Physicians advised to adopt conservative prescribing habits

Physicians should think twice before jotting a prescription for nearly every patient they see, according to a study published online June 13 in Archives of Internal Medicine.

Too often, doctors prescribe medicines too liberally, increasing the risk of adverse drug reactions when nonpharmaceutical treatments may be safer and better for the patient's long-term health, said Gordon D. Schiff, MD, lead author and associate director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston.

"We really need to shift the thought process," he said. "We need to have a better balance of thinking more critically about the prescriptions we write."

The article makes several recommendations on how physicians can revamp their prescribing habits, including considering other treatment options, being more strategic about the prescriptions they write, being educated about and aware of possible adverse effects, and being cautious of prescribing new drugs.

News reports of adverse events from some drugs have helped raise awareness about prescribing risks, Dr. Schiff said. The drug Vioxx, for example, was voluntarily removed from the U.S. market in 2004 due to concerns about an increased risk of cardiovascular events. Overuse of antibiotics leading to antibiotic resistance is another example.

An estimated 4.5 million annual outpatient visits are due to adverse drug events, according to a study published online May 10 in Health Services Research. More than 60% of patients younger than 65 receive at least one prescription drug a year, says the Archives article.

Pressure to prescribe

Physicians may feel pressured to write prescriptions by persuasive drug company representatives or patients requesting medications they have seen advertised.

But time -- or a lack of it -- is perhaps the biggest reason physicians routinely hand out prescriptions, Dr. Schiff said. Writing a prescription is often the fastest way to wrap up a patient visit.

"As a practicing primary care physician trying to see 10, 12 or 14 patients in succession, I recognize that it is often easier to take 30 seconds to write a prescription than to explain to the patient why they don't really need it," he said.

Another issue is a lack of easily accessible, accurate sources of information on medications that are free of industry influence, said Adriane Fugh-Berman, MD, associate professor at Georgetown University School of Medicine in Washington, D.C., and director of PharmedOut, the university's research and education project focusing on the pharmaceutical industry's influence on prescribing.

"We really need to bring more rationality to prescribing," Dr. Fugh-Berman said. "The most promoted drugs are the most prescribed drugs, and that harms patients."

A pharmaceutical industry representative said physicians should base decisions on what's best for patients.

"We believe that physicians should make prescribing decisions based on the best possible information that is specific to each individual patient -- that may include an innovative new medicine or an older medication or a generic," said Karl Uhlendorf, deputy vice president of communications for the Pharmaceutical Research and Manufacturers of America, which represents pharmaceutical research and biotechnology companies.

A need for education

A lack of instruction on prescribing in medical school contributes to overprescribing, Dr. Schiff said. "Learning to prescribe, like learning to perform a procedure or becoming facile in physician examination, is a skill," the Archives article says.

Medical students should be taught not to start patients on several medications at once, because how different drugs will interact is largely unknown, Dr. Schiff said. They also should be taught to consider nonpharmaceutical treatments. For example, physical therapy may be a better long-term solution to foot pain than a painkiller, he said.

More conservative prescribing also would help control rising health care costs. "If you give drugs to the patients who need them the most, then you get more bang for your buck," Dr. Schiff said.