Tackling Overprescription: Difference between revisions

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=='''Introduction'''==
=='''Introduction'''==
[[File:Polypharmacy.jpeg|thumb|399x399px|Polypharmacy]]
[[File:Polypharmacy.jpeg|thumb|399x399px|Polypharmacy]]
Over the last 30 years, people have been prescribed increasing number of medicines, in particular older people. The reasons are manifold and include:
Over the last 30 years, people have been prescribed increasing number of medicines, in particular [[Medication and Older People|older people]]. The reasons are manifold and include:


* A rise in [[multimorbidity]] and ageing populations
* A rise in [[multimorbidity]] and ageing populations
* Use of of evidence-based medicine
* Use of [[Evidence Based Practice (EBP)|evidence-based practice]]
* Greater expectations for outcomes from patients and their families<ref name=":0">NHS UK [https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ Understanding polypharmacy, overprescribing and deprescribing] Available:https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ (accessed 29.12.2022)</ref>
* Greater expectations for outcomes from patients and their families<ref name=":0">NHS UK [https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ Understanding polypharmacy, overprescribing and deprescribing] Available:https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ (accessed 29.12.2022)</ref>


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== Deprescribing ==
== Deprescribing ==
Deprescribing is the complicated process undertaken for the safe and effective withdrawal of inappropriate medication.
[[File:Drug interaction .png|591x591px|alt=|thumb|Chance of adverse reactions with multiple medications]]
Deprescribing is the complicated process undertaken for the safe and effective withdrawal of inappropriate medication. A lot of of the evidence underpinning deprescribing is from observation, being based on the patient’s physical functioning, co-morbidities, preferences and lifestyle.


A lot of of the evidence underpinning deprescribing is from observation, being based on the patient’s physical functioning, co-morbidities, preferences and lifestyle.[[File:Drug interaction .png|591x591px|alt=|thumb|Chance of adverse reactions]]Deprescribing
Deprescribing:  


* Should be part of good prescribing, with re-evaluation of dosages periodically.  
* Should be part of good prescribing, with re-evaluation of dosages periodically.  
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== Overprescribing ==
== Overprescribing ==
[[File:Pill organising safe.png|thumb|384x384px|Medications: review regularly]]
Overprescribing is when people are prescribed medicines:
Overprescribing is when people are prescribed medicines:


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* Where the medicine is correct for a condition but not the individual.
* Where the medicine is correct for a condition but not the individual.
* When a condition alters and the medicine is no longer appropriate.<ref name=":0" />
* When a condition alters and the medicine is no longer appropriate.<ref name=":0" />
The extensiveness of polypharmacy reported in literature differs, being between 10% to 90% according to the age group, definition used, healthcare and geographical setting of the study.<ref name=":1" />
== Patient Engagement ==
Medication reviews, joint decision-making and deprescribing rely on people becoming involved in decisions regarding their health care. Information to give patients and their carers about the medicines they are taking should be a priority, taking into account language, culture and level of health literacy.<ref>UK Government [https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf Good for you, good for us, good for everybody] Available:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf (accessed 29.12.20220</ref>
== Common Populations at Risk ==
[[File:Elderly woman.jpeg|thumb|Age: risk factor for over medicated.]]
The use of multiple drugs is not always an indicator of poor drug treatment or overmedication<ref name=":12">Tamminga C. When Is Polypharmacy an Advantage?. American Journal of Psychiatry. 2011;168(7):663-663.</ref>. Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics<ref name=":12" />. 
At risk populations include:
* [[Introduction to Frailty|Frail]]
* [[Obesity]]
* [[Older People - Patterns of Illness, Physiological Changes and Multiple Pathology|Elderly Populations]]
* [[Mental Health]] Patients
* [[Multimorbidity]]
* Recent hospitalizations/major [[Surgery and General Anaesthetic|surgery]]
* People seeing multiple doctors
* [[Oncology and Palliative Care|Terminally ill patients]]
Sex, educational level, and [[Smoking Cessation and Brief Intervention|smoking]] apparently appear not to be related to polypharmacy.<ref name=":1">FAQs clear [https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ What Population Is At Risk For Polypharmacy?] Available:https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ (accessed 29.11.2022)</ref>


==The Potential Role of the Physiotherapist in Deprescribing==
==The Potential Role of the Physiotherapist in Deprescribing==
[[File:Non-pharma approaches.png|frameless|558x558px|alt=|right]]


Available literature linking physiotherapy with deprescribing has focused only on the role of physiotherapy as a supplementary treatment for pain relief when reducing opioid dosage.  
Available literature linking physiotherapy with deprescribing has focused only on the role of physiotherapy as a supplementary treatment for pain relief when reducing opioid dosage.  
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General advice that may be given on the effects of medication. For example the general side effects of non-steroidal anti-inflammatory drugs (NSAIDs). While providing advice it should also be recommended that the patient should seek advice from a pharmacist or independent prescriber before altering any medication they currently take<ref name=":33">Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy [Internet]. CSP; 2016. Available from: <nowiki>http://www.csp.org.uk/publications/medicines-prescribing-physiotherapy-4th-edition</nowiki></ref>.
General advice that may be given on the effects of medication. For example the general side effects of non-steroidal anti-inflammatory drugs (NSAIDs). While providing advice it should also be recommended that the patient should seek advice from a pharmacist or independent prescriber before altering any medication they currently take<ref name=":33">Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy [Internet]. CSP; 2016. Available from: <nowiki>http://www.csp.org.uk/publications/medicines-prescribing-physiotherapy-4th-edition</nowiki></ref>.


Other non-pharmacological (only with doctors input) interventions to help with deprescribing include:
'''Is patient taking their medication incorrectly?:''' If a non-prescriber physiotherapist notices a patient is not taking their medication correctly, they can refer the patient to the medications instructions and remind them how and when/ dose they should be taking their medication as prescribed<ref name=":33" />. This can also apply to medication devices, e.g. an inhaler, advice can be given how to use it according to guidelines.
* Encouraging low-salt diets and exercise to reduce prescription of antihypertensives,
* Psychotherapy and changing sleep habits to reduce or avoid prescription of antidepressants,<ref>Kahan M, Mailis-gagnon A, Wilson L, Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain Clinical summary for family physicians. Part 1: general population. Canadian Family Physician 2011'';''57:1257-1266.
</ref><ref>Berna C, Kulich R.J, Rathmell J.P. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clinic Proceedings 2015;90:828-842</ref>.
The majority of physiotherapists should be able to signpost patients to where they could obtain appropriate medication advice<ref name=":18">Chartered Society of Physiotherapy. Practice Guidance for Physiotherapist Supplementary and/or Independent Prescribers in the safe use of medicines. [Internet]. London: CSP; 2016. Available from: <nowiki>http://www.csp.org.uk/publications/practice-guidance-physiotherapist-supplementary-prescribers</nowiki></ref>.
{{#ev:youtube|caoCN-J5FEE}}<ref>Youtube. What is Pharmacokinetics? - A simple Introduction! [Internet]. 2017 [cited 15 April 2018]. Available from: <nowiki>https://www.youtube.com/watch?v=caoCN-J5FEE</nowiki></ref>
 
'''Patient taking their medication incorrectly? Advice non-prescribers can give:'''
 
If a non-prescriber physiotherapist notices a patient is not taking their medication correctly, they can refer the patient to the medications instructions and remind them how and when/ dose they should be taking their medication as prescribed<ref name=":33" />. This can also apply to medication devices, e.g. an inhaler, advice can be given how to use it according to guidelines.
Expected adverse effects of medication? What non-prescribers can do:
Physiotherapists can refer the patient back to the GP/pharmacists or can contact the GP directly providing information on their concerns <ref name=":3">Reznik J, Keren O, Morris J, Biran I. ''Pharmacology Handbook for Physiotherapists.'' Australia: Elsevier; 2016.
</ref>.
== Common Populations at Risk ==
The use of multiple drugs is not always an indicator of poor drug treatment or overmedication<ref name=":12">Tamminga C. When Is Polypharmacy an Advantage?. American Journal of Psychiatry. 2011;168(7):663-663.</ref>. Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics<ref name=":12" />. At risk populations include:
 
* Elderly Populations
* Psychiatric Patients 
* Multimorbidity
* Recent hospitalizations/major surgery
* People seeing multiple doctors
* Terminally ill patients


Adverse Effects:Physiotherapists can refer the patient back to the GP/pharmacists or can contact the GP directly providing information on their concerns re adverse effects <ref name=":3">Reznik J, Keren O, Morris J, Biran I. ''Pharmacology Handbook for Physiotherapists.'' Australia: Elsevier; 2016.
</ref>.
== Non-Pharmacological Interventions==
== Non-Pharmacological Interventions==
The use of non-pharmacological options in tackling overprescription should be considered across all allied health professionals. For physiotherapists, the vast majority of interventions utilized in practice are non-pharmacological as most clinicians are non-prescribers. It is important for physiotherapists and other relevant health care providers to be aware of the wide array of treatment options for sufficient provision of holistic patient care, to be used on their own or in conjunction with drug therapies, in effort to address clinical scenarios where overprescription may be an issue. The most common treatment for chronic pain is traditionally pharmacological<ref>Nalamachu S. An overview of pain management: the clinical efficacy and value of treatment. American journal of managed care 2013;19:261-266</ref>.  Health care professionals should be aware of the benefits of non-pharmacological options with sufficient evidence bases for a range of relevant domains such as improvements in pain and functional status, as well as cognitive and emotional states.
Physiotherapists are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment<ref>[[Non Pharmacological Interventions|Non-Pharmacological Approaches to Deprescription]]</ref>. See this page for more: [[Non Pharmacological Interventions|Non-Pharmacological Interventions]]
 
A recent 2017 study has discovered barriers to non-pharmacological options with regards to chronic pain<ref name=":17">Becker W.C, Dorflinger L, Edmond S.N, Islam L, Heapy A.A, Fraenkel L. Barriers and facilitators to use of non-pharmacological treatments in chronic pain. BMC Family Practice 2017;18 [online] [viewed 18/04/2018]. Available from: <nowiki>http://doi.org/10.1186/s12875-017-0608-2</nowiki>.</ref>. Top ranked patient-reported barriers included high cost, transportation problems, and low motivation. While top provider-reported barriers include scepticism about efficacy of the non-pharmacological options<ref name=":17" />. For this reason, the authors of this Physiopedia page have constructed a non-exhaustive list of common [[Non-Pharmacological Approaches to Deprescription|Non-Pharmacological Approaches]], accompanied with descriptions and mechanisms of the interventions, brief summary of the evidence base, and suggestions for referrals and signposting patients for options outside the scope of physiotherapy. Some of these options listed are covered under the National Health Service, others can be used for self-management, and some address beliefs and cognitive effects. Therefore, this resource should be used in hopes to address the high cost, transportation, and low motivation barriers of patients, while providing a brief population dependent evidence base for a wide array of non-pharmacological options so healthcare providers can be confident in their choice of treatment option in accordance with the individual values of their patient<ref name=":17" />.
 
The decision to seek non-pharmacological options outside conventional care, should be discussed with a patient’s general practitioner or wider multidisciplinary team, and include patient preferences and values, in order to provide safe and optimal patient-centred care. Non-Pharmacological approaches are listed for both inside and outside the scope of physiotherapy (Figure 3).
[[File:Non-pharma approaches.png|center|frameless|558x558px]]


== References ==
== References ==

Latest revision as of 00:19, 20 February 2023

Original Editor - Debbie Kenny Top Contributors - Debbie Kenny, Lucinda hampton, Peter Lynch, Kim Jackson, Lauren Lopez and Aminat Abolade

Introduction[edit | edit source]

Polypharmacy

Over the last 30 years, people have been prescribed increasing number of medicines, in particular older people. The reasons are manifold and include:

The dangers of using multiple medicines include greater chances of:

  • Adverse drug experiences
  • Hospital admissions and health care costs
  • Non-adherence to medication[1]

Overprescribing may occur when:

  • A better alternative is available but not suggested
  • The drug is suitable for a condition but not the individual.
  • A condition alters and the medicine is no longer suitable/relevant.
  • The patient has ceased needing the medicine but it continues to be prescribed.[2]

Deprescribing[edit | edit source]

Chance of adverse reactions with multiple medications

Deprescribing is the complicated process undertaken for the safe and effective withdrawal of inappropriate medication. A lot of of the evidence underpinning deprescribing is from observation, being based on the patient’s physical functioning, co-morbidities, preferences and lifestyle.

Deprescribing:

  • Should be part of good prescribing, with re-evaluation of dosages periodically.
  • Involves health care professional direction and supervision with the same level of expertise and attention that prescribing entails [3].

The following videos provides an easy to follow in-depth discussion regarding the concept (6 minutes)

Overprescribing[edit | edit source]

Medications: review regularly

Overprescribing is when people are prescribed medicines:

  • They no longer need or want
  • The medicine has greater possible harmful than beneficial effects.
  • When a more effective alternative is not prescribed
  • Where the medicine is correct for a condition but not the individual.
  • When a condition alters and the medicine is no longer appropriate.[1]

The extensiveness of polypharmacy reported in literature differs, being between 10% to 90% according to the age group, definition used, healthcare and geographical setting of the study.[4]

Patient Engagement[edit | edit source]

Medication reviews, joint decision-making and deprescribing rely on people becoming involved in decisions regarding their health care. Information to give patients and their carers about the medicines they are taking should be a priority, taking into account language, culture and level of health literacy.[5]

Common Populations at Risk[edit | edit source]

Age: risk factor for over medicated.

The use of multiple drugs is not always an indicator of poor drug treatment or overmedication[6]. Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics[6].

At risk populations include:

Sex, educational level, and smoking apparently appear not to be related to polypharmacy.[4]

The Potential Role of the Physiotherapist in Deprescribing[edit | edit source]

Available literature linking physiotherapy with deprescribing has focused only on the role of physiotherapy as a supplementary treatment for pain relief when reducing opioid dosage.  

General advice that may be given on the effects of medication. For example the general side effects of non-steroidal anti-inflammatory drugs (NSAIDs). While providing advice it should also be recommended that the patient should seek advice from a pharmacist or independent prescriber before altering any medication they currently take[7].

Is patient taking their medication incorrectly?: If a non-prescriber physiotherapist notices a patient is not taking their medication correctly, they can refer the patient to the medications instructions and remind them how and when/ dose they should be taking their medication as prescribed[7]. This can also apply to medication devices, e.g. an inhaler, advice can be given how to use it according to guidelines.

Adverse Effects:Physiotherapists can refer the patient back to the GP/pharmacists or can contact the GP directly providing information on their concerns re adverse effects [8].

Non-Pharmacological Interventions[edit | edit source]

Physiotherapists are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment[9]. See this page for more: Non-Pharmacological Interventions

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 NHS UK Understanding polypharmacy, overprescribing and deprescribing Available:https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ (accessed 29.12.2022)
  2. ↑ BBC news Overprescribing of medicines must stop, says government Available:https://www.bbc.com/news/health-58639253 (accessed 28.12.2022)
  3. ↑ Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine.2017;38:3-11.
  4. ↑ 4.0 4.1 FAQs clear What Population Is At Risk For Polypharmacy? Available:https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ (accessed 29.11.2022)
  5. ↑ UK Government Good for you, good for us, good for everybody Available:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf (accessed 29.12.20220
  6. ↑ 6.0 6.1 Tamminga C. When Is Polypharmacy an Advantage?. American Journal of Psychiatry. 2011;168(7):663-663.
  7. ↑ 7.0 7.1 Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy [Internet]. CSP; 2016. Available from: http://www.csp.org.uk/publications/medicines-prescribing-physiotherapy-4th-edition
  8. ↑ Reznik J, Keren O, Morris J, Biran I. Pharmacology Handbook for Physiotherapists. Australia: Elsevier; 2016.
  9. ↑ Non-Pharmacological Approaches to Deprescription
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