Twelve strategies or interventions to overcome irrational use of drugs. 

1.A mandated mult-disciplinary national body to coordinate medicines use policies:

• A mult-disciplinary approach is needed to develop, implement and evaluate interventions to promote more rational use of medicines.

• Many  activities  need coordination with many stakeholders such as: Health professionals, academia, the regulatory authority, pharmaceutical industry, consumer group and non-governmental organization involved in health care.

2.Clinical guidelines:

• Is a standard treatment guidelines or prescribing policies, consist of systematically developed statements to help prescribers make decisions about appropriate treatments for specific clinical conditions.

• It has been proven to promote more rational use of drug provided they are: developed in a particular way     involving end-users, easy to read, introduced with an official launch, training and wide dissemination,      Reinforced by prescription audit and feedback.

3. Essential medicines list based on treatment of choice:

•  Are those that satisfy the priority health care needs of the population.

• It makes medicines management easier in all respects like procurement, storage,  distribution, prescribing and dispensing as they deal with few items.

• National essential medicine list should be based upon national clinical guidelines.

• Medicine selection done by a central committee with agreed membership and explicit, previously agreed criteria, based on efficacy, safety, quality, cost which will vary locally and cost-effectiveness. 

4. Drug and therapeutic committees in district and hospitals:

• A drugs and therapeutic committee (DTC) or pharmacy and therapeutic committee is a committee designated  to ensure the safe and effective use of medicine in the facility or area under its jurisdiction.

• Government encourage hospitals to have DTCs by making it an accreditation requirement to various    professional societies.

• Responsibility of DTCs:

  1. Developing, adapting or adopting clinical    guidelines for the health institution or district.

  2. selecting cost-effective and safe medicines     (hospital/ district drug formulary);

 3.Implementing and evaluating strategies to improve medicine use (including drug use evaluation, and liaison with antibiotic and infection control committees

Twelve strategies/interventions to overcome irrational use of drugs. cont.

4. Providing on-going staff education (training and printed materials);

5. Controlling access to staff by the pharmaceutical industry with its promotional activities;

 6. Monitoring and taking action to prevent adverse drug reactions and medication errors;

 7.Providing advice about other drug management issues, such as quality and expenditure.

5. Problem-based training in pharmacotherapy

    in undergraduate curricula:

•The quality of basic training in pharmacotherapy

      for undergraduate medical and paramedical students can significantly influence future prescribing.

•Rational pharmacotherapy training, linked to clinical guidelines and essential medicines lists, can help to establish good prescribing habits.

6. Continuing in-service medical education as a licensure requirement:

•Continuing in-service medical education (CME) is a requirement for licensure of health professionals in many countries.

•It is  more effective if it is problem-based, targeted, involves professional societies, universities and the ministry of health, and is face-to-face.

• CME need not be limited only to professional medical or paramedical personnel, but may also include people in the informal sector such as medicine retailers.

 

7.Supervision, audit and feedback:

•Supervision is essential to ensure good quality of care.

•Supervision that is supportive, educational and face-to-

    face, will be more effective and better accepted by prescribers than simple inspection and punishment.

•Effective forms of supervision include prescription

Audit and feedback, peer review and group processes.

•Prescribers may be told how their prescribing

   compares with accepted guidelines or with that of their peers.

 In hospitals, such audit and feedback is known as drug use evaluation.

Group process approaches amongst prescribers consist of health professionals themselves identifying a medicine use problem and developing, implementing and evaluating a strategy to correct the problem.

8. Independent medicine information

•Often, the only information about medicines that practitioners receive is provided by the pharmaceutical industry and may be biased.

•Provision of independent (unbiased) information is therefore essential.

•Drug information centres (DICs) and drug bulletins are useful ways to disseminate such information.

•Both may be run by government or a university teaching hospital or a nongovernmental organization, under the supervision of a trained health professional.

•Whoever runs the DIC or bulletin must (1) be independent of outside influences and disclose any financial or other conflict of interest, and (2) use evidence-based medicine and transparent deduction for all recommendations made.

 9. Public education about medicines:

•Without sufficient knowledge about the risks and benefits

    of using medicines and when and how to use them,

   people will often not get the expected clinical outcomes

   and may suffer adverse effects.

• Governments have a responsibility to ensure both the quality of medicines and the quality of the information about medicines available to consumers. This will require:

• Ensuring that over-the-counter medicines are sold with adequate labelling and instructions that are accurate, legible, and easily understood by laypersons.

  The information should include the medicine name, indications, contra-indications, dosages, drug interactions, and warnings concerning unsafe use or storage.

• Monitoring and regulating advertising, which may adversely influence consumers as well as prescribers,

   and which may occur through television,radio,newspapers and the internet.

Running targeted public education campaigns, which take into account cultural beliefs and the influence of social  factors. 

 

10. Avoidance of perverse financial incentives:

•Financial incentives may strongly promote rational or irrational use. Examples include:

• Prescribers who earn money from the sale of medicines e.g. dispensing doctors will prescribe more medicines, and more expensive medicines, than prescribers who do not; therefore the health system should be organized so that prescribers do not dispense or sell medicines.

•Patients prefer medicines that are free or reimbursed.

 If only essential medicines are provided free by government or reimbursed through insurance,

 patients will pressure prescribers to prescribe only essential medicines.

If medicines are only reimbursed when the prescription conforms to clinical guidelines, there may be an even stronger pressure on prescribers to prescribe rationally

 

11. Appropriate and enforced regulation

Regulation of the activities of all actors involved in the use of medicines is critical to ensuring  rational use

If regulations are to have any effect, they must be enforced, and the regulatory authority must be sufficiently funded and backed up by the judiciary.

Regulatory measures to support rational use

• Registration of medicines to ensure that only safe

   efficacious medicines of good quality are available in the market and that unsafe non-efficacious medicines are banned;

• limiting prescription of medicines by level of prescriber;

  this includes limiting certain medicines to being available only with a prescription and not available over-the counter;

• Setting educational standards for health professionals

   and developing and enforcing codes of conduct;  this requires the cooperation of the professional societies and universities;

• licensing of health professionals – doctors, nurses, paramedics – to ensure that all practitioners have the necessary competence with regard to diagnosis, prescribing and dispensing;

• licensing of medicine outlets – retail shops, wholesalers

  – to ensure that all supply outlets maintain the necessary stocking and dispensing standards;

• Monitoring and regulating medicine promotion to ensure that it is ethical and unbiased. All promotional claims should be reliable, accurate, truthful, informative, balanced, up-to-date, capable of substantiation and in good taste.

 

12. Sufficient government expenditure to ensure availability of medicines and staff:

• Lack of essential medicines leads to the use of nonessential medicines, and lack of appropriately trained personnel leads to irrational prescribing by untrained personnel.

• Furthermore, without sufficient competent personnel and finances, it is impossible to carry out any of the core components of a national programme to promote rational use of medicines.

• Achieving these will require limiting government procurement and supply to essential medicines only, and investing in adequate training, supervision and health staff salaries.

Key Point

 The most effective approach to improving medicines use in primary care in developing countries is a combination of education and supervision of health personnel, consumer education, and ensuring an adequate supply of appropriate medicines.

 What are you planning to do to stop irrational use of drugs in your working place?