Inappropriate medicines and prescribing – why it matters

Payne RA (2011). Prescribing safety: the case of inappropriate medicines. The British journal of general practice : the journal of the Royal College of General Practitioners, 61 (590), 542-3 PMID: 22152727 Access this article

Medications are the major therapeutic intervention offered by clinicians in the NHS. Pharmacological usage is increasing year on year, by around two-thirds over the past decade in primary care. One billion prescription items were issued in the general practice setting in England alone last year, and the NHS spends roughly 20% of its entire budget on drugs. But are all these pills really necessary? And if not, what about the potential for harm? This is an issue I wrote about in an editorial in the British Journal of General Practice back in 2011, in response to a series of articles loosely tied together by the topic of prescribing safety. The issue is not one that is going to go away any time soon.

High medication use is driven by evidence-based clinical guidelines, coupled to our ageing, increasingly multi-morbid population. Fair enough – there is a wealth of high quality research out there supporting the use of many medicines. Yet, unfortunately, the use of drug treatments is too often not backed up with robust science. Evidence is often built around single diseases, and the artificial environment of the well-conducted clinical trial is often far removed from the real world of general practice. RCTs rarely include older, frailer patients, and do not reflect the complex clinical scenarios so common in modern medicine. Patient expectations may influence clinicians’ prescribing behaviour, not always in a favourable way. The more cynical might also point to disease mongering by the pharmaceutical industry and others, driving the use of unnecessary drug therapy through over-medicalization. And the downright pessimists among us might blame straightforward poor doctoring – a prescription is arguably a simple and quick way of getting a patient out of the consulting room, regardless of whether it is fully justified.

But unnecessary and inappropriate pills breed potential harms. Adverse drug reactions and medication interactions. Poor medication adherence. Increased burden of treatment adversely impacting upon quality of life. Public health implications, such as microbial antibiotic resistance. Unfortunately, these problems are hard to quantify – traditional tools such as STOPP and Beers are far from ideal – and this is compounded by under-reporting of medication safety issues in primary care. Addressing this is an important priority for researchers.

And what do we do about it? Targeted interventions, aimed at specific prescribing areas, may have a role, but I suspect more general approaches will have the greatest benefit. Education around clinical pharmacology and therapeutics should be improved, communication strategies enhanced to better enable clinicians to meet patient’s expectations, and doctors need to be empowered to stop medications as well as start them. Such approaches need to be underpinned by good-quality research. Moreover, they need supported by a cultural shift in prescribing practice. We need to move away from being overly reliant on protocol-driven medicine, and move towards taking a more holistic approach to prescribing, considering first-and-foremost not the guidelines but the patient.

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