THINKING ALOUD: How doctors are causing poverty through overprescription

The fifth phase government has increased the budget of medicines by almost ten-fold yet I still hear that Tanzania does not have enough medicines.

The irony here is that there aren’t enough medicines and yet too much is prescribed unnecessarily.

Medicines are mostly imported at a high cost and this is taxpayer’s money. When medicines are not appropriately utilised it is actually waste of money and medicines will never be enough because it’s like having a bucket with a hole that will never be full.

Over prescriptions by our own doctors and indirectly promoted by the big pharma are causing the poor to be poorer.

There is no dispute that for many people, prescriptions are beneficial, even lifesaving in many instances. But hundreds of millions of these prescriptions are wrong, either entirely unnecessary or unnecessarily dangerous. Inappropriate prescribing is an academically gentle euphemism for prescriptions for which the risks outweigh the benefits, thus conferring a negative health impact on the patient and inviting poverty.

It is estimated that about twenty per cent of the prescriptions are inappropriate or unnecessary. Following is the seven all-too-often-deadly sins of prescribing.

First: the “disease” for which a drug is prescribed is actually an adverse reaction to another drug, DID (drug-induced disease) masquerading as a disease but unfortunately not recognised by the doctor or the patient. Instead of lowering the dose of the offending drug or replacing it with a safer alternative, the physician adds a second drug to the regimen to “treat” the adverse drug reaction caused by the first drug.

Second: A drug is used to treat a problem that, although in some cases susceptible to a pharmaceutical solution, should first be treated with commonsense lifestyle changes.

Third: The medical problem is both self-limited and completely unresponsive to treatments such as antibiotics or does not merit treatment with certain drugs. This is seen most clearly with viral infections such as colds and bronchitis in otherwise healthy children or adults.

Fourth: A drug is the preferred treatment for the medical problem, but instead of the safest, most effective and often least expensive treatment, the physician prescribes one of the Do Not Use drugs listed on this web site or another, much less preferable alternative. An example of a less preferable alternative would be a drug to which the patient has a known allergy that the physician did not ask about.

Fifth: Two drugs interact. Each on its own may be safe and effective, but together they can cause serious injury or death.

Sixth: Two or more drugs in the same therapeutic category are used, the additional one(s) not adding to the effectiveness of the first but clearly increasing the risk to the patient. Sometimes the drugs come in a fixed combination pill, sometimes as two different pills. Often heart drugs or mind-affecting drugs are prescribed in this manner.

Seventh: The right drug is prescribed, but the dose is dangerously high. This problem is seen most often in older adults, who cannot metabolise or excrete drugs as rapidly as younger people.

Apart from medicines the laboratory is another place, which is being grossly misused for commercial purposes. Unnecessary laboratory requests are made that have no bearing on the treatment of the patient. Glaring example is the “widal test” for typhoid fever, all doctors know that this is an obsolete test but is still done and the poor patients get poorer.

When treating a patient the conceptual focus of the doctor appears to shift from broader questions like ‘What is wrong with this patient?’ or ‘What can I do to help?’ to the much narrower concern, ‘Which prescription shall I write?’ this approach is supported by the barrage of promotional materials that only addresses drug treatment, not the more sensible lifestyle changes to prevent the problem.

There are many reasons why there is unnecessary prescriptions but the root cause analysis pinpoints that its because there is no regulatory framework in place hence doctors are unnecessarily overprescribing. It is the primary responsibility of Ministry of Health to create a framework that will regulate the doctors prescribing behaviors. In Ghana where such a system was introduced and doctors received feedback about their performance on prescriptions, unnecessary prescriptions were significantly reduced. Now soft wares are available to create a nation wide monitoring system.

The other reason for overprescribing of medicines is the pharmaceutical industry, which spends a fortune in advertising, cohesiveness and other market tricks for medicines where proof of superiority is lacking but still new medicines are introduced. The MoH should ban all medicine related advertisement including over the counter medicines.

Doctors, including myself, are also to be blamed for overprescriptions. There is a heavy influence by drug companies, accepting free meals, free drinks, and free medical books in exchange for letting the drug companies “educate” them at symposia in which the virtues of certain drugs are extolled. Unfortunately, many of these doctors are too arrogant to realise that there is no such thing as a free lunch. The majority of doctors attending such functions have been found to increase their prescriptions for the targeted drugs following attendance at such continuous medical education sessions.