Doctors urge greater caution, skepticism in prescribing drugs
Feb. 25, 2009
Gordon D. Schiff, M.D.
Mark Almberg, (312) 782-6006, firstname.lastname@example.org
Physicians should be more conservative in their drug prescribing practices and more skeptical about the benefits of drugs that don't have a proven track record, says an article in today's Journal of the American Medical Association, or JAMA.
Citing the "well-documented prevalence of medication-related harm and inappropriate prescribing," and pointing to "disasters" like the Vioxx episode, in which a popular painkiller was later found to increase the risk of heart disease, the authors welcome recent proposals for the reform of pharmacology education by the Association of American Medical Colleges. But such reforms are not enough, they say.
"With all the strengths of our nation's medical curricula, including in pharmacology, there is surprisingly little time devoted to teaching trainees how to become lifelong effective prescribers," said Dr. Gordon Schiff, associate professor of medicine at Harvard Medical School and co-author of the JAMA commentary. "More training in pharmacokinetics and drug dosing is all to the good. But trainees also need to acquire a set of guiding principles to help them become more careful, cautious, evidence-based, and frankly skeptical prescribers throughout their careers."
To that end, Schiff and co-author Dr. William Galanter, assistant professor of clinical medicine at the University of Illinois at Chicago and head of the UIC Medical Center's pharmacy and therapeutics committee, offer 25 "principles for more conservative prescribing" grouped under six subheadings:
* Think beyond drugs. Prescribe non-drug alternatives first, including physical therapy, exercise and diet changes, rather than reflexively reaching for the prescription pad to treat every symptom a patient might experience.
* Practice more strategic prescribing. Take a smarter approach to initiating or changing a drug regimen. Use only a few drugs; learn to use them well. Start only one drug at a time, so if there is a side effect it will be less confusing which drug is responsible.
* Heightened vigilance regarding adverse effects. Maintain a high index of suspicion for adverse drug effects. Rather than failing to warn patients about potential side effects, educate patients to recognize them earlier so the drug can be discontinued before more serious harm occurs.
* Caution and skepticism regarding new drugs. Limit use of new drugs. New drugs always appear safer, but as pointed out in earlier research conducted by physicians associated with Physicians for a National Health Program ("Timing of new black box warnings and withdrawals for prescription medications," JAMA, 2002), serious adverse effects can take five or more years to emerge. Instead, rely on proven drugs with long-term safety records and do not stretch indications away those supported by trial-based evidence.
* Shared agenda with patients. Become more skillful at handling patients' requests for drugs that they have seen advertised. Obtain accurate medical histories. Patients themselves often favor more conservative use of drugs, so physicians should build trust based on realistic expectations and a shared desire to use the minimum drugs necessary.
* Weigh longer-term, broader impacts. Think beyond short-term effects. For example, weight-loss drugs are often promising in the short-term, but longer-term results are often disappointing.
While the authors say these principles are not novel and should not be terribly controversial, "taken together they represent a significant shift in current prescribing patterns."
Beyond countering the massive advertising and miseducation of physicians and the public to use more and more drugs, there are other barriers to physicians adopting more conservative prescribing practices, they say. These include the time pressures doctors are under, their desire to enhance their reputations by embracing the latest medical advances, and their fear of disappointing patients who request a drug they have seen advertised. The medical literature is also biased against conservative prescribing, because studies with negative results are less likely to be published or publicized.
Given existing practices and recent experience, the authors say, it is time to swing the pendulum back from "newer and more is better" back in favor of a prescribing philosophy that states that "fewer and more time-tested is best."
Dr. Quentin Young, national coordinator of PNHP, said, "This is yet another example of why and how we have to put patients' needs for safe and effective treatment ahead of the profitability of the insurance and drug companies. While drug companies promote using the newest, often most expensive and aggressive treatments, we favor a more cautious patient-centered approach - one that stresses the more 'tried and true drugs' over the 'latest and greatest' drugs pushed by the industry."
The JAMA commentary was an outgrowth of a Chicago-based project funded by the Attorney General Consumer and Prescriber Education Grant Program (the Neurontin settlement) and also supported by grant U18HS016973 from the Agency for Health Care Quality and Research.
"Promoting more conservative prescribing," Gordon D. Schiff, M.D., and William L. Galanter, M.D., Ph.D., Journal of the American Medical Association (JAMA), Feb. 25, 2009, Vol. 301, No. 8.
A copy of the study is available at www.pnhp.org/prescribing
Physicians for a National Health Program (www.pnhp.org), a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. PNHP is headquartered in Chicago and has chapters across the United States.