Wednesday, March 11, 2009

“Conservative” Drug Prescribing

While Victor Fuchs in his (somewhat pessimistic) commentary on “Reforming US health care” in a recent JAMA observes that one problem with the Clinton-plan era was that the public focused on “…`greedy drug companies’ and ‘overpaid’ physicians rather than on systemic problems in funding, organization, and delivery of care.”[1], there can be little doubt that the pharmaceutical industry has an enormous influence on the delivery of health care, much of it negative. The Association of American Medical Colleges (AAMC) issued a recent report expressing serious concern about the influence of the pharmaceutical industry on medical education[2], while recent media coverage of researchers’ ties to the drug companies has been widespread. Any number of books and articles documenting the influence of the pharmaceutical industry on physician choice of drugs have been published.[3] Gordon Schiff, MD, co-author of a recent Commentary in JAMA entitled “Promoting more conservative drug prescribing”,[4] has said that while the pharmaceutical industry promotes the idea that it works in “partnership” with physicians in the care of patients, and thus that the 3 groups have the same interests, the fact is that the wider use of many of the principles he promotes would not be in the interest of the drug companies.

Schiff and William Galanter, his co-author, provide a list of 25 principles for more conservative prescribing, grouped under 6 larger headings that are discussed at greater length in the article. Unsurprisingly, several of them would result in the use of fewer and cheaper drugs, and they would thus, in fact, decrease drug company profit. These include:

Think Beyond Drugs: to first consider the use and effectiveness of other, non-pharmacologic approaches to treatment of a person’s symptoms, such as diet, exercise, physical therapy, stress reduction, and “…even surgery where appropriate.”. This is exactly what virtually all review articles about treating most conditions suggest, and yet physicians frequently see these as pro forma, not to be seriously considered except as adjuncts to drug therapy, as they reach for their prescription pads.

More strategic prescribing:
“Too often clinicians reflexively prescribe for each symptom a patient experiences.” Sometimes this may be appropriate, but it clearly increases the risk of drug-drug interactions, as well as the possibility that drugs prescribed for one symptom may make another worse (requiring yet a third drug?). This leads to:

Heightened vigilance regarding adverse effects. Drugs have adverse effects. Some of them are less common, and less known by physicians, but no less serious for the patient who experiences them. Many of these effects are not discovered before mass marketing because they are relatively uncommon – or worse they are discovered or suspected by the manufacturer and the information is suppressed. Vioxx®, anyone?

Caution and skepticism regarding new drugs is my personal favorite, violated every day, and the most important place where the interests of drug companies diverge from those of physicians and patients – though the latter two groups often miss this. The marketing of new drugs is where pharmaceutical companies make their money; it is these drugs that are heavily advertised in the medical journals (including JAMA), and to consumers in popular magazines and on TV. It is these new drugs that fill the sample closets of physicians, drugs still under patent and highly profitable. If patients respond to the samples, then they will want the doctors to prescribe them. Rarely are they the first “drugs of choice” and never are they low-priced or generic. Cost may well be the less important issue of prescribing generic drugs – the fact that their patents have expired means that they have been out long enough for us to know how well they work and what their side effects are, something we well may not know about the newer, highly-promoted drugs. “Although many payers stress prescribing generic medications for cost savings,” Schiff and Galanter write, “another important value of generics is the greater safety knowledge inherent in their longer track record compared with more newly marketed brand name products.”

The other two broad headings that they identify:
Shared agenda with patients, and
Weigh longer-term, broader effects
are also both very important. Regarding the latter, many drugs that seem to work initially may lose their effectiveness (relief of the undesired symptom) but perhaps not their side effects (undesired effect) over time. This can also affect the broader community, with emerging resistance to antibiotics being a prime example.

The idea of a “shared agenda with patients” seems to be redundant to the practice of medicine – after all, shouldn’t all of our work be to enhance the well-being of our patients? However, there are many times when, because the agenda is not made explicit to and by both parties, and negotiated between physician and patient, they may end up not working effectively together. Some physicians still believe in the “miracle, mystery and authority” of the physician, exemplified by the title character in “The Chief of Medicine”, chapter 1 of Howard Brody’s classic book “The Healer’s Power”.[5] Others, less authoritarian, are often frustrated by the patient’s lack of “compliance” (or “adherence”, a newer term that seems to me to be no less judgmental) to the doctor’s “orders”. In reality, most of the time the physician (unless actively performing surgery, giving an injection, etc.) is an advisor or consultant to the patient; even the ritual of giving a piece of paper with writing on it (a prescription) is only advice, until the patient takes it to a pharmacy, exchanges it and money for a drug, and then takes the drug. Some of the lack of understanding by patients may be from the above-noted authoritarianism, but much more is cultural (differences in the culture of the doctor and the patient, which includes although it is not limited to, ethno-cultural and language differences), abetted by the lack of time for adequate communication in the typical short visit required by the fee-for-service system. Inadequate communication about drug therapy may be part of this.

The patient may be most interested in relief of a symptom, while the physician, with a longer term teleological view of illness, is more worried about downstream effects of an untreated disease; thus they may not share an agenda. Patients, while perhaps not getting the “full-court press” that physicians do about new drugs, certainly see the advertisements, and they (at least in the US) are often enamored by the “newer is better” view we have of most things (technology, etc.). When we see the lists of medications some patients are on, we may begin to believe that the main reason they don’t have more drug interactions is because they don’t take all the medication prescribed; as physicians, however, we must be concerned that the ones they don’t take may be the ones that we think are more important. Thus, limit, to the extent possible, polypharmacy.

Finally, there is the issue of cost. Generic drugs may be good for most conditions because they are the best known, safest, and first-line choices, but indeed they save money as well. And with the increasing cost of medicine being driven at least in part by drug costs, this is no small matter. Schiff and Galanter’s principles are well-worth implementation by all physicians, and indeed consideration of these issues should be demanded by knowledgeable patients.

[1] Fuchs VR, “Reforming US Health Care”, JAMA 4Mar09;301(9):963-4.
[2] Association of American Medical Colleges. “Industry funding of medical education: report of an AAMC Task Force”. AAMC. Washington DC. June 2008.
[3] E.g., Angell, M. The Truth about drug companies: how they deceive us and what we can do about it. Random House. New York. 2005.
[4] Schiff GD, WL Galanter, “Promoting more conservative drug prescribing”, JAMA 25Feb09;301(8):865-7.
[5] Brody H. The Healer’s Power. Yale University Press. New Haven. 1992.

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