tag:theconversation.com,2011:/fr/topics/over-prescription-5951/articlesover prescription – The Conversation2017-08-28T02:44:58Ztag:theconversation.com,2011:article/826232017-08-28T02:44:58Z2017-08-28T02:44:58ZThe opioid epidemic is finally a national emergency – eight years too late<figure><img src="https://images.theconversation.com/files/183347/original/file-20170824-18740-l5137a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People without ID, like Steven Kemp, are sometimes turned away from the country's already threadbare system of drug treatment centers.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Addicted-Without-ID/adcb4b23ab414c9dba8220d049ded453/25/0">Matt Rourke/AP Photo</a></span></figcaption></figure><p>“It has been many long, hard, agonizing battles for the last few years and you fought like a warrior every step of the way. Addiction, however, won the war. To the person who doesn’t understand addiction, she is just another statistic who chose to make a bad decision.”</p>
<p>Despite working nearly two decades as an addiction scientist, I cannot read <a href="https://www.facebook.com/notes/kathleen-errico/kelsey-grace-endicott-eulogy/10154023124488818/">Kelsey Grace Endicott’s mother’s eulogy</a> without crying. The opioid epidemic has turned those who lost their lives to addiction into statistics, while leaving their families in sorrow. </p>
<p>Overdose deaths in the U.S. have tripled since 2000, with 52,404 deaths in 2015 as the highest ever recorded. While the Centers for Disease Control and Prevention (CDC) has yet to release official statistics for 2016, <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">early estimates</a> put the number of deaths at as many as 65,000.</p>
<p>In a speech on October 26, President Trump declared the opioid epidemic a national emergency. Nearly a decade into this epidemic, this national emergency was declared at least eight years too late. Policymakers have missed opportunities to implement strategies scientifically demonstrated to reduce overdose deaths and help people recover.</p>
<p>His announcement was vague on details and did not specify how much money would be dedicated to reducing overdose deaths. The President restated many initiatives that have already been initiated and focused on supply-reduction efforts that, while important, do little for the millions of Americans who are struggled with opioid addiction. We have proven prevention and treatment services that we need to significantly expand, and states need the money to do this. </p>
<h1>The right treatments</h1>
<p>Declaring the opioid epidemic a <a href="http://www.npr.org/sections/health-shots/2017/08/11/542767898/president-trump-to-declare-national-opioid-emergency">national emergency</a> expands the availability of federal funding; frees up public health workers to address the issue; and makes it possible to remove regulatory barriers to lifesaving medications. </p>
<p><a href="http://wchstv.com/news/raw-news/raw-news-sessions-addresses-opioid-problems-at-west-virginia-summit">In a speech on May 11</a>, Attorney General Jeff Sessions suggested that tools like “Just Say No” and Drug Abuse Resistance Education (DARE) can help fight the opioid epidemic. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/10450631">addiction science</a> has repeatedly proven that such drug prevention programs are <a href="https://www.scientificamerican.com/article/why-just-say-no-doesnt-work/">ineffective</a>. Some would argue that we are biologically wired to try new things, so education alone is not sufficient to prevent repeated drug use. </p>
<p>Prevention efforts are part of the solution, but we need more immediate solutions for people already ensnared by addiction. <a href="http://www.huffingtonpost.com/entry/naloxone_b_1475812.html">Naloxone</a>, known by the brand name Narcan, is usually the only thing that can prevent death when someone has overdosed on opioids. Science has <a href="http://www.nejm.org/doi/full/10.1056/NEJMra1202561">unequivocally demonstrated</a> that naloxone can reverse an opioid overdose, if administered in time and in an adequate dose. </p>
<p>When patients with opioid use disorders are treated with FDA-approved medications like methadone and buprenorphine, they not only reduce their use of opioids but they are also less likely to overdose. When these drugs are used to treat addiction, they are referred to as medication-assisted treatment. Medication-assisted treatment helps many people, particularly early in recovery, when otherwise their brains seem to focus only on using more drugs. In fact, <a href="http://ctndisseminationlibrary.org/protocols/ctn0030.htm">a National Institute on Drug Abuse study</a> found that only about 7 percent of patients can stop using opioids without buprenorphine.</p>
<p>We need drugs like naloxone and buprenorphine to prevent deaths and help people recover from addiction. In the past few years, state governments have taken significant steps to remove regulatory barriers and expand community access to naloxone.</p>
<p>But policies are infrequently aligned with addiction science. In 2015, only 11 percent of <a href="https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.pdf">people who needed addiction treatment</a> received it. There are not enough medication-assisted treatment treatment slots available: A recent study estimated that the U.S. was short 1.3 million treatment slots for medication-assisted treatment in 2012. Demand has <a href="http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2015.302664">only increased since then</a>. </p>
<p>There is an entrenched belief that people choose to use drugs and that this choice reflects a moral failing. Even the director of the U.S. Department of Health and Human Resources – which cites medication-assisted treatment as part of its strategy – <a href="https://www.hhs.gov/about/news/2017/06/19/sec-price-meets-opioid-addiction-specialists-providers-and-treatment-facilities-stakeholders-readout.html">has been quoted saying</a>: “If we’re just substituting one opioid for another, we’re not moving the dial much.”</p>
<h1>Moving too slowly</h1>
<p>Early on, everyone believed that the epidemic was fueled by widely available <a href="http://www.latimes.com/opinion/op-ed/la-oe-hari-prescription-drug-crisis-cause-20170112-story.html">prescription pain relievers</a>. Books like <a href="http://johntemplebooks.com/books/american-pain/">“American Pain”</a> by John Temple described “drug tourists” routinely traveling from states like Kentucky and West Virginia to Florida, where millions of prescription pills were dispensed at “pill mills.” </p>
<p><iframe id="Nmi7F" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Nmi7F/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Such overprescribing and doctor-shopping <a href="https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf">did contribute</a> to the current epidemic. States <a href="https://www.cdc.gov/media/releases/2017/p0706-opioid.html">have been successful</a> at dispensing fewer prescription opioids, but this doesn’t help the nearly 2.6 million Americans <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf">already addicted</a>, or the 329,000 who report currently using heroin. </p>
<p>And, since 2014, it has become clear that the epidemic is no longer just about prescription opioids. In addition, heroin is frequently mixed or substituted with <a href="http://www.herald-dispatch.com/_recent_news/dealer-behind-huntington-s-overdoses-sentenced-to-years-in-prison/article_4e22304c-2398-11e7-bcd1-97ce0311d81c.html">powerful synthetic opioids</a> like fentanyl or carfentanil. They require far more of the overdose reversal drug naloxone than is routinely dispensed in communities.</p>
<p>Meanwhile, in <a href="http://www.npr.org/2017/06/29/534916080/ohio-town-struggles-to-afford-life-saving-drug-for-opioid-overdoses">poor and rural areas</a>, community resources for public services are being <a href="https://www.nbcnews.com/news/us-news/too-many-bodies-ohio-morgue-so-coroner-gets-death-trailer-n733446">exhausted</a> by the costs of the epidemic.</p>
<p>Areas that have been disproportionately impacted by the epidemic, like West Virginia, have woefully inadequate access to harm-reduction services like syringe exchange programs and specialty addiction treatment. A clinic at our university that dispenses buprenorphine has more than 600 people on its waiting list. We will soon open a second clinic that will help reduce but not eliminate the waiting list. </p>
<p>A bill passed by President Obama, <a href="https://www.samhsa.gov/newsroom/press-announcements/201612141015">the 21st Century Cures Act</a>, is making approximately US$1 billion in funding available to help states combat the opioid epidemic. But, as <a href="https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end">Dr. Keith Humphreys at Stanford University</a> has said: This is not enough. We likely need <a href="https://www.nytimes.com/2017/06/30/health/drug-treatment-opioid-abuse-heroin-medicaid.html?mcubz=1">50 times that</a>, as Ohio spent $1 billion in 2016 on the opioid epidemic. </p>
<h1>Fighting back</h1>
<p>It can be hard to grasp the devastation of the opioid epidemic. As the President’s Commission on Combating Drug Addiction and the Opioid Crisis <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf">has described it</a>, in the scale of deaths, it’s like the September 11 terrorist attacks happening every three weeks. A national emergency would have been declared 10 years ago if such a disaster occurred every three weeks. And it can be even harder to imagine the emotional turmoil and the depth of sorrow felt by the families who’ve lost their daughters, sons, brothers, sisters, mothers and fathers. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Joe Fitzpatrick looks at a portrait of his daughter, Molly, at an exhibit honoring those who have died in New Hampshire’s opioid epidemic.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Angels-of-Addiction/90769b4151664523b3effc0158f9c704/23/0">Holly Ramer/AP Photo</a></span>
</figcaption>
</figure>
<p>I think it’s fair to say that we all want a simple solution – something that we can wrap our arms around. Something that can be done in one legislative session. But that has not worked and it will not work, just as declaring a national emergency is not enough. </p>
<p>Addiction scientists know what needs to be done to turn the tide. While we may not understand every aspect of the epidemic and certainly need more research to understand these <a href="https://www.brookings.edu/bpea-articles/mortality-and-morbidity-in-the-21st-century">deaths of despair</a>, we are eager to collaborate with communities to find empirically informed solutions, such as medication-assisted treatment. The President’s <a href="https://www.whitehouse.gov/ondcp/presidents-commission/members">Commission on Combating Drug Addiction and the Opioid Crisis</a> consists of four politicians and one addiction scientist. It might help to start by asking an expert, rather than politicians, what should be done.</p>
<p><em>This is an updated version of an article originally published on August 27, 2017.</em></p><img src="https://counter.theconversation.com/content/82623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Winstanley receives funding from the Hilton Foundation, CDC, and NIH. </span></em></p>President Trump declared the opioid epidemic a national emergency. But we need to do a lot more to prevent this crisis from escalating even further.Erin Winstanley, Associate Professor of Pharmacy, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/603002016-06-21T10:01:02Z2016-06-21T10:01:02ZTo fight antibiotic resistance, we need to fight bad prescribing habits<figure><img src="https://images.theconversation.com/files/126555/original/image-20160614-22388-nb92ko.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-432400009/stock-photo-antibiotic-resistance-concept-antibiotic-resistance-is-one-of-the-most-important-worldwide.html?src=kAi8ZzwIV4O9C_Bj-JkHug-1-0">Antibiotics image via www.shutterstock.com.</a></span></figcaption></figure><p>May’s announcement that a strain of bacteria <a href="http://www.cnn.com/2016/05/26/health/first-superbug-cre-case-in-us/">with genes conferring resistance</a> to colistin, our antibiotic of last resort, was identified in the United States, is just the latest report highlighting the growing threat of antibiotic resistance. </p>
<p>Antibiotic resistance is driven by many factors, the most significant of which is <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6432a3.htm">inappropriate prescribing</a>. This is when patients get a prescription for an antibiotic that they don’t really need, or get a prescription for the wrong antibiotic, the wrong dose or the wrong duration. And doctors know that inappropriate prescribing feeds the problem. So why do they keep doing it?</p>
<p>As a clinical pharmacist who has studied antimicrobial resistance and developed intervention programs to reverse the trend, I know firsthand how challenging this problem is to solve.</p>
<p>I believe there are two reasons inappropriate prescribing is so hard to curb. First, there is a philosophical disconnect between the data about antibiotic resistance and what drives prescriber behavior. The second is that physicians may bend to patient demand for antibiotics, even if the physician knows it won’t help or isn’t really needed.</p>
<h2>Physicians: Does your hospital have a resistance problem?</h2>
<p>Typically, antibiotic resistance data is captured at the population level. Reports about resistance look at what is going on in <a href="http://gis.cdc.gov/grasp/PSA/MapView.html">countries, states or regions</a>. But antibiotics are prescribed by individual physicians to individual patients. So looking at population-level data makes it easy to deny that it’s a problem in your clinic or hospital, and that your behavior is contributing to it. </p>
<p>That means one of the solutions to curbing antibiotic resistance is to personalize the problem for doctors to get them to change their prescribing habits. And, at least in hospitals, this approach has been shown to work.</p>
<p>In the 1990s, I led a group at the University of Florida College of Pharmacy that established the <a href="http://www.armprogram.com/">Antimicrobial Resistance Management (ARM) Program</a>. ARM worked with over 400 hospitals nationwide and in Puerto Rico. We sent customized reports to hospitals that included their antibiotic use over at least the past three years, which was compared to resistance levels for several types of bacteria that commonly cause infections. That meant we could determine if there was any statistically significant relationship between antibiotic prescribing habits and resistance at the hospital level. </p>
<p>Because the data was institution-specific, providers couldn’t deny that their hospital had a resistance program, and that they may be contributing to it. </p>
<p>What does that mean in practice? ARM examined the relationship between imipenem, a broad spectrum antibiotic, and Pseudomonas, a bacteria that often causes healthcare-acquired infections, at a particular medical center. The program found that if the medical center did not change their prescriber behavior for this antibiotic, resistance would rise one percent for every 30 average daily doses in adults.</p>
<p>This tells prescribers much more about the chance that a key antibiotic will become less effective against a common infection than <em>general</em> population-level data would. Knowing this, hospital staff and individual providers might think carefully about when to prescribe antibiotics, and to prescribe the right dose, the right frequency of dose and the right duration if and when they do.</p>
<p>Those behavior changes have a big effect. For example, at the same medical center, these reports helped to change prescribing habits for ciprofloxacin, a widely used antibiotic that you may know as Cipro, to the point that it became <a href="http://www.ahcmedia.com/articles/15665-using-antibiotic-stewardship-programs-to-curb-resistance-in-fight-against-hai">26-76 percent more effective</a> at treating infections caused by certain organisms, especially those associated with hospital-acquired infections. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126785/original/image-20160615-14016-1dgk1tr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients get prescriptions for illness that don’t require them.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-296155079/stock-photo-prescription-form-clipped-to-pad-lying-on-table-with-keyboard-and-stethoscope-medicine-or-pharmacy.html?src=IZCi9ksi8NB30BW2R8IWeg-1-14">Prescription pad image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Patients play a role</h2>
<p>So there’s a way to get physicians in hospitals to think about how they prescribe antibiotics. But most antibiotics are prescribed in <a href="http://www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html">outpatient clinics</a>.</p>
<p>In fact, a <a href="http://jama.jamanetwork.com/article.aspx?articleid=2518263">recent sample of outpatient visits</a> in the United States revealed that there were about 506 antibiotic prescriptions per 1,000 people in the U.S. Of these, about 69.7 were deemed appropriate. The rest weren’t, and were often prescribed for diseases include bronchitis, sinusitis, ear infections and sore throats, which will often go away on their own. And many of these diseases are often caused by viruses, which won’t respond to antibiotics. </p>
<p>So to really combat inappropriate prescribing, we also need to reach physicians in outpatient clinics. Targeted data could help here. But the problem is that the systems that monitor antibiotic resistance and prescribing rates do not collect quality data on outpatient clinics. Even if they did, there is no standardized mechanism to deliver that information back to the community-based provider.</p>
<p>Beyond that, we also need to reach their patients. Part of the reason physicians prescribe antibiotics is that they bend to the expectations of their patients.</p>
<p>If a patient with a chest cold decides to see his provider, the patient most likely took off work, spent time in a waiting room, then more time waiting in the exam room until the provider finally came in to spend a few minutes of face-to-face time with him. The last thing the patient wants to hear is that he should get some rest, drink plenty of fluids and take Tylenol. He feels as if he made an investment, and for his investment, he wants a return. Hence a prescription, often for an antibiotic. Providers know this and realize that patients will leave sooner <a href="http://dx.doi.org/10.3399/bjgp15X688105">and happier</a> if the provider gives patients what <a href="http://www.ncbi.nlm.nih.gov/pubmed/19799568">they want</a>. </p>
<p>The challenge for patients is complicated by the fact that numerous pharmacies will now provide them <a href="http://thekrazycouponlady.com/tips/finance/6-pharmacies-offer-free-antibiotics/">free antibiotics</a> with a proper prescription. This not only increases the demand from patients for an antibiotic from their provider but it also increases the demand for select antibiotics since not all antibiotics are offered free of charge. </p>
<p>The increased demand for a select group of antibiotics speeds up the development of resistance against those drugs and cuts down on the time before they become useless. </p>
<p>While physicians should avoid prescribing antibiotics to patients unless they are truly necessary, patients must also accept the fact that <a href="http://www.cdc.gov/Features/GetSmart/index.html">not all infections require an antibiotic</a>. </p>
<p>Patients have to take responsibility for the retention of antibiotic efficacy for future generations. They should share with their provider that they want to partner with him or her toward a more responsible level of infectious disease care. </p>
<p>There are solutions, but to realize them, we need to stop discussing antibiotic resistance as an abstract, population-level problem and drive the solutions down to where the problem started, the patient-provider relationship.</p><img src="https://counter.theconversation.com/content/60300/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Gums does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Doctors know that inappropriate prescribing can lead to antibiotic resistance. So why do they keep doing it?John Gums, Associate Dean for Clinical Affairs and Professor of Pharmacy and Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/512112015-11-26T16:26:14Z2015-11-26T16:26:14ZHow the health system is skewed towards harm for pill-popping pensioners<figure><img src="https://images.theconversation.com/files/103044/original/image-20151124-18233-ve9jcm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Overdoing it? Pills and thrills and bellyaches.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/theloushe/4398776292/in/photolist-7GGSWy-4HcCQN-9FzXUW-4Jzs2D-4Sjv2F-4o2Vx7-qiCHRc-9Fx382-9rA4CA-4KUvLd-4KQexF-9DoYGq-86mmkA-35Wmxp-82QfFL-9DoUZy-9Dm2bT-9Dm3di-9DoTJy-9DoSKy-4DaNqj-82Qiih-82M8WZ-asQxQW-4DaPq7-4D6xyc-4D6xRP-4YRtwa-5ZkLeq-82Qg7Y-82QhCb-82M7sB-82QkgL-82Qmgu-82M89R-73yLv5-86mmBG-73yLqo-86ibpV-6viS2v-4YQapq-4YKT9i-4YQ9HA-4YKSXB-aDKmP-5JzkVv-grGSMs-3KxyJp-t1HFiL-6BECfT">Jessica Lucia</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>The population of Europe is ageing rapidly. But as we add years to life, are we successfully adding life to years? A <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2900195-6.pdf">recent analysis</a> suggests not. The concept of healthy ageing – emphasising physical, social and mental well-being – has become a policy priority with the EU’s ambitious target to <a href="http://eurpub.oxfordjournals.org/content/early/2013/03/13/eurpub.ckt030">increase healthy life expectancy by two years by 2020</a>. To achieve this, we will need to tackle head-on the crucial, yet often neglected, problem of medication-related harm among older people.</p>
<p>The World Health Organisation (WHO) estimates that one in every four people in Europe will be aged over 65 by 2050. This reflects a doubling in the older adult population, and the fastest population growth <a href="http://www.euro.who.int/__data/assets/pdf_file/0006/161637/WHD-Policies-and-Priority-Interventions-for-Healthy-Ageing.pdf?ua=1">will be in those aged 80 years and over</a>. This growing cohort of older people is the largest consumer of healthcare services and prescription [medications in Western society](http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf](http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf). </p>
<p>It is a global trend, and the US gives us some useful data to describe it. Between 1990 and 2000, prescription drug spending in America grew by 11.6%. It cost US$263 billion in 2011, when it represented almost <a href="http://www.cdc.gov/nchs/data/hus/hus13.pdf">10% of national health expenditure</a>. Over a similar period, the expenditure on marketing of prescription drugs by pharmaceutical companies tripled to <a href="http://www.cdc.gov/nchs/data/hus/hus13.pdf">over US$4 billion</a>.</p>
<h2>War on inappropriate drugs</h2>
<p>The situation in the UK is no different, where two-thirds of the primary care prescribing budget is spent on older people in an NHS which has a rising drugs bill currently sitting <a href="http://www.pharmaceutical-journal.com/news-and-analysis/news/nhs-expenditure-on-prescribed-medicines-up-by-76-with-151-increase-in-hospital-sector/20067182.article">at more than £14 billion annually</a>. Over the last decade, there has been a 55% increase in the number of prescription drugs dispensed in England. <a href="http://www.theguardian.com/society/2013/nov/03/behind-the-scenes-gp-surgery-evenings-weekends">Excessive demands on GPs</a> have contributed to this. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103189/original/image-20151125-23864-1avqpwd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Breaking the habit. With services under pressure, it’s time to act.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/santheo/2438840018/in/photolist-4HvGaQ-9yNJUZ-5s32sr-7gKjQG-xd8Bws-6KH7jf-bbx7NT-azjwr-rmjEp-6pQsRR-dFamrA-6bfL1X-7ueErX-7ueED4-5osdzj-vhsEp-6RfvFj-5onWNt-vhsuk-3QHqsU-MzJy-orTsnB-4FdwYs-6EuR14-A4BTa-ahCQ4A-5LDsTX-abanU6-8MCUGP-abuNw-9jGEVr-5tFwKC-aGkkUp-7eqkfF-9nMEfr-9NH9LR-9NGYZA-edLav9-ehTZti-9tpxN4-9zAqiz-4fALot-jamia-4qJFGV-fGpmCx-9tpxXe-otDfuT-6ToU58-7yUgW1-sjYd7P">Sandor Weisz</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>As the UK government pushes almost £22 billion in efficiency <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/budget-2015-live-emergency-uk-8bn-more-annual-funding-for-nhs-by-2020-10375397.html">cuts on the NHS</a> by 2020 and £200m <a href="http://www.kingsfund.org.uk/blog/2015/08/cuts-public-health-spending-falsest-false-economies">removed from the public health budget</a> for the 2015-16 financial year, “deprescribing” medications that have poor evidence for benefit and good evidence for harm should be a priority. This can be done safely, and has been <a href="http://archinte.jamanetwork.com/article.aspx?articleid=226051">shown to improve health</a>. </p>
<p>Despite this, public health programmes which are evidence-based, cost-effective with a focus on primary prevention, and with low potential to cause harm are <a href="http://www.bbc.co.uk/news/health-34912767">suffering the brunt of austerity</a>. Inappropriate prescribing of antibiotics has attracted attention with the first <a href="http://www.who.int/mediacentre/events/2015/world-antibiotic-awareness-week/event/en/">World Antibiotic Awareness Week</a> launched by the WHO, but this must be considered within the wider public health context of over-medicalisation and harm.</p>
<h2>Medication harm</h2>
<p>The alarming fact at the centre of this is that at least one in every six hospitalisations of older people is due to a harmful effect of their medication. The vast <a href="http://ageing.oxfordjournals.org/content/38/4/358.full.pdf+html">majority of these are preventable</a>. In 2004, it was estimated that adverse drug reactions cost the NHS £466m but given the <a href="http://www.hscic.gov.uk/catalogue/PUB17644/pres-disp-com-eng-2004-14-rep.pdf">substantial increase in prescriptions</a> since this estimate, it is reasonable to assume that the cost today is greater. The most <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000562/pdf/bcp0063-0136.pdf">commonly implicated drugs</a> in preventable hospital admission are anti-platelets, diuretics, nonsteroidal anti-inflammatory drugs and anticoagulants.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103191/original/image-20151125-23816-1wzweyd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Overloading hospitals.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/policeblue999/3288476949/in/photolist-61AiCr-oKXiF9-9BgPJX-6hawhV-wqhKgq-3wCrfk-6ynh8b-dRYL4c-6JTWhF-p94tVL-4dkWxb-2WZAZ8-2WZz7k-2X4N6S-hoqyzN-2X4YRC-66bSDn-2X4Yb7-hyRuYP-2WZypR-7Fyw4x-5ng8D6-7FCrPG-7Gh7iJ-7FCozu-4pK8N8-7vnWa8-daxsQr-5aRMG9-4JanVu-5qRCz-6qa5ym-GSEZD-7FCpqj-4eqggv-cFeE9b-9ZmJ5W-82uob9-dMaCA2-hF9ViS-ajubHU-4VnBmh-77F2EQ-6E55VP-4P1SaF-5Ahxea-5AmNEs-4hQMG2-8Hge2s-cg3QDJ">TheEssexTech</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Medicine is conceptualised as both a science and an art. The science is about evidence-based patient management and the art is about considering the person as a whole rather than a single disease entity. Much of the management of older patients is based on extrapolation from clinical trials that exclude this population, particularly those that are frail or have cognitive impairment which today represents a significant proportion of this population.</p>
<p>Furthermore, clinical trials are far from representative of real life for the average patient. They do not have a research team monitoring and supporting an ideal use of a medication to achieve therapeutic benefit.</p>
<p>As such, the evidence for benefit of many commonly prescribed medications is patchy at best, and is dependent on large numbers of older people adhering to the medication regimen for a long period of time. For example, Statins, a class of drug that <a href="http://www.bmj.com/content/350/bmj.h3397.full?ijkey=2mYjSgnGBlAGkOP&keytype=ref">commonly attracts public attention</a>, is one of the most commonly prescribed drugs for older people at risk of cardiovascular disease despite an absence of robust evidence to make <a href="https://www.ucsf.edu/news/2015/04/125236/statin-use-elderly-would-prevent-disease-could-carry-considerable-side-effects">an informed risk-to-benefit analysis</a>.</p>
<h2>Laser-guided treatment</h2>
<p>The art of treating an older person requires consideration of this complex analysis, including their multiple possible chronic illnesses, their life expectancy, and most important their own informed wishes for medical management. “Successfully” treating one illness at the expense of the patient is no success at all. </p>
<p>The National Institute for Health and Care Excellence (NICE) has been criticised for its guidance on the management of many conditions that affect older people such as hypertension and diabetes. This is because the guidance is disease-specific, treating patients as an example of the disease <a href="http://www.gponline.com/gps-urged-ignore-nice-diabetes-advice-when-treating-frail-elderly/elderly-care/prescribing-for-the-elderly/article/1351453">rather than as a whole, complex person</a>. This misguided patient management has even been incentivised through payment mechanisms in primary care which reward doctors for tackling certain chronic illnesses through <a href="http://www.bmj.com/content/346/bmj.f659">the quality and outcomes framework</a>. </p>
<p>Nevertheless, it is an encouraging sign that <a href="http://www.pulsetoday.co.uk/clinical/prescribing/nice-multimorbidity-guidelines-due-next-year-announces-nice-chief/20009472.fullarticle">NICE will publish guidance</a> for the management of patients with multiple long-term conditions next year which is hoped to rationalise the medicalisation of older people.</p>
<p>Ivan Illich infamously described the medical establishment as a major threat to health in the opening line of his polemic <a href="https://books.google.co.uk/books/about/Limits_to_Medicine.html?id=Ac24QgAACAAJ&source=kp_cover&hl=en">“Limits to Medicine”</a>. While I wholeheartedly disagree with this assertion, it is time to step away from the status quo of a pill for every ill and remind ourselves of a central tenet of medicine <em>primum non nocere</em> – first, do no harm.</p><img src="https://counter.theconversation.com/content/51211/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nikesh Parekh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When one in six hospitalisations of older patients are due to harm from their medicines, then something is going seriously wrong.Nikesh Parekh, Research Fellow in Ageing, Brighton and Sussex Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/367482015-02-09T11:07:28Z2015-02-09T11:07:28ZMore doctors means more competition and more antibiotics<figure><img src="https://images.theconversation.com/files/70858/original/image-20150202-13049-1t8jzwi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More doctors, more antibiotics?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-159421511/stock-photo-cropped-image-of-a-pharmacist-holding-many-colorful-pills-in-the-palms-on-the-foreground.html?src=xI3DlQCdJPmaFotv9QXqIg-1-0&ws=0">Pills via Dragon Images/Shutterstock</a></span></figcaption></figure><p>According to the Centers for Disease Control and Prevention, two million people become infected with antibiotic resistant bacteria each year, leading to at least <a href="http://www.cdc.gov/drugresistance/">23,000 deaths</a>. And these infections cost a lot – US$20billion in extra health care costs <a href="http://www.cdc.gov/media/releases/2013/p0916-untreatable.html">each year</a>. To combat the problem, the White House is requesting <a href="http://www.whitehouse.gov/the-press-office/2015/01/27/fact-sheet-president-s-2016-budget-proposes-historic-investment-combat-a">$1.2 billion</a> in the 2016 budget for diagnostics, new antibiotics, outbreak surveillance – and stewardship, which is how antibiotics are prescribed and used. </p>
<p>One of the reasons that antibiotic-resistant bacteria have become such a problem is because we take so many antibiotics. Per capita consumption of antibiotics in the United States is among the highest in the world. In 2010, 258 million antibiotic prescriptions were written nationally, almost one per person (<a href="http://dx.doi.org/10.1056/NEJMc1212055">0.83 prescriptions per person</a>). </p>
<p>There is a direct link between antibiotic use and antibiotic resistance, and <a href="http://wwwnc.cdc.gov/eid/article/13/12/07-0629_article">studies</a> have found that antibiotic resistance rates are variable across the country. Thus it is important to understand what drives doctors to prescribe antibiotics as this could explain variable resistance rates. So we decided to examine if increased competition among providers leads to more prescriptions for antibiotics. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/70857/original/image-20150202-13069-1ac1gx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The more doctors there are per capita, the more likely you are to walk out of an appointment with a prescription for antibiotics.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-57554398/stock-photo-attractive-male-doctor-giving-a-prescription-to-his-patient.html?src=D8DBwAkjgtzM8j6PxYa6hg-1-55&ws=0">Doctor via wavebreakmedia/Shutterstock</a></span>
</figcaption>
</figure>
<h2>More doctors mean more prescriptions</h2>
<p>Prescribing rates can vary between states and within states. Many factors can drive these differences, like age, for instance. Children under the age of 10 and the elderly both consume <a href="http://dx.doi.org/10.1056/NEJMc1212055">large amounts of antibiotics</a>. Access to health insurance, which in the US is primarily provided through <a href="https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7451-08.pdf">employment</a> (for those under 65), also plays a role. So rates can vary based on the population makeup of a given area (ie, more young children, more elderly residents, unemployment rates). </p>
<p>But, we found that the number of physicians per capita can also drive up prescribing. In other words, the more physicians there are per person in an area, the more prescriptions per person there will be. </p>
<p>Why would more physicians lead to more prescriptions? One reason is that more physicians simply means it is easier to see a doctor and thus people may go to visit a physician more often than they need to. This is sometimes referred to as <a href="http://dx.doi.org/10.1016/j.healthpol.2008.11.013">supplier-induced demand</a>.</p>
<p>The second reason is that physicians are competing for business either by increasing the number of patients they see by adding walk-in hours and same-day <a href="http://www.aafp.org/fpm/2006/0500/p19.html">scheduling</a> or by prescribing antibiotics more readily – even if they wouldn’t do any good – to maintain good patient <a href="http://www.bmj.com/content/317/7159/637">relationships</a> or to help retain <a href="http://home.uchicago.edu/%7Edmbennett/abx.pdf">patients</a>. </p>
<p>To try to understand the relative effect of access vs. competition in driving prescribing rates, we looked at what happens when retail and urgent care clinics move into an area.</p>
<h2>The doc-in-the-box will see you now</h2>
<p>Retail and urgent care clinics, a delightfully American-style invention, have recently exploded in popularity and greatly expanded their reach. Sometimes called “Doc-in-the-Box” establishments, they are open nights and weekends when many doctor’s offices are closed and don’t require appointments. They also tend to cost less than a visit to more traditional medical practices. And when they enter a new area, they often compete with existing medical practices. </p>
<p>Because the number of retail and urgent care clinics has increased dramatically in recent years, we used these “Doc-in-the-Box” establishments to examine how physician prescribing is influenced by this competition and how an increase in provider density affects prescribing. </p>
<h2>More competition means more antibiotics</h2>
<p>We found that these clinics are great for improving access when they are placed in areas that are poorer. So in these areas we find that a clinic results in more antibiotic prescriptions because access is better. This doesn’t lead to competitive effects with physicians because the clinics are not drawing people away from physicians. Instead they allow people who would not have gone to the doctor to have access to the healthcare system.</p>
<p>In wealthier areas, where people already have access to providers, these retail clinics generally mean competition for physicians. So people now have a choice: they can just walk-in to a clinic or try to make an appointment at their doctor. Thus in areas with a lot of physicians, the introduction of a clinic and the resulting competition for patients pushed prescribing rates by physicians up even further. </p>
<h2>What can be done?</h2>
<p>Understanding the factors that drive variability in prescribing rates, can help policy makers better target the activities that lead to inappropriate prescribing, like competition between providers.</p>
<p>Retail and urgent care clinics in both the US and <a href="http://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/report-out-of-hours-gp-services-in-england/">abroad</a> have increased access for people who lack access to primary care. But compliance with prescribing guidelines and oversight of clinics is necessary to ensure that better access and more competition doesn’t result in unnecessary antibiotic prescriptions.</p>
<p>While health care is a business, greater coordination between different kinds of practitioners (including clinics, primary care physicians, and specialists) and fostering more collaborative environments between physician offices and clinics could help reduce factors that lead to over-prescribing of antibiotics.</p><img src="https://counter.theconversation.com/content/36748/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eili Klein receives funding from The Models of Infectious Disease Agent Study (MIDAS) awarded by the National Institutes of General Medical Sciences at the National Institutes of Health (U54 GM088491).</span></em></p><p class="fine-print"><em><span>Ramanan Laxminarayan receives funding from the Extending the
Cure Project funded by a Pioneer Portfolio grant of the Robert Wood
Johnson Foundation.</span></em></p>When retail health clinics move into new areas, antibiotic prescription rates go up.Eili Klein, Assistant Professor, Johns Hopkins UniversityRamanan Laxminarayan, Senior research scholar and lecturer, Princeton Environmental Institute , Princeton UniversityLicensed as Creative Commons – attribution, no derivatives.