Too many patients are prescribed drugs they don’t need. So here’s a radical solution: Let pharmacists de-prescribe

Community pharmacists say the following true story is sadly all too familiar these days: a High Street pharmacy is handed a new prescription by a regular customer who is already taking a range of medicines prescribed by his GP.

The new prescription is for Parkinson's disease. The pharmacist wonders about the man's misfortune: this patient has been taking so many medications for his various symptoms that he has also recently been prescribed a medication called prochlorperazine (brand name Stemetil) just to combat the dizziness and nausea that the different medications cause. side effect.

And now the patient has developed Parkinson's disease on top of that – and has been given a new prescription for a drug with its own serious potential side effects, including nausea (again), confusion and an uncontrollable urge to gamble, have sex or do things after to strive for. being obsessive about hobbies (the drugs interfere with the brain's chemical reward systems).

But something in the back of the pharmacist's mind starts nagging him about prochlorperazine, so he double-checks the drug's warning list.

This shows that the drug can cause Parkinson's-like symptoms as a side effect in some patients, such as shuffling gait. (The drug can block the action of the chemical dopamine in the brain, and in Parkinson's itself, the brain steadily loses its ability to produce dopamine, which is key to coordinating movement.)

So instead of dispensing this last prescription, the pharmacist called the patient's doctor.

“The prescriber agreed to evaluate the patient,” the pharmacist told Good Health, “and the patient ultimately did not receive the Parkinson's disease medication.” Instead, his doctor stopped prochlorperazine and his Parkinson's-like symptoms disappeared.

The pharmacist has asked Good Health to keep his name confidential because he wants to maintain a good relationship with his local prescriber.

But his trade body, the Association of Independent Multiple Pharmacies (AIMP), said this story is typical of a growing national problem: patients being prescribed an ever-growing list of drugs, or 'polypharmacy'.

And while pharmacists themselves can act to protect against the dangers of polypharmacy, their ability to verify that prescriptions are always appropriate is being seriously hampered by the large-scale closure of pharmacies – some 540 in 2023 alone – due to soaring overhead costs and frozen incomes. .

The fact is that many prescription medications can be both harmful and helpful. This is especially true when people are taking multiple medications that can interact poorly or overload the patient's body.

A 2022 study from the University of Newcastle concluded that each additional drug prescribed to a patient was associated with a 3 percent increased risk of death.

And as a report published by NHS England (NHSE) in July 2023 concluded, it is not unusual for patients, especially older people, to take ten or more prescription medications, which could mean a 30 percent increased risk of death based solely on the number medications the patient is taking, not their actual condition.

Polypharmacy is often caused by patients going to hospital doctors or new GPs who are unaware of the other medicines they are already taking, explains Fin McCaul, director of Prestwich Pharmacy in Manchester, and committee member of the High Street pharmacies negotiating group . , Community Pharmacy England (CPE).

“The problem can also arise if a patient's GP replaces one of his medications with another medication, but the old medication is not removed from the prescription list, causing him to end up taking both medications,” he says.

Dr. Leyla Hannbeck, CEO of AIMP, blames the increase in polypharmacy on cuts to NHS services, which mean doctors do not have time to see patients as individuals, but rather as a series of diseases requiring medication.

“This leads to additional medications being 'screwed on' to control symptoms as they arise,” she says. 'This is especially true as patients move from primary care to hospitals, and back again – and leads to them receiving increasingly complex medication regimens.'

The government itself acknowledges that at least 10 percent of drug prescriptions are unnecessary. The National Overprescribing Review report, published in 2021, states that stopping these unnecessary prescriptions would be 'equivalent to a reduction of approximately 110 million items per year'.

Medicines prescribed in the community will cost the NHS in England £10.4 billion in 2022/2023, according to the Dispensing Doctors' Association.

Cutting that by 10 percent would save almost £1.5 billion, without counting the cost of human misery saved by reducing hospital admissions. A spokesperson for NHSE told Good Health that efforts are being made to reduce unnecessary prescriptions.

They pointed to this year's NHSE medicines 'optimization strategy', which recommends that local NHS commissioners consider 'tackling problematic polypharmacy' as a new project.

In fact, the NHS has had a policy to reduce polypharmacy for over twenty years. However, excessive prescription levels do not appear to have changed, and the Dispensing Doctors' Association prescribing figures look about the same as they did three years ago.

Why does the problem remain so persistent?

Dr. Victoria Tzortziou Brown, vice-chairman for external affairs at the Royal College of General Practitioners, told Good Health that GPs are highly trained experts in both prescribing and 'prescribing', but they are facing unprecedented demands and declining resources.

'GPs are seeing a greater number of patients with multiple conditions requiring complex treatment plans, some of which will involve careful consideration of the interactions between their medications, to minimize the potential risk of adverse side effects,' she says.

'It is therefore very important that general practitioners have sufficient time for patient consultations. But general practice is buckling under the pressure of the labor shortage, while demand is rising.'

Community pharmacists understand the intense pressures faced by primary care physicians. However, they see other causes of overprescribing that pharmacists could tackle themselves – if they were allowed to do so.

They say that although community pharmacists are the professionals who physically dispense medications, see patients most often and are knowledgeable about medications and their interactions, under the current system there is no intention to 'prescribe' medications as a patient is being treated. prescribed them unnecessarily.

Under a system introduced by the NHS in 2020, GP practices will instead be paid to carry out structured medicine reviews (SMRs) on patients at risk of polypharmacy.

At these reviews, which may be performed annually or at varying intervals depending on the physician's discretion, a primary care physician or other primary care professional is expected to review the patient's medications with them to discuss whether they are necessary, safe, and effective are.

Although community pharmacists are the professionals who physically dispense medications, see patients most often, and are knowledgeable about medications and their interactions, under the current system they are not intended to 'prescribe' medications (file image)

But no one seems to know how comprehensive or useful these new SMRs are. Research is currently underway at the University of Oxford on the effects (if any) on drug prescribing since its introduction. The first findings are expected in the second half of 2024.

However, it appears that access to SMR services from these GP practices may be slow and difficult to say the least, given that NHSE figures in July show that 1.3 million patients per month are waiting four weeks for a treatment. see your doctor.

Jay Badenhorst, vice president of the National Pharmacy Association, told Good Health that “people have to make do with the limited number of SMR appointments offered by physician practices.”

In countries such as Sweden, the Netherlands, Spain, Canada, Japan and Australia, community pharmacists already have the authority to dispense medicines.

A 2021 review in the British Journal of Clinical Pharmacology of 24 studies, involving more than 4,000 patients in these countries, concluded that this approach works effectively.

So why not in Britain? In September, two highly respected health policy charities, the King's Fund and the Nuffield Trust, published a report recommending that the NHS pay community pharmacists to carry out medication reviews.

Fin McCaul believes such a system is being held back by an unspoken government policy of funding GPs over community pharmacists.

'But empowering community pharmacists to review patients' medications and eliminate unnecessary medications is not only good for the patient, it can also save significant sums of money if it prevents them from harm and needing hospital admission. '

Instead, as Jay Badenhorst says: 'Cuts to NHS funding mean the number of community pharmacies continues to fall, with hundreds of closures every year.'

Meanwhile, more and more patients are receiving more and more medications.