Getting it right with medicines is essential

MEDICAL MATTERS:Rational use of drugs will save money and lives

THE PUBLICATION last week of a model for the substitution of medicines and new reimbursement rules is long overdue. Promised at least 18 months ago by Minister for Health Mary Harney, the policy has both economic and clinical merit. There are so many reasons to promote the rational use of medicines, it’s a door waiting to be pushed open.

The World Health Organisation (WHO) said recently that more than half of all medicines are not correctly prescribed, dispensed and sold; and more than 50 per cent of patients take their drugs incorrectly.

What factors cause such high levels of misuse? Prescribers may be using information about treatments supplied by pharmaceutical companies rather than referring to evidence-based clinical guidelines; a less than complete diagnosis of a person’s disease could result in inadequate treatment; and for patients, the temptation to obtain cut-price versions of drugs on the internet means they may end up taking low quality formulations with unpredictable consequences.

Visiting a patient in their home can also be instructive. It is common for a large box to be produced when you ask to see what tablets they are taking. The box will inevitably have an oversupply of correctly dispensed medicines; it is likely to contain drugs no longer prescribed for the patient; and occasionally you will see medications prescribed for a relative or neighbour, which you are told were recommended.

The rational use of medicines means that patients receive an appropriate medicine, in the proper dose, for the correct period of time at the lowest cost. It is quite a challenge to achieve, but is arguably as important as putting resources into developing new drugs. Across the world, between 10 and 40 per cent of national health budgets are spent on drugs and medicines.

In 2008, the HSE paid for about 65 million prescription items at a cost of more than €1.9 billion. As a result of demographic changes and prescribing trends, the number of prescription items is estimated to increase to 105 million by 2021 at cost of €2.4 billion. This is clearly unsustainable.

And the downside of irrational use of medicines is more than just economic. Overuse of antibiotics during the past 70 years has played a big part in the emergence of drug-resistant forms of infectious diseases. Some surgical operations are no longer possible without antibiotics and resistance prolongs hospital stays.

From a patient safety perspective, the incorrect use of drugs can complicate a person’s illness and may even be fatal.

According to WHO, solutions include the creation of special committees to monitor and improve use of medicines; training students in pharmacotherapy and prescription of drugs; removal of financial incentives for prescribers; and establishment of criteria for ethical drug promotion.

The Minister’s statement referred to the need for legislation to allow the introduction of reference pricing and to permit generic substitution.

Unfortunately, it did not contain any sense of urgency for the project, with heads of a Bill still to be drafted. A new law will need to define what is meant by interchangeable medicines and must list any exemptions that need to be made in order to protect patient safety.

Are there any downsides to this policy? The Irish Pharmaceutical Union has warned that reference pricing could lead to medicine shortages.

And there are certain drugs with what is called a narrow therapeutic index – essentially they only work safely and effectively when present in a narrow concentration in the blood – which must be excluded from any substitution proposals.

Overall, however, the benefits of the new policy far outweigh any negatives.

Last week’s column referred to Dr Mel Fullam, whose full title is continuing medical education (CME) tutor with the Limerick faculty of the Irish College of General Practitioners.

mhouston@irishtimes.com