Healthy Skepticism Library item: 16421

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: Journal Article

The principles of conservative prescribing
Harvard Health Letter 2009 Jun; 6-7
https://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2009/June

Abstract:

No matter what your politics, a conservative approach to medications is a good idea.

The old, jokey line was “take two aspirins and call me in the morning.”

But, of course, doctors prescribe a lot more than just aspirin these days. The medicine cabinet is crammed full: cholesterol-lowering statins, stomach acid–reducing proton-pump inhibitors, antidepressants, asthma drugs, diabetes drugs, sleeping pills, hormones.

The amount of money that Americans spent on prescription drugs tripled between
1997 and 2007, although growth in our collective “pill bill” has slowed recently for many reasons (see sidebar on next page).
People who genuinely need medications should take them; indeed, getting people to take medications
as prescribed is a persistent problem. But there’s some questioning of prescribing practices these days, much of it inspired by a growing conviction that American health care has become too dependent on expensive medications.

Dr. Gordon D. Schiff , a researcher at the Center for Patient Safety Research and Practice at Harvard-affiliated Brigham and Women’s Hospital, wrote an article about more judicious use of
medications that was published earlier this year in The Journal of the American Medical Association. The article grew out of an educational project funded by a settlement of a lawsuit against the maker of gabapentin (Neurontin) alleging that the drug had been promoted illegally. Dr. Schiff and his coauthor, Dr. William Galanter at the University of Illinois at Chicago, identifi ed a halfdozen broad principles of what they call “conservative prescribing.” We’ve listed them below, revised so they take into account more of the patient’s point of view. We also spoke with Dr. Schiff
to get a few more specifics.

Some of the items may seem a little obvious-did anyone ever say that side effects shouldn’t be a concern? But saying and doing often diverge. Besides, the hope here is that by laying out a
few principles, in contrast to a long list of dos and don’ts, a better balance between
the risks and benefits (and costs) of taking drugs might be found.

1. Consider alternatives to medication
It’s understandable that people want to leave the doctor’s office with a prescription.
A prescription sends the message that the doctor believes you’ve got a real illness-and, better yet, that there’s something that can be done about it.

But playing to this psychology can mean that nondrug alternatives get
short shrift . Improving your diet, becoming more physically active, getting enough sleep, using stress-reduction techniques-they take more time and effort. But study after study has shown that
they can have a powerful effect-often more powerful than any medicine-on a whole range of health problems.

Perhaps the trick is to view the nondrug alternatives as being just as “medical” as any pill you might take. Examples mentioned by Dr. Schiff include properly attending to your sleep
“hygiene” (avoiding evening caffeine or long daytime napping) instead of getting a prescription for sleeping pills and using orthotics (shoe inserts that alter the alignment of your foot and leg) instead of taking pain relievers for foot pain.

We published an article last year about alternatives to medications.
We’ve made a full-text version available on our Web site at www.health.harvard.edu/healthextra.

2. Take it step-by-step. Depend on the evidence.
Doctors and patients can be a little scattershot in their use of medications.
There’s a lot of switching from one drug to another. Or people start taking several
drugs all at the same time.

A more cautious, step-by-step approach can help you-and your doctor – figure out what’s working, what’s not, and whether certain medications might be causing undue side effects.
Dr. Schiff also has a somewhat contrarian view of individualizing therapy,
which ordinarily is seen as something to strive for. In his opinion, individualizing
therapy can sometimes (not always, by any means) amount to a blank check to try all sorts of treatments that stand very little chance of working based on the evidence from clinical
trials. The time may be coming soon when medications-and treatments of all types-will be exquisitely individualized, calibrated to each person’s individual genetic makeup. But for most
conditions and medications we aren’t there yet, and until we are, the clinical trial result remains the best guide to treatment.

3. Keep a lookout for side effects
There’s no such thing as drug side effects, quips Dr. Schiff , only effects- the ones we want and the ones we don’t. The unwanted effects-other wise known as side effects-may be mild or affect just a handful of people.

Even so, you should be clear about what they are and watch for them, especially when you first start taking a medication. And side effects should be a prime topic of conversation with
your doctor.

You should also talk to your doctor about withdrawal symptoms if you stop taking a drug. People often mistake the symptoms of drug withdrawal for the symptoms of the condition being treated, which can create a vicious cycle of taking a medication just to avoid the withdrawal symptoms. A common example is the headaches people get when they stop taking pain relievers, especially if the pain relievers included some caffeine.

4. Remember that new isn’t necessarily better
Sometimes new medications are a real advance. They are more effective, have fewer side effects, or-best of all-both.

But sometimes we are just responding to an ad campaign, equating new with improved when it isn’t necessarily so.
And new drugs, by definition, don’t have much of a track record to go on, so it is oft en better to start first with the tried-and-true older ones.
Clinical trials are the best way we have to test medications and other interventions, but a trial involving just a few hundred, or even a few thousand, people taking a drug for a relatively
short time can tell us only so much. It may take years and many more patients before the full side-effect profile of a drug is known. Similarly, the full picture of a drug’s longer-term outcomes
how it affects health events like heart attacks, strokes, even death may be slow to emerge, in contrast to so-called surrogate markers, like cholesterol counts and blood sugar levels, which may point to health benefits but are, in the final analysis, convenient lab values.

5. Work with the doctor
The doctor-patient prescribing relationship used to be straightforward and top-down: the doctor knew
best, and the patient got a prescription.
But for a host of reasons, that paternalistic approach has been rejected.
Now, ideally, in many circumstances, the doctor’s role is to present choices, explain the pros and cons, but let the patient-within limits-make the decision.

But the doctor-patient relationship is-and always will be-a difficult one to get right. Some of us try to manipulate doctors into prescribing a certain treatment. Some of us want to be good
patients, so if we’re not taking a pill as prescribed, we may not fully own up
to our nonadherence. We take medications out of inertia, whereas if we were to talk it over with our doctors we’d find out that we were taking pills that aren’t needed any longer and possibly doing
more harm than good.

Of course, the burden shouldn’t be all-or even mainly-on patients. Doctors should take the time to raise these issues. And they need to be more open and encouraging of patients who want to try nonpharmaceutical approaches to health problems.

Time is a factor in all this. Many physicians are under pressure to fit in as many appointments per day as possible, and if they are working against the clock, then it’s harder for them to be
working with the patients. The shortage of primary care physicians in many places doesn’t help matters.

6. Taking responsibility
Some medications start out like gangbusters, but their effectiveness seems to fade over the long haul. Others may take a while to kick in. Either way, sticking with the prescribed dose for the prescribed period is important, especially when the prescription is for antibiotics.

Increasingly, good prescribing practices are going to hinge on the adoption of the electronic health record that will check for allergies, interactions, correct dosing, and so on. As hospitals
and other groups introduce Web sites that allow people to see their personal health records online, more of us will experience the computerization of the medical record firsthand. The hope is that patient access to this information will add another layer of protection against bad prescribing practices and get us all more involved in taking responsibility for our health care.

End of the spendthrift era?
After going up and up, American spending on prescription drugs has leveled off in recent years. It’s still growing, but at a slower rate.
In fact, in 2007, the amount spent on prescription drugs increased by just 1.6%, the smallest increase in over 30 years, according to an article published in Health Affairs earlier this year.
The spending spree is abating for several reinforcing reasons, explained the article. The number of blockbuster drugs-those with annual sales of over $1 billion-started to boom in the late 1990s. In 1997, there were just six blockbusters. Nine years later, there were 52. But over the past several years, several blockbuster drugs have lost patent protection. That change has opened the door to competition from less expensive generic versions of the same medication, or from slightly different medications that are in the same class. And generic sales have taken off because health insurers have passed along the price difference to their customers in the form of lower copayments: getting the generic pills means an out of-pocket expense of $5 or $10, whereas buying the brand-name
ones requires laying out, say, $20 to $30.

This trend is likely to continue for the next several years as the patents for several big-name drugs expire. Losartan (Cozaar), the blood pressure medication, is scheduled to lose protection next
year; atorvastatin (Lipitor), the cholesterol-lowering statin and the biggest blockbuster of them all, in 2011; and sildenafil (Viagra), the erectile dysfunction drug, in 2012.

It’s too soon, though, to declare victory. Even when a drug loses patent protection, there may not be enough competition from generic manufacturers to drive down prices significantly. And, as discussed in the Health Affairs piece, spending patterns are shifting away from primary care drugs to specialty ones. Cancer drugs, in particular, are fantastically expensive. For example, a single course of bevacizumab (Avastin), a new drug for advanced breast, colon, and lung cancer, can cost over $40,000. And vaccines, once touted as public health’s great bargain, are now being marketed much like pharmaceuticals. Prevnar, a pneumococcal vaccine, and Gardasil, the anti–human papillomavirus vaccine that’s designed to prevent cervical cancer, are now members of the blockbuster club.