03 Jun Problematic Prescribing
A recent report conducted by Public Health England found that 1 in 4 people in England are taking addictive prescription medicine such as antidepressants, sleeping pills and opioid pain killers. People living in deprived areas are also more likely to be taking medicines for longer and taking more than 1 of these drugs.
Over recent years, long-term opioid prescribing for patients with chronic pain has increased in the UK despite incompatibility with best practice and the UK now has one of the world’s fastest-growing rates of opioid use. Many patients are unlikely to be benefiting from long term opioid use and are instead being exposed to significant harm.
Benzodiazepines and z drugs (zopiclone, zolpidem) are also commonly being prescribed long term, despite only being licensed for short term use. Gabapentinoids (gabapentin, pregabalin), which are widely prescribed for a range of conditions including pain, have recently been linked to new risks including increased suicidal behaviour and unintentional overdoses.
Unfortunately, the over-prescribing of addictive medicines in the UK is just the tip of the iceberg and reflects a much wider problem of polypharmacy (the use of multiple medications), which has become now become the norm rather than the exception, particularly in elderly patients. Data from 2016 shows that one third of over 75s in the England now take at least six medicines and the NHS spends £16.8 billion a year on medicines. A person taking ten or more medications is 300% more likely to be admitted to hospital and 6.5% of hospital admissions are for adverse effects of medicines. This rises to 17% in the over 65 age group. There continues to be poor public awareness of the harm caused from medications and the impact on health services from problematic polypharmacy.
Why are so many unnecessary scripts being issued?
The underlying causes of inappropriate prescribing and polypharmacy appear to be complex and multifactorial. There are, however, a number of possible contributing factors to consider:
Time constraints. 10 mins has become the widely accepted time for a GP consultation appointment in the UK. It is worth remembering that this includes time for the patient to walk from the waiting room, history taking, examination and a possible referral letter. Generally, no time is factored in for medication reviews, which are often opportunistic additions to a 10-minute consultation. To make matters more challenging, patients may present with multiple problems to their GP as they have often waited weeks to be seen.
Phone appointments on average are 5 minutes and may be booked for medication reviews. Studies have identified that shorter consultation lengths are likely to adversely affect patient healthcare, contribute to polypharmacy and also lead to additional physician workload and stress. An ageing population with co-existing multiple health conditions is clearly an important factor for driving polypharmacy.
A disease-specific approach to prescribing has led to disease-specific clinics with many clinicians working to checklists based on national guidelines. Long waiting times for patients to see specialists, which is particularly the case for specialist pain clinics. Whilst waiting, patients will often check back in with their GP as symptoms remain poorly controlled. As non-pharmacological methods and medications fail to bring adequate relief and patients experience a deterioration in quality of life, GPs are often left with little option but to prescribe. It is worth noting that mismanaged conditions often perpetuate new problems, risking a downward spiral for patients. Poorly controlled pain for example may lead to disrupted sleep, low mood and a lack of ability to work, potentially leading to financial stress and impact on family dynamics and wider relationships. The unintended consequence of this may be a prescribing cascade where more and medications are added on, often with little evidence of efficacy with no improvement on function and quality of life. By intervening early and managing initial symptoms properly this can prevent further downstream problems and improve patient outcomes.
Over-medicalisation of patient care. Over the years medical practice has evolved from doctors responding to patient’s symptoms, to a more pro-active assessment of population risk with the issuing of preventative treatments, sometimes for people with no symptoms at all. There may additionally be a desire for individual doctors to eliminate risk which is reflected in prescribing habits. Clinical guidelines have traditionally been developed around single conditions and may not consider patients who are already taking medicines for other ailments. It is also worth considering that doctors at times may medicalise and label problems, which when explored to a deeper level may have roots in an underlying social problem. Managing patient’s expectations. Many people (wrongly or rightly) still believe that medication is the most effective and quickest way to solve a problem. Over recent years the patient has been encouraged to be a consumer and encouraged to move around between doctors, expressing choice and may pressure GPs to prescribe particular medication.A culture in the NHS of any “anything is better than nothing”. A lack of safe and effective alternative treatment options often leaves both patients and doctors stranded with little option but to turn to medication.
Medication reviews and deprescribing
Funding for dedicated teams of doctors and pharmacists to undertake medication reviews in the community should be seen as a matter of priority if we are to tackle problematic prescribing. There are already a number of excellent resources and clinical tools in existence for clinicians to utilise which actively involve the participation of patients. The widely accepted 10-minute GP appointment no longer seems appropriate for anything but minor ailments and could be seen as counterproductive in terms of long-term healthcare and patient outcomes.
There is a growing body of evidence demonstrating the therapeutic effects of non-pharmacological interventions for a wide number of conditions. For example, talking therapies have been shown to work more or less equally well for the initial treatment of people with moderate to severe depression and as effective as antidepressants. CBT has been shown to be an effective non-pharmacological treatment for insomnia and demonstrates comparable efficacy and long-term benefits when compared to sleep medications (z-drugs). Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices have been shown to improve function and pain for specific chronic pain conditions such as fibromyalgia and chronic back pain and Mindfulness has been demonstrated to show some improvements in well-being within the workplace.
Western medicine and medical schools have traditionally taught doctors to think in terms of body systems and specific diseases. In reality, however, humans are complex with subtle biopsychosocial elements playing their part, meaning that many diseases do not fall into neat categories but overlap with one another. This is particularly the case for complex conditions such as fibromyalgia, CFS, IBS and migraines which all have a strong psychosomatic component.
A more holistic approach to clinical practice which considers the person as a whole rather than focusing on specific systems and treatment pathways could improve both prescribing habits of doctors and improve patient outcomes. A useful starting point could be to develop clinical tools for doctors to use in partnership with patients exploring what they want to achieve as their target goal/ end point and providing the necessary tools to make realistic steps.
Technology may also have its part to play in improving prescribing habits and reducing polypharmacy. NHS Education for Scotland has recently launched a Polypharmacy Guidance app to support healthcare professionals to carry out comprehensive face-to-face medication reviews. Apps for patients may help to track symptoms and provide scoring systems (pain, mood, sleep etc), which can serve as useful indicators for healthcare professionals involved in care.
In line with a change in attitude from doctors there is also an obvious need to educate the wider public, empowering patients with the tools for self-help and to understand the value of non-pharmaceutical measures such as exercise, mind-body practices, psychological therapies, mindfulness practices and manual therapies.
Polypharmacy and inappropriate prescribing are clearly a worrying and growing international public health issue with potentially devastating consequences for patients. The US opioid epidemic which is currently claiming more than 130 lives per day could be seen as problematic prescribing in its most devastating and dangerous form. The WHO, recognising the urgent need for reform has recently released “Medication Without Harm”, a global initiative driving a process of change to reduce patient harm generated by unsafe medication practices and medication errors. Polypharmacy and inappropriate prescribing have been identified as area of high priority.
As the majority of prescribing occurs in primary care in the UK, I believe GPs who are at the front line of care could do more to question the current status-quo and re-assess the way that medicines and healthcare are being delivered to patients. Doctors need to take responsibility for their individual prescribing habits and must not forget the ethical code that underpins medical practice of to “do no harm” – and not to underestimate our capacity to cause harm with prescribed medications, ensuring that full consideration has been given to all non-pharmacological interventions. GPs should also resist pressure from patients to prescribe addictive medications if these are not deemed appropriate. Patients can also play a vital part in tackling polypharmacy and inappropriate medication use if provided with the right information, tools and resources to make informed decisions about their choice of medicines.