A shift toward more conservative medication-prescribing practices would serve patients better, according to a review article published Online First today by Archives of Internal Medicine, one of the JAMA/Archives journals. The article is part of the journal's Less Is More series.

As background, the article notes that the majority of patients under age 65 years receive at least one prescription drug annually. However, according to the authors, not every patient visit needs to result in a prescription. They point to "the recent spate of revelations of undisclosed and unexpected adverse effects of drugs in multiple therapeutic categories" as just one reason to take a more measured approach to medication usage.

Gordon D. Schiff, M.D., from Harvard Medical School, Boston, with colleagues in the medical and pharmacy divisions of the University of Illinois at Chicago, outlines a series of steps that can be taken to rein in prescription writing. "Although others have used labels such as healthy skepticism, more judicious, rational, careful, or cautious prescribing," they write, "we believe that the term conservative prescribing conveys an approach that goes beyond the oft-repeated physician's mantra, 'first, do no harm.'" Among the steps they recommend for conservative prescribing:
  • Think beyond drugs. Would other interventions help? Would a medication simply mask symptoms without treating the problem? Can a condition be prevented instead of treated? Would waiting to see if the symptoms self-resolve be wise?
  • Practice more strategic prescribing. Do you have a solid understanding of medication choices? Is there a valid reason to switch to a new drug? Is it the right drug for your patient? Can you avoid using multiple medications?
  • Maintain heightened vigilance regarding adverse effects. Do you check with patients about potential drug reactions? Do you teach them the warning signs? Are the drugs you're choosing prone to withdrawal symptoms or relapse?
  • Approach new drugs and new indications cautiously and skeptically. Where do you get your information about new treatments? Can you wait until a new drug has had a longer track record? Does the drug actually help resolve the core problem? Is it actually indicated for this problem? Does it deliver what it promises? Do studies tell the whole story on a drug?
  • Work with patients for a more deliberative shared agenda. Can you persuade patients not to demand drugs they have seen or heard advertised? Is a patient's noncompliance with therapy the source of the problem? Has the patient already tried this drug without success? Can you encourage healthy skepticism in your patients?
  • Consider longer-term, broader effects. Would a different therapy be less likely to cause future harm? Can you find a way to make the prescribing system better?
"Individually, none of these principles is particularly novel, nor should any of them be terribly controversial," write the authors. "But taken together, they represent a shift in prescribing paradigm from 'newer and more is better' to 'fewer and more time tested is best.'" The authors recommend taking greater care when deciding to prescribe a drug, especially one that is new or not well understood. "While clinicians must always weigh the benefits of conservative prescribing against the risks of withholding potentially needed medications, at the very least we should seek to shift the burden of proof toward demanding a higher standard of evidence of benefit before exposing patients to the risks of drugs."

(Arch Intern Med. 2011;10.1001/archinternmed.2011.256.)

This work was supported in part by the Formulary Leveraged Improved Prescribing (FLIP) project, funded by the Attorney General Consumer and Prescriber Education Grant Program, and a Centers for Education and Research (CERT) grant from the Agency for Healthcare Research and Quality. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Commentary: Conservative Prescribing of Opioids

An accompanying editorial suggests that, whenever reasonably possible, physicians scale back the use of opioids for treating pain. The piece, authored by Deborah Grady, M.D., M.P.H., and Seth Berkowitz, M.D., both from the University of California, San Francisco, and Mitchell Katz, M.D., from the Los Angeles Department of Health Services, is also part of theLess Is More series.

As background, the authors note that opioids are the most commonly prescribed drugs in the country, and that up to one in five office visits ends in a prescription for these medications. "This situation would be acceptable if the benefits of opioid treatment outweighed the risks," remark the authors. However, they say, the drugs do not always deliver substantial pain relief, and carry a high risk of addiction, side effects and death.

To reduce the reliance on opioids, the authors promote many of the same principles discussed by Schiff and colleagues. They advise pursuing nonpharmacologic treatments, starting therapy with trusted over-the-counter and nonopioid prescription drugs and referring patients to pain specialists as needed. Lastly, they point to the need to communicate effectively with patients. "The desire to relieve the pain and illness of others is the reason many of us went to medical school," they acknowledge. "However painful it is to explain to patients who are experiencing chronic pain that we do not have effective and safe treatments for their pain, we should be willing to do so when appropriate."

(Arch Intern Med. 2011;doi:10.1001/archinternmed.2011.213.)

Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

C. Myron