Preventing the Inappropriate Use of Prescription Drugs

By Jennifer Larson, contributor

December 1, 2010 - Prescription drug use continues to climb in the United States. The Kaiser Family Foundation notes that the number of prescriptions paid for increased 39 percent from 1999 to 2009, during which time the country’s population grew by just 9 percent. Many healthcare experts would like to reverse this trend, both to reduce costs and to improve the quality of care received by patients.

Limiting prescriptions may be a tough sell, however. Patients are frequently exposed to direct-to-consumer advertising for pharmaceuticals—with ad costs hovering near $4 billion per year—and they ask for certain medications by name. Many patients also ask for, and receive, antibiotics that are unnecessary and can lead to drug-resistance problems.

Cost doesn’t equal quality

The United States spends more money on prescription medications than any other country in the world. But spending more on prescription drugs does not produce higher quality results, according to a new study published online in the New England Journal of Medicine.

Researchers from the University of Pittsburgh and Harvard University found a great deal of variation in the quality of prescribing medications to seniors. Certain regions of the country logged a much higher use of high-risk or potentially harmful drugs among Medicare recipients than other regions, yet the amount of money spent on prescription drugs was lower in areas where the recipients were less likely to receive those harmful medications.

Lead investigator Yuting Zhang, Ph.D., said she hopes that providers will take more time to analyze whether they are prescribing potentially harmful medications to their patients and think about the alternatives. They should also consider their patients’ financial situations when prescribing.

“In general, they probably should be aware of cost,” she said.

Unnecessary antibiotic use

The inappropriate use of prescribed antibiotics is an ongoing problem that frustrates infectious disease experts, as well as many healthcare providers.

Some patients ask for antibiotics when they don’t really need them, especially for upper respiratory infections that are likely caused by a virus. And their providers acquiesce to these requests too often--sometimes because they’re unsure whether the culprit for the illness is a virus or something else, and sometimes because they bow to patient pressure. During a short office visit, it may seem easier to prescribe an antibiotic than to convince patients that they don’t really need it.

But this is a huge problem, experts say. The Centers for Disease Control and Prevention (CDC) maintain that inappropriate prescribing of antibiotics contributes to the spread of antibiotic resistance and strains the healthcare system by creating an unnecessary economic burden.

In fact, the CDC reports that more than $1 billion is spent each year on unnecessary antibiotic prescriptions for upper respiratory infections in adults. A recent post on the CDC’s Safe Healthcare blog noted that just a 10 percent reduction in the diagnosis of acute otitis media and sinusitis would results in a drop of 1.75 million prescriptions annually, offering savings up to $59 million. |

Pain medication prescription woes

Prescription pain medications are another area of concern. Officials around the country are trying to curb the inappropriate use of these drugs, which include controlled substances.

In 2007, the FDA established risk evaluation mitigation strategies (REMS) for certain new drugs as one way to regulate the use of these medications. But the American Pain Foundation has charged that REMS on opioids and other pain medications, while well-intentioned, may create barriers to effective pain management for legitimate pain patients.

In Florida, the state legislature enacted legislation to establish a prescription drug monitoring program (PDMP), which is likely to go into effect in early 2011, in an attempt to regain control over the widespread abuse of prescription drugs.

Sanford Silverman, M.D., who oversees a comprehensive pain management program in Pompano Beach, noted that Florida became the prescription drug abuse capital of the country in part due to a proliferation of “pill mills,” where opioids and other medications have been inappropriately and frequently overprescribed. He hopes that the new state PDMP will keep doctors from unethically prescribing such medications in the future.

But the PDMP isn’t perfect, noted Silverman, who works with a campaign called The Pain Truth to educate the public about the prevalence of prescription pain medication abuse. A drug monitoring program can create troublesome hurdles for qualified pain specialists and others who use appropriate prescription practices, and possibly hamper them from effectively managing pain for their patients.

“But it does prevent the illegal diversion of prescription drugs,” he said.

Roadblocks and hurdles

In some cases, there are roadblocks to best practices when it comes to prescribing medications. For example, Dee Swanson, MSN, NP-C, past president of the American Academy of Nurse Practitioners, explained that some providers may be hampered by patient variables (including compliance levels) and by the cost of the medications that a patient’s insurance company is or isn’t willing to cover.

And for nurse practitioners, scope of practice regulations in certain states that prohibit them from practicing—and prescribing—independently can be problematic. Sue Schrand, MSN, CNRP, executive director of the Pennsylvania Coalition of Nurse Practitioners, said these restrictions can prevent a nurse practitioner from being able to fully manage his or her patients’ health. They can also be frustrating to patients, who might have to wait for a collaborating physician to provide a specific prescription.

“People lose steam,” she said. “They don’t feel well, and you’re asking them to go through three extra steps.” Schrand said she and many others believe a more streamlined process would be more effective, adding,“I think it just takes a lot of manpower to get the person on the best medicine sometimes.”

Technology’s advantage

Today’s providers are fortunate to have better resources available to help them prescribe appropriately.

Zhang noted that e-prescribing programs offer an important tool to help providers in keeping down costs when prescribing medications: they suggest alternate medications that can be used as substitutions. That gives an important piece of information to the physicians and nurse practitioners before they commit to what could be an unnecessarily expensive medication.

Swanson noted that these programs can also catch potentially harmful drug interactions, especially in patients who are taking multiple medications. She uses ePocrates and UpToDate to run a check before sending a patient out with a prescription for a particular drug. And she hopes that other providers will have increasing access to such programs.

“The best way for organizations like hospitals and health organizations to support prescribers is to make tools available that will help with keeping up to date, financial support for electronic prescribing (which has many built-in safeguards), making access to handheld devices and the appropriate software to enable quick referencing for drug side effects, interactions and contraindications that can used at the point of care,” she said.

An article titled “Appropriate Prescribing of Medications: An Eight-Step Approach” that was published in American Family Physician in 2007 supported a six-step approach advocated by the World Health Organization, but added two additional steps: the use of prescribing software and electronic drug references and the consideration of drug cost when prescribing.

Such advances in technology—along with policy improvements and personal vigilance—can go a long way toward helping providers overcome the inappropriate uses and overuse of prescription medications.