [ 5 ]


One concern is whether medication adherence is affected by the use of telepharmacy. One retrospective cohort study that examined the dispensing records of a low-income Chicago neighborhood showed that medication adherence was lower among users of telepharmacy than users of a traditional pharmacy in some but not all drug classes examined. [ 6 ]  More research is needed to see whether the usage of telepharmacies coupled with other interventions could improve medication adherence.


The implementation of telepharmacy varies by region and jurisdiction. Factors including geography, laws and regulations, and economics influence its implementation.


A form of telepharmacy has been in use by  Australia 's  Royal Flying Doctor Service  since 1942. Medical chests containing medications and equipment are placed in remote communities where they can be administered to patients during a  telehealth  consultation. Some 3,500 chests were distributed around Australia as of 2006. In one year,  Queensland  recorded 21,470 telehealth consultations, of which 13.7% resulted in administration of a medication from a medical chest. The medication types administered most often are  antibiotics ,  analgesics  and  gastrointestinal medications . This system improves access to both emergency and routine medical care in remote parts of Australia and reduces the need for patients to travel to seek medical care. [ 7 ]


Another application of telepharmacy in Queensland has been the provision of pharmaceutical reviews in rural hospitals that lack on-staff pharmacists. [ 8 ]  Although broader use of telepharmacy could help alleviate a shortage of pharmacists, Australia has lagged the United States in its implementation of telepharmacy, partly because doctors, nurses, and other health care workers provide pharmacy services in rural and remote areas where there are no pharmacists. [ 9 ]