Prescribing ills need healthy overhaul

There should be continued efforts of research to study and understand the behavioural aspects of drug use, particularly the beliefs and motivations of providers and consumers, says Anantha Naik Nagappa and Kalyan Mahip Verma

The prescribers in our country comprise heterogeneous group of professionals including barefoot doctors, rural traditional healers, quacks, private practitioners, physicians and superspeciality doctors, belonging to different faith and traditional system of medicine namely, allopathy, ayurveda, homeopathy, unani, naturopathy, siddha systems. The medicines are essential ingredients in a healthcare system. It is necessary to regulate the manufacture, stock, distribution and sale of the medicines so that timely availability of quality of medicines to the patients does not hamper.

The practice of medicine, over the years, due to self interest of vested groups, certain wrong practices are prevalent and needs to be identified, stopped and right processes rewarded so that right practices replaces the wrong ones. As mentioned above, the problems of prescribing starts with gross negligence and keeping our eyes shut on prescribing habits of the prescriber.

Although it is observed that we find examples of crossover and switching of prescription, like an ayurveda practician prescribing an allopathic medicine. There is no record of the medicines prescribed by the prescriber, over a day, month or over years. Neither the regulatory agencies nor the government seems to be interested in the control of prescribing.

Quite recently there was a hue and cry regarding irrational use of medicated stents by the private physicians. It cannot be anything than for unfair economic reasons they are misused. This is not restricted to super specialty medicines like cardiac diseases. This practice is even deep rooted than it seems. In general the medicines are sold in our country without a regard and concern for public health in general. The existing laws regarding distributions storage and sale of medicines are grossly misinterpreted and violated is an open secret.

There are some private practitioners ubiquitously present from Kashmir to Kanyakumari in rural to urban sector throughout the country, who run their own pharmacies and sell huge quantities of medicines like pharmacists to their patients. It is quite strange why a prescriber should indulge in large-scale retail sale of the medicines. This practice has an adverse impact on the development of pharmacy profession as such.

The prescriber who runs parallely his own pharmacy is likely to be lured by manufacturers to over-prescribe the formulations and add on therapy to the unsuspecting ignorant patients. The problem of irrational prescribing is rampant and unless serious steps are taken to curb this practice no improvement in the field of rational use of drug is likely to come in our society.

This practice of focused wooing of prescriber alone has an adverse impact on the medical practice. We find lot of marketing programme held in five star hotels, which are called as CME (continuous medical education) for doctors alone by drug manufacture. It is very strange to know that these companies have seldom conducted CME for community pharmacists.

Since community pharmacist can make a difference in medical practice if he/she is aware of the information. All these practices have made a bad impact and lead to an unfair battle over the market share which again is fictitious. For example, if we consider the cough remedies market sector, the picture is clearly emerging.

The advertisements in the electronic media regarding medicines are illegal and unethical also. This clearly promotes one to indulge in self-medications and gives the mass appeal that medicines are safe and can be treated like food items, which is wrong again. The advertisements are also in violation of Drugs and Magic Remedies Act, which clearly bans advertisements. Cough and cold do cause minor sufferings initially, the best ways to deal with such a situation is to drink excess fluids especially water, which would make the thick sticky viscous mucous adhering to the respiratory track to hydrate and loosed up, thus water acts as an expectorant in the real sense.

Have you observed any cough manufacturer prescriber imparting this vital information to the patient. The empirical treatment with cough remedies and antibiotics are prescribed on large scale. As the saying goes, one cannot fool all the people all the time. It is high time for our governments, regulatory bodies restrain the over-commercialisation of prescribing. The public is aware of this basic problem, but have suffered and tolerated this nonsense. What public can do to this, you may ask?

There are independent drug information centres established in our country. Essentially in Delhi, Bangalore and Mumbai where one can get an opinion on quality of prescription and get screened them for rationality. If found irrational, that should be questioned in a consumer court.

In our experience, we have come across a popular prescriber who used to prescribe ethambutol, an anti-tubercular drug, as an add-on therapy for treatment of common cold and cough. Soon I could realise that a manufacturers’ representative lured him. The open secret arrangement with prescriber and manufacturer is a threat to the rational use of medicines.

Individualisation of therapy for a particular patient requires a basic understanding of pharmacokinetics and pharmacodynamics. Many factors can influence that the patients respond to a drug, including the age of the patient, diseases of kidney of liver. The concomitant use of drug, foods and chemicals, drug interactions, previous treatment with similar drugs (tolerance) can cause change in the drug action. A variety of genetic factors can influence the kinetics and toxicity of the drug (pharmacogenomic).

Whenever a drug is first marketed, it has been tested in only a limited number of well-characterised patients. Adverse events that occur as commonly as one per one thousand patients may not be discovered during clinical trials. Any rare event found during the years after the drug hits market has to be recorded. It is the responsibility of all the health care professionals to monitor the effects of drugs post-marketing and to report the serious adverse events that may be related to the drugs. Hence post-marketing surveillances has become necessary procedures of drug marketing.

There should be a watch on the drug utilisations by individual prescriber, hospitals, and nursing homes and should be revised periodically to influence the prescribing habits. If left alone, we can only be sure of irrational use of drug with repetition of tragedies like thalidomide and stilbosterol, which has awakened the medical fraternity regarding medical tragedies, which could have been avoided.

The strategy to improve the quality use medicines should focus on implementing essential drugs policy of WHO and promotion of rational use of drugs. Taking an interdisciplinary approach to promoting rational drug use should curb irrational use of drug. Focusing research, planning, and implementation efforts based on recommendations of local experts from the public and private sectors, universities, and NGOs on nationwide should be implemented in its true spirit.

There should be continued efforts of research to study and understand the behavioural aspects of drug use, particularly the beliefs and motivations of providers and consumers. The research outcome should be applied to implement interventions, based on research, to improve drug use. The data banks on drug utilisations for practical research tools, including simplified sampling and data collection strategies and user-accessible computer software are the urgent requirements of the system.

The writers are with Pharmacy Group, Birla Institute of Technology and Science, Pilani, Rajasthan 333031. anantha@bits-pilani.ac.in