CHAPTER ONE MISPRESCRIBING AND OVERPRESCRIBING OF DRUGS: Evidence and Causes
The numbers are staggering: in 1997, an estimated 2.35 billion prescriptions were filled in retail drugstores in the United States. For those people who got at least one prescription filled, this amounts to an average of 11.6 prescriptions per person that year.
There is no dispute that for many people, prescriptions are beneficial, even lifesaving in many instances. But hundreds of millions of these prescriptions are wrong, either entirely unnecessary or unnecessarily dangerous. At the very least, misprescribing wastes tens of billions of dollars, barely affordable by many people who pay for their own prescriptions. But there are much more serious consequences. More than 1.5 million people are hospitalized and more than 100,000 die each year from largely preventable adverse reactions to drugs that should not have been prescribed as they were in the first place. What follows is a summary of the seven all-too-often-deadly sins of prescribing.
First: The "disease" for which a drug is prescribed is actually an adverse reaction to another drug, masquerading as a disease but unfortunately not recognized by doctor and patient as such. Instead of lowering the dose of the offending drug or replacing it with a safer alternative, the physician adds a second drug to the regimen to "treat" the adverse drug reaction caused by the first drug. Examples discussed in this book include drug-induced parkinsonism, depression, sexual dysfunction, insomnia, psychoses, constipation, and many other problems.
Second: A drug is used to treat a problem which, although in some cases susceptible to a pharmaceutical solution, should first be treated with common sense lifestyle changes. Problems such as insomnia and abdominal pain often have causes that respond very well to nondrug treatment, and often the physician can uncover these causes by taking a careful history. Other examples include medical problems such as high blood pressure, mild adult-onset diabetes, obesity, anxiety, and situational depression. Doctors should recommend lifestyle changes as the first approach for these conditions, rather than automatically reach for the prescription pad.
Third: The medical problem is both self-limited and completely unresponsive to treatments such as antibiotics or does not merit treatment with certain drugs. This is seen most clearly with viral infections such as colds and bronchitis in otherwise healthy children or adults.
Fourth: A drug is the preferred treatment for the medical problem, but instead of the safest, most effective -- and often least expensive -- treatment, the physician prescribes one of the 160 Do Not Use drugs listed in this book or another, much less preferable alternative. An example of a less preferable alternative would be a drug to which the patient has a known allergy that the physician did not ask about.
Fifth: Two drugs interact. Each on its own may be safe and effective, but together they can cause serious injury or death.
Sixth: Two or more drugs in the same therapeutic category are used, the additional one(s) not adding to the effectiveness of the first but clearly increasing the risk to the patient. Sometimes the drugs come in a fixed combination pill, sometimes as two different pills. Often heart drugs or mind-affecting drugs are prescribed in this manner.
Seventh: The right drug is prescribed, but the dose is dangerously high. This problem is seen most often in older adults, who cannot metabolize or excrete drugs as rapidly as younger people. This problem is also seen in small people who are usually prescribed the same dose as that prescribed to people weighing two to three times as much as they do. Thus, per pound, they are getting two to three times as much medicine as the larger person.
Evidence of Misprescribing and Overprescribing
Here are some examples from recent studies by a growing number of medical researchers documenting misprescribing and overprescribing of drugs:
Treating Adverse Drug Reactions -- as Diseases -- with Other Drugs
Researchers at the University of Toronto and at Harvard have clearly documented and articulated what they call the prescribing cascade. It begins when an adverse drug reaction is misinterpreted as a new medical condition. Another drug is then prescribed, and the patient is placed at risk of developing additional adverse effects relating to this potentially unnecessary treatment. To prevent this prescribing cascade, doctors -- and patients -- should follow what we call Rule 3 of the Ten Rules for Safer Drug Use: Assume that any new symptom you develop after starting a new drug might be caused by the drug. If you have a new symptom, report it to your doctor.
Some of the instances of the prescribing cascade that these and other researchers have documented include:
- The increased use of anti-Parkinson's drugs to treat drug-induced parkinsonism caused by the heartburn drug metoclopramide 4 (REGLAN) or by some of the older antipsychotic drugs.
- A sharply increased use of laxatives in people with decreased bowel activity that has been caused by antihistamines such as diphenhydramine (BENADRYL), antidepressants such as amitriptyline (ELAVIL) -- a Do Not Use drug -- or some antipsychotic drugs such as thioridazine (MELLARIL).
- An increased use of antihypertensive drugs in people with high blood pressure that was caused or increased by very high doses of nonsteroidal anti-inflammatory drugs (NSAIDs), used as painkillers or for arthritis).
Failing to Treat Certain Problems with Nondrug Treatments
Research has shown that many doctors are too quick to pull the prescription trigger. In one study, in which doctors and nurse practitioners were presented with part of a clinical scenario -- as would occur when first seeing a patient with a medical problem -- and then encouraged to ask to find out more about the source of the problem, 65% of doctors recommended that a patient complaining of insomnia be treated with sleeping pills even though, had they asked more questions about the patient, they would have found that the patient was not exercising, was drinking coffee in the evening, and, although awakening at 4 A.M., was actually getting seven hours of sleep by then.
In a similar study, doctors were presented with a patient who complained of abdominal pain and endoscopy showed diffuse irritation in the stomach. Sixty-five percent of the doctors recommended treating the problem with a drug -- a histamine antagonist (such as Zantac, Pepcid, or Tagamet). Had they asked more questions they would have discovered that the patient was using aspirin, drinking a lot of coffee, smoking cigarettes, and was under considerable emotional stress -- all potential contributing factors to abdominal pain and stomach irritation.
In summarizing the origin of this overprescribing problem, the authors stated: "Apparently quite early in the formulation of the problem, the conceptual focus [of the doctor] appears to shift from broader questions like 'What is wrong with this patient?' or 'What can I do to help?' to the much narrower concern, 'Which prescription shall I write?'" They argued that this approach was supported by the "barrage" of promotional materials that only address drug treatment, not the more sensible lifestyle changes to prevent the problem.
In both of the above scenarios, nurse practitioners were much more likely than doctors to take an adequate history that elicited the causes of the problems and, not surprisingly, were only one-third as likely as the doctors to decide on a prescription as the remedy instead of suggesting changes in the patient's habits.
In later discussions about insomnia, high blood pressure, situational depression, mild adult-onset diabetes, and other problems, you will find out about the proven-effective nondrug remedies that should first be pursued before yielding to the riskier pharmaceutical solutions.
Treating Viral Infections with Antibiotics or Treating Other Diseases with Drugs That Are Not Effective for Those Problems
Two recently published studies, based on nationwide data from office visits for children and adults, have decisively documented the expensive and dangerous massive overprescribing of antibiotics for conditions which, because of their viral origin, do not respond to these drugs. Forty-four percent of children under 18 years old were given antibiotics for treatment of a cold and 75% for treatment of bronchitis. Similarly, 51% of people 18 or older were treated with antibiotics for colds and 66% for bronchitis. Despite the lack of evidence of any benefit for most people from these treatments, more than 23 million prescriptions a year were written for colds, bronchitis, and upper respiratory infections. This accounted for approximately one-fifth of all prescriptions for antibiotics written for children or adults. An accompanying editorial warned of "increased costs from unnecessary prescriptions, adverse drug reactions, and [subsequent] treatment failures in patients with antibiotic-resistant infections" as the reasons to try to reduce this epidemic of unnecessary antibiotic prescribing.
Similar misprescribing of a drug useful and important for certain problems, but not necessary or effective -- and often -- dangerous for other problems can be seen in another recent study. In this case, 47% of the people admitted to a nursing home who were taking digoxin, an important drug for treating an abnormal heart rhythm called atrial fibrillation or for treating severe congestive heart failure, did not have either of these medical problems and were thereby being put at risk for life-threatening digitalis toxicity without the possibility of any benefit.
A final example in this category involves the overuse of a certain class of drugs, in this case calcium channel blockers, which have not been established as effective for treating people who have had a recent heart at...
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