Inappropriate use of medicines is a longstanding problem; a Google ngram for polypharmacy shows it first appeared in 1843 and its usage quarupled in the second half of the 20th century.
Deprescribing has yet to appear on Google ngrams, but is highly prevalence on social media and in more recent academic work. One definition is:
Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes.1
Deprescribing appears to have gained more traction than polypharmacy amongst practitioners. Perhaps because deprescribing does not merely describe the world, but seeks to change it. Invert the act of prescribing, and you give permission to act. A tribe of like-minded people are starting to change the culture. People are doing great work.2
Pharmaceutical marketing, single-disease state evidence based medicine guidelines, government targets, and socio-cultural expectations of treatment added to the problem of polypharmacy.3 Polypharmacy seemed insurmountable. You can try to build a movement on a problem, but a solution is better.
As a meme, deprescribing is an evolutionary shift of emphasis. A pivot. It’s not entirely new, anyone working as an enlightened clinical pharmacist back in the 1990s would have done some, but the stop(p)-start growth of concern about the burden of medicine harms, extension of clinical pharmacists into primary care, prescribing rights, and pharmacogenomics have given greater opportunities to make a difference.
Could a single word change help change practice?
In the case of deprescribing, on balance, I think so.
Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254–1268. doi: 10.1111/bcp.12732. LINK ↩
Amongst other things… ↩
Adverse drug reactions (ADRs) are badly reported in clinical trials, and many rare and long-term ADRs cannot be detected in standard tests for efficacy. This makes systematic reviews of specific ADRs associated with a drug difficult to perform, and the sensivity and precision of searches can be poor if methods used to find efficacy studies are used.
Golder et al1 have published an excellent evidence-based best practice for systematic reviews of ADRs in the literature, from question formulation, to search strategies and database choices, to use of unpublished sources of data (such as spontaneous data and theses). Essential reading if you are involved in the search for harms, and want to avoid false negatives…
Overview: comprehensive and carefully constructed strategies are required when conducting searches for adverse effects data Golder, Su et al. Journal of Clinical Epidemiology, Volume 113, 36 - 43 ↩
Back in 2000, before social media1, my first website was a simple set of static webpages about adverse drug reactions. In 2003, as the then blogosphere expanded, I integrated Blogger into the site. Later, I moved to the more complex Movable Type, before finally settling on Wordpress.
Wordpress has been great. It’s fantastic blogging software, but it is high maintenance. Constant updates are required, and the high usage of Wordpress mean it is under constant attack by hackers. After multiple hacking attacks, the last of which injected spam into 16 years worth of posts, I’ve moved back to a static website using the Marie Kondo of blogging, Jekyll, as a generator, with the standard minima theme. It’s not as convenient as Wordpress, but the benefits of low maintenance and having to learn new skills (like Markdown) far outweigh that.
It’s medicines safety week this week, and medicines continue to be an avoidable harm of modern healthcare. Modern pharmacovigilance stems from the birth defects arising from the use of thalidomide, but despite improvements in pharmacovigilance new issues arise with both new medicines and ancient medicines. Some issues with well established drugs can rumble on for years before effective action is taken.
A useful update on your knowledge of adverse drug reactions and how harms can be reduced can be found at the BMJ written by Ferner and McGettigan.
One meaningful outcome of this week, should be a commitment to improving medicines safety by reporting an adverse drug reaction to regulatory authorities by the end of the year. Do it before the leaf turns, and when the leaf has turned make it a habit of your practice.
Only by pooling our efforts can we improve medicines safety, and each report contributes to detecting and dealing with the safety issues that cause. In the UK, you can report via the Yellow Card Scheme if you are a patient or healthcare professional, but if you aren’t based in the UK there will be a system for you.
The picture at the top of this post is from the Uppsala Monitoring Centre, who are running an excellent social media campaign to raise awareness globally along with regulatory bodies around the world.
The use of a multi compartment compliance aid (MCA) or monitored dosage systems (MDS), as pictured above, is often seen as an easy way to deal with the sometimes complex problems of ensuring patients take their medicines. There is scant evidence of benefit, and they aren’t without harm. In one area of the UK it was reported that 30% of reported medication safety incidents related to MCAs.PDF
The MCA above comes from a BBC report on the tragic death of a patient following an error, leading to the patient taking two MCAs at the same time. I was asked to look at a number of the MCAs that the family had in their possession to look at alleged failures to follow the Standard Operating Procedures in their production. The programme is on BBC iPlayer for a short time, if you wish to view it. See update at bottom for clarification about the case.
The case itself got me thinking about the use of MCAs in the context of the changing context of pharmacy practice, as well as the drive in therapeutics on polypharmacy, and the deprescribing movement. It’s five years since the publication of the Royal Pharmaceutical Society’s report on MCAs PDF.
With the limited evidence base currently indicating a lack of patient benefit outcomes with the use of MCA, it is a recommendation of the RPS that the use of original packs of medicines, supported by appropriate pharmaceutical care, should be the preferred intervention for the supply of medicines in the absence of a specific need for an MCA in all settings.
I’m not sure matters have improved, and a number of questions have arisen in my mind.
Firstly, what are the incentives for moving away from MCAs? It seems as though MCAs are seen as a method of script capture by pharmacy businesses. How can we change the model to reduce their use?
Secondly, making up an MCA is essentially a manufacturing process. It is not dispensing. It has just as complicated a production process, with many potential pitfalls, as extemporaneous dispensing. We no longer do that in community pharmacy. Shouldn’t MCAs be made in designated production areas, away from clinical activity, that can run standard operating procedures as production unit? There may be a cost involved, and a move to hub supply, but see point one.
Thirdly, shouldn’t we be focusing on ensuring that patients can develop the simplest and most appropriate medication regime for their health needs? Sticking an MCA-plaster on top of the accumulated medicines that a patient finally finds too much too cope with is not the answer. If some says “I think we should use an MCA for this patient”, the answer should be “Let’s review the patients’s medication” with them.
UPDATE: On LinkedIn, the MD of a company supplying MCAs suggests that this blog post blames MCAs for the death reported in the BBC programme. It does not. The purpose of this post wasn’t to tar MCAs with that specific incident, but to explore some points the case had made me think about. Whether the circumstances that arose to the double supply of a medication would have arisen if the patient had not been put on MCAs no one can guess. He is correct however to note that this blogpost does not mention the primary error (relating to communication) leading to the patient death or the company involved, that is set out in the TV programme and the BBC webpage dealing with programme if you are interested. At the inquest it was found that the patient “was inadvertently given double his medicine by two separate Boots pharmacies in a “communication breakdown”.