The prescribing of a drug is the
most common outcome of a patient visit to a physician; 60% of physician visits
result in a prescription or injection for patients. It is incumbent on health
professionals to ensure that this process of receiving and taking medications
benefits and does not harm patients. Clinicians are often called upon to
identify, resolve, and prevent problems that occur due to undertreatment,
overtreatment, or inappropriate treatment. Problems occurring with the use of
drugs can include:
• Suboptimal drug, dose, regimen,
dosage form, and duration of use;
• Unnecessary drug therapy;
• Therapeutic duplication;
• Drug-drug, drug-disease,
drug-food, or drug-nutrient interactions;
• Drug allergies; or • Adverse
drug effects, some of which are preventable.
The readers of this book can help
to reverse these problems, improve outcomes of care both clinically and
economically, and enable drug use to meet stated goals and objectives. This
text provides a thorough analysis and summary of treatment options for commonly
occurring diseases and the medications or alternative therapies used to
successfully treat these conditions.
The use of drugs as a form of
medical treatment in the United States is an enormously complex process.
Individuals can purchase medications through numerous outlets. Over-the-counter
(OTC) medications can be purchased in pharmacies, grocery stores, supermarkets,
convenience stores, via the Internet, and through any number of additional
outlets. OTCs are widely used by all age groups. Prescriptions can be purchased
through traditional channels (community chain and independent pharmacies), from
mail order pharmacies, through the Internet, from physicians, from health care
institutions, and elsewhere. Herbal remedies are marketed and sold in numerous
outlets. The monitoring of the positive and negative outcomes of the use of
these drugs, both prescription and OTC, can be disjointed and incomplete.
Clinicians and health professions students need to take ownership of these
problems and improve patient outcomes resulting from drug use.
It is important to realize that
although clinicians are the gatekeepers for patients to obtain prescription
drugs, patients can obtain prescription medications from numerous sources.
Patients may also borrow from friends, relatives, or even casual acquaintances.
In addition, patients obtain OTC medications from physicians through
prescriptions, on advice from pharmacists and other health professionals,
through self-selection, or through the recommendations of friends or
acquaintances. Through all of this, it must be recognized that there are both
formal (structural) and informal (word of mouth) components at play. Health
professionals may or may not be consulted regarding the use of medications, and
in some cases are unaware of the drugs patients are taking. In addition, herbal
remedies or health supplements may be taken without the knowledge or input of a
health professional.
External variables may greatly
influence patients and their drug-taking behaviors. Coverage for prescribed
drugs allows those with coverage to obtain medications with varying cost
sharing requirements. However, many do not have insurance coverage for drugs or
other health-related needs. With the advent of Medicare coverage for prescription
medications, more of the elderly will have access to needed therapy—more than
ever before.
SELF-MEDICATION
Self-medication can be broadly
defined as a decision made by a patient to consume a drug with or without the
approval or direction of a health professional. The self-medication activities
of patients have increased dramatically in the late twentieth and early
twenty-first centuries. Many factors affecting patients have continued to fuel
this increase in self-medication. There are ever increasing ways to purchase
OTC medications. There have been many prescription items switched to OTC
classification in the last 50 years. In addition, patients are increasingly
becoming comfortable with self-diagnosing and self-selection of OTC remedies.
The number of switched products is dramatically and significantly fueling the
rapid expansion of OTC drug usage. Dean2 noted in the past that in many
studies, self-medication with nonprescribed therapies exceeds the use of
prescription medications.
Patients’ use of self-selected
products has the potential to bring enormous benefits to patients, as well as
others. Through the rational use of drugs, patients may avoid more costly
therapies or expenditures for other professional services. Self-limiting
conditions and even some chronic health conditions (e.g., allergies and
dermatologic conditions), if appropriately treated through patient
self-medication, allow the patient to have a degree of autonomy in health care
decisions.This book provides a thorough analysis of common disease states,
discussion of therapies to treat these conditions, and specific advice to
provide to patients to help them self-medicate when appropriate and safe to do
so.
COMPLIANCE WITH MEDICATION REGIMENS
Both self-medication and patient
compliance behaviors are exceedingly complex. McDonald and colleagues point out
that patient interventions to impact compliance are complex, labor intensive,
and not particularly effective. McDonald and colleagues further suggest that
more convenient care, reminders, self-monitoring by patients, reinforcement,
family therapy, and additional attention may need to be in play for compliance
to improve. Meredith notes that a focus on the individual, rather than a
general approach, is more likely to be successful. Haynes and colleagues call
for better approaches to enhance compliance that are more efficient and more
effective.
For the most part, with regard to
compliance-enhancing strategies, the more things that can be done the better
the chances of success. Enhancing compliance is more art than science, and more
trial and error than precisely delineated. Success may be frustratingly
difficult to achieve, but enhanced and suitable patient compliance should be the
ultimate goal of the prescribing, dispensing, and therapeutic monitoring
process. Clinicians can have no more rewarding, yet vexing, opportunity than
trying and succeeding in helping patients comply with medication regimens and
achieve treatment goals.
Compliance Issues
Patient noncompliance with
prescription regimens is one of the most understated problems in the health
care system. The effects of noncompliance have enormous ramifications for
patients, caregivers, and health professionals. Compliance with medications is
a worldwide problem, and measures that are effective in one country may not
have work elsewhere.
In the recently released book on
worldwide compliance issues (Adherence to Long-term Therapies, Evidence for
Action), published by the World Health Organization, researchers indicate that
the problem of noncompliance is worse in countries in the developing world than
in countries in the industrialized world. Many parts of the United States have
similar morbidity and mortality rates as countries in the Third World. Specific
disease states may have significant additional noncompliance ramifications due to
the development of drug-resistant strains of bacteria. Many times what is
necessary is referral to specific clinicians for individualized treatment and
monitoring to enhance compliance. The case histories provided in this text will
allow you to follow what others have done in similar situations to optimally
help patients succeed in improving compliance rates and subsequent positive
health outcomes.
DRUG COSTS
Spending for prescription drugs
in the United States has skyrocketed in the recent past. Between 1990 and 2003,
the amount spent on prescription drugs in the United States quadrupled, far
outstripping the increase in cost of other commodities in the United States
health care system. This large increase in spending has stressed financing of
the health care system. Americans pay the highest prices for prescription drugs
in the world. United States prices are 72% higher than those in Canada, and
102% higher than those in Mexico. An increase of 25% in the percentage of expenditures
for prescription drugs as a percentage of all health care costs has occurred
over the past 5 years.
Numerous types of marketing have
impacted the usage of prescription drugs, and marketing has come under
increasing scrutiny as one reason for the use of costly alternatives rather
than less expensive therapies that might be equally efficacious. More and more
of these types of comparisons are appearing in the lay press (magazines and
newspapers). A good share of the success of the pharmaceutical industry is due
to lobbying efforts, which have been substantive and effective. Knowledgeable
clinicians can counter the misleading marketing that sometimes occurs, and in
doing so provide a significant service that improves the prescribing and drug
use process.
DRUG USE BY THE ELDERLY
Various components of drug use in
the elderly are worth noting. Problems with health literacy (i.e., the
understanding of medical terminology and directions from providers) are more
common among the elderly. The burgeoning population of the elderly coupled with
their lack of health literacy means that this issue will become even more
problematic in the future.
Over the next decade, seniors
will spend $1.8 trillion on prescription medications. Medicare proposals to
provide a drug benefit for seniors have been suggested to cost $400 billion over
a 10-year period. Thus, the most elaborate of the current drug programs will
pay only 22% of seniors’ drug costs. Enhanced use of pharmacoeconomic tenets to
select appropriate therapy while considering cost and therapeutic benefits for
seniors and others will become even more crucial for clinicians in the future.
IMPACTING THE PROBLEMS OF DRUG USE
Medication Errors
Brass, commenting on the change
from prescription to over the-counter status of many medications, notes
increasing problems with polypharmacy. This is no surprise to anyone
considering the several classes of drugs that can cause problems. These problem
drugs include analgesics, sleep preparations, pseudoephedrine, caffeine, cough
and cold preparations, and laxatives. The problems with these drugs have been
also noted in studies elsewhere. Inaccurate self-diagnosis leads to suboptimal
therapy, high patient cost, and more adverse effects and/or drug interactions.
Elsewhere, it was found that
errors by physicians and others is often not reported to patients, and
surprisingly, 23% of physicians and 11% of patients in one study did not feel
that physicians should report such errors to patients. Clinicians in the future
will be expected to interact more, and more effectively, with patients. These
expectations for improved interaction with patients will help both clinicians
and patients to reach their therapeutic goals.The authors of the chapters in
this text have worked through patient care problems that are commonly seen in
practice, and the reader will benefit by using similar tactics to help their
patients.
Health Literacy and Indigent Care
The negative influence of health
illiteracy on all affected patients has tangible outcomes, namely higher rates
of hospitalization with lower rates of health literacy. Much of the elaborate
technology used by the United States health care system is not accessible to
the uninsured. It is estimated that $1.1 billion per year in additional
expenditures are needed to deal with undertreatment of myocardial infarction,
cataracts, and depression. As governmental programs expand to provide drug coverage
for more seniors in Medicare Part D, and for patients shifted from drug
coverage under Medicaid to Medicare coverage, the impacts of health illiteracy
and the need for clinicians to provide interventions that will enhance drug use
will dramatically increase.
Health professionals are at a
crucial juncture as we face an uncertain, yet promising future. Technological
advances, including electronic prescribing, may stem the tide of medication
errors and inappropriate prescribing. Pilot studies have implemented these
technological enhancements for physician order entry (via personal data
assistants or through web access to pharmacies) in order to reduce drug errors.
The skills and knowledge that enable effective pharmacotherapy practice have
never been more daunting among the numerous health professions. Sophisticated
computer technology can further empower health professionals to play an ever
increasing and effective role in helping patients and fellow health
professionals to practice safe and effective medicine.
This book, which incorporates
materials written by some of the finest minds in pharmacy practice and
education, can enable the reader to play a crucial role in improving the drug
use process for patients, providers, payers, and society. The purpose of this
book is to help hone your skills so you can make a real improvement in the
therapies you provide to your patients. Current and future clinicians can rely
on the information laid out here to enhance your knowledge and allow you to
assist your patients with the sound advice that they expect you to provide. Use
the text, case histories, and numerous examples detailed here to expand your
therapeutic skills, and to help positively impact your patients in the years to
come.
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