For Quality, Essential, Generic Medicines

CHAPTER  3

RATIONALITY OF DRUGS

The Oxford English Dictionary defines "rational" as that which is based on reason, which is sensible, sane or moderate. Rational Drug Therapy is described as "Ordering the right medicine for the right patient at the right time and in the right amount with due consideration of costs" (1). Rationality is also to be looked at within a particular medical system. In this book, we are concerned with rationality within the allopathic medical system only. (Rationality of use of two or more systems is a knotty if unresolved issue. A recent hearing of the Supreme Court (1996) prohibits prescribers trained in one system to prescribe medicines of another system in which the prescriber is not trained.)

Rational drug therapy means the use of drugs which are efficient, safe, low-cost and easy to administer. It requires that health practitioners have adequate medical knowledge and appropriate skill for correct diagnosis and treatment They would also be required to have time and concern for their patients.
Causes of Irrationality
Irrational use occurs owing to:
1.
1. Lack of knowledge: Or when prescribers have no scientific knowledge. This happens in the case of so-called quacks or when doctors have not kept abreast of current developments in medicine. (It is indeed debatable whether any formally trained doctor with a medical degree who does not have knowledge to treat even simple problems, or treats common problems irrationally, should be considered a 'quack'; likewise, should a well-trained village health worker knowing how to prescribe for specific conditions be considered 'practising' medicine unethically and illegally?). Lack of knowledge also occurs when patients treat themselves without sufficient knowledge about the drug. Most OTC drugs have instructions for use in English - a language understood only by a minority of the Indian population. Moreover, very often instructions are couched in technical jargon (and often in small, unreadable print) which cannot be understood by lay persons. In addition, people tend to recommend drugs based on their personal experience.
2.
Inaccurate diagnosis: This occurs due to lack of interest, lack of time, over-crowded OPDs, inadequate health personnel and lack of diagnostic aids.
3.
Lack of objective drug information: It is doubtful whether a majority of doctors in India are in the habit of referring to standard textbooks or standard medical journals. So they probably tend to take the easy way out by relying on information supplied by medical representatives and drug companies which can be very biased and selective (see Chapter 4). Also, doctors are led to believe a lot of new products are being marketed every day. Many of these are not new discoveries which radically alter the course of treatment. Therefore to say that it is difficult to keep up with new knowledge is not quite correct. Thirdly, absence of compulsory recertification of medical degrees and continuing education programmes is another drawback in updating whatever relevant new knowledge that does come out.
4.
Aggressive drug promotion influencing doctors: As mentioned in the earlier chapter, there are more than 100,000 formulations (at five products per company for the estimated 20,000 manufacturing units in India) in the Indian market, many of which are similar except for different brand names or for a few unnecessary additional ingredients. Pharmaceutical companies therefore indulge in aggressive marketing to promote the sale of their brands. Sometimes, it results in unethical marketing practices such as bribing doctors with diaries, calendars, posters, gifts and even foreign trips and vacations
5.
Over/under-prescribing by doctors: Over-prescribing occurs when doctors prescribe too large quantities, for too long duration, too many at the same time for the same problem, or sometimes even unnecessary drugs. This causes wastage of money, drugs, adverse reactions due to drug interaction, and saddest of all, is that the patient's condition does not improve, and in fact may have deteriorated. Doctors over-prescribe because they may not be able to diagnose the patient's condition and hope to "hit or miss" with a wide range of drugs. They may also be influenced by the pharmaceutical companies which supply doctors with excessive samples. In addition, doctors may not be able to resist the clamour of patients' demand for more medicines, lest they lose their practice to a competing private practitioner.Under-prescribing occurs, among other reasons, due to lack of knowledge on the part of the prescriber, non-availability of drugs as in the case of long-term, regular treatment necessary for the treatment of diseases like tuberculosis and leprosy, and patients' inability to purchase drugs.
6.
Cut-Practice: Another reason irrational and often expensive treatment occurs is due to the presence of cut practice, that is, kickbacks offered by specialists, pathologists, X-ray clinics, CAT scan centres, etc., to prescribers who refer patients to them.


Some of the common irrational prescription and treatment practices include (see also box on 'Specialists and Inappropriate Prescription'):

*
Prescribing antibiotics for ailments like diarrhoea or viral infection where they are useless, thus causing antibiotic resistance by the body when needed for dangerous diseases.
*
Prescribing combination products where one medicine is sufficient..
*
Prescribing unnecessary expensive vitamins or tonics, virtually regardless of the condition being treated.
*
Prescribing expensive new drugs in preference to established, less expensive ones.
*
Ordering of unnecessary investigations.


 

Specialists and Inappropriate Prescription

Prescription patterns reflect the frequency of visits by medical representatives, particularly high among medical teachers and busy consultants. Studies suggest that attendance at 'scientific' company-sponsored symposia and acceptance of pharmaceutical companies' publications "alter physicians' prescribing practices and patient care", often resulting in their prescribing inappropriate and expensive drugs even for unapproved indications. All doctors working for the Bangladesh government, including professors of medical institutes, are free to indulge in unlimited private practice. Doctors in a position of authority and influence are encouraged by drug companies to attend company-sponsored seminars in their own countries and abroad.

This practice is rife in industrialised countries. One survey in Canada revealed that 17 percent of doctors had their travel expenses and conference fees paid by pharmaceutical companies and 3 per cent were presented with computer equipment. Unfortunately, many symposium proceedings are later published in well-known journals with financing from the same sponsor; the British Medical Journal, the Lancet, the New England Journal of Medicine and the Journal of the American Medical Association are notable exceptions to the plethora of medical journals which publish drug companies' symposium proceedings
These journals are then distributed free to other, less senior doctors to make sure that they too prescribe the new, often dubious products. Such publications also promote untested new technology. The prescriptions issued by senior physicians are immediately copied by juniors, and gradually by general practitioners and by unqualified doctors. This tendency is pronounced in Third World countries.

 
 
Number of Symposia Proceedings Published in Selected Journals
 
  Journals
Number of symposia
1966-1979
proceedings published
1980-1989
  American Journal of Cardiology
32
79
  American Heart Journa
0
25
  Hypertension
0
17
  Circulation
3
11
  American Journal of Medicine
18
67
  American Journal of Obstetrics
0
10
  British Journal of Anaesthesia
5
11
  Cancer
6
13
  Journal of Allergy Immunology (Clinical)
1
11
  Kidney International
5
23
  Transplantation Proceedings
6
56
  British Medical Journal
0
0
  New England Journal of Medicine
0
0
  Lancet
0
0
  Journal of the American Medical Association
0
0
 
  Source: Bero, L.A. et al, "The Publication of Sponsored Symposiums in Medical Journals", New England
Journal of Medicine
, October 15, 1992
  Drugs of doubtful value such as vinpocetine (brand name Cavinton, from Medimpex of Hungary), bencyclane hydrogen fumerate (brand name Fludilat, from Organon) and oxpentifylline (brand name Trental, from Hoechst) appear remarkably frequently in the prescriptions written by senior teachers of neuromedicine. These drugs, at best of doubtful efficacy, at worst useless, remain in Bangladesh because of the persistent pressure by well-known senior professors for their retention.
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