Drugged up beyond belief
Copperfield on whether general practice is shooting itself in the foot by prescribing too many drugs to too many people
Is there a sense, do you think, that we are prescribing way too many drugs to way too many people? Just about every other headline seems to brings a new pharmaceutical mandate, and this week we are mostly prescribing semaglutide.
Yes, of course there is a sense we are prescribing too much. We’d all agree on that, then we’d remember QOF, and guidelines, and litigation, etc etc, and sigh, and carry on as before.
And carrying on as before, of course, means that yer average patient with T2DM, heart failure, hypertension and CV disease will be on around 10 medications per day and (now) one injection per week – once you’ve rattled through the T2DM management flow chart, propped up the four pillars of CF, remembered that a properly controlled hypertensive needs three drugs, and ticked all the secondary prevention boxes.
That’s before you get to the PPI for gastroprotection, the laxatives for the GI side effects and the antidepressants because, honestly, wouldn’t you be?
We know this causes us GPs numerous problems unaccounted for in any guidelines/cost benefit analysis. The endless up-titration appointments. The relentless cycle of blood monitoring and follow up of inevitable biochemical blips. Those rewarding consultations starting with the patients emptying their meds on the table and saying: ‘One of those is giving me side effects.’
But I’m going to be unusually patient-centred here. Because what the decision makers never consider is the Pain in the Friggin Arse Factor (PFAF) for the patient.
PFAF should be taken seriously. Every medication is a reminder of their vulnerability. Each change to their regime is a new stress. Every missed dose is a trigger for panic or guilt.
Plus, there’s the ongoing trauma of repeat-prescribing admin. Negotiating systems. Duplicated meds. Missing meds. Drug shortages. Lack of synch requiring multiple requests. Having enough for holidays. Changes in med suppliers. The GP insisting the red ones are as good as the blue ones, which everyone knows is rubbish.
And God help them (and us) when they’ve been admitted to hospital and discharged on a new regime. We could easily employ a full-time member of staff just to deal with the fallout.
It’s time for all this to be taken into account. What I think I’m saying is that NICE should incorporate PFAF when calculating QALYs and to inform QOF. QED.
Otherwise, there must come a point when the psychological stress of polypharmacy outweighs any theoretical physical benefit. Or even a point when the risk of being hit by a bus on the way to one of the multiple appointments required at the surgery is greater that the risk of not taking the treatment.
When will we reach that point? About five years ago.
Dr Tony Copperfield is a GP in Essex
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READERS' COMMENTS [9]
Please note, only GPs are permitted to add comments to articles
Visiting the patient at home and discovering countless boxes of unopened, unswallowed repeat meds, Dr Trump loses it….
“Open your mouth, you Crazy B**tard and let the meds flow down. Or your whole Civilised body will die. You have 24 hours to comply !!!*@&%??!!😡. Thank you for your attention.”
As usual straight to the nail’s head 👍👏👏👏
This was such a relief to read. Having recently returned from the EuroPrev conference on overdiagnosis and overtreatment, I’m much more aware of the ever lower thresholds for lipid management, ever more definitions for pre-disease. One thing we can say for sure is that the medical-industrial/ prevention-industrial complex is alive and well. The impact our activity has on climate change, the potential harm done to individual patients and the misery caused is enormous.
Just scrap QOF .Do not agree to any similar system in its place. It will free Gps up to exercising clinical judgment.
Next Nice and its diktats needs a serious review .
Would be nice if GPs could do a bit better prescribing GLP 1 drugs – life changing for those who can tolerate them.
Wise and masterly inactivity cures 90 % of a lot of problems.
As a student our first Dermatology lecture was “The Dangers of Topical Steroids”.
We then sat in clinics where virtually every patient was prescribed increasingly potent topical steroids.
We are frequently browbeaten about polypharmacy, especially when elderly patients are admitted with hypos and postural hypotension.
And yet we are still criticised for not prescribing ever more pills to ever more punters.
Damned if you do, damned if you don’t.
Let’s not be too hasty to damn appropriate polypharmacy. Absolutely we have an issue with over prescribing harmful drugs – anti-psychotics (when there is no SMI), Opiates, Benzos, Gabapentinoids, Anti-depressants, NSAIDs, TCAs. There is huge evidence these drugs do harm and yet many of our patients continue to be prescribed them. Then we have evidence based prescribing for particular conditions – the 4 pillars in heart failure, diabetes meds, anti-hypertensives, statins, all show an appreciable improvement in outcome. Yes its difficult to square away NNTs and RRR vs ARR but we can help our patients to make informed choices. Before we rail against potentially appropriate polypharmacy we need to ensure our own house is in order through deprescribing the drugs we know to be harmful with no evidence of benefit. But to do this deprescribing work and do help patients make informed choices is very time consuming and there is currently no funding for much of this work. We do our best but would love to do more!
A related if slightly tangential point is I see first hand through family members how confusing it is for patients when the appearance of and/ or packaging of whatever drug they take changes each time they get a new prescription – one month they’re on a small blue, a brown, and a round and diamond shaped white ones, the next month they’re given 4 round white ones. No wonder some folk struggle to keep track. I suspect this is a contributory factor to non compliance, ineffective meds or even side effects (overwhelm, missing or doubling up on meds in error etc). The sensible logical approach would be for the appearance of any given pill to be the same across all pharmaceutical suppliers, whoever makes it, whether on or off patent, . This must be feasible but of course this will never happen…. profit over common sense.