Wednesday, October 12, 2011

Conservative Rxing of Pain Medications Advised

Pain Meds Medication therapy is a mainstay for helping to relieve pain of all types, facilitate functionality, and improve quality of life. It is sometimes difficult for patients and practitioners alike to imagine ending a clinical encounter without a medication prescription. However, an important new article outlines 24 principles of prescribing that advocate for a paradigm shift from “more and newer” to “fewer and more time-tested” drugs when it comes to managing pain and other health conditions. There are vital lessons here for healthcare providers and their patients.

Writing in the September 12, 2011 edition of the Archives of Internal Medicine, Gordon D, Schiff, MD, from Harvard Medical School, along with colleagues from the University of Illinois at Chicago College of Medicine and College of Pharmacy, describe a series of principles for more appropriate prescribing [Schiff et al. 2011]. Overall, they urge all clinicians to think beyond drugs, practice more strategic prescribing, avoid unwarranted drug switching, maintain heightened vigilance for adverse effects, exercise caution and skepticism regarding new drugs, work with patients toward shared goals, and consider the long-term, broader impact of medication therapy.

While they are not specifically addressing the pharmacologic management of pain, the paradigm they describe as “conservative prescribing” seems highly relevant for the pain field. “Although others have used labels such as healthy skepticism, more judicious, rational, careful, or cautious prescribing,” the authors state, “we believe that the term conservative prescribing conveys an approach that goes beyond the oft-repeated physician's mantra, ‘first, do no harm.’”

This is especially pertinent today, with growing concerns about many medications, not just opioids, that are sometimes inappropriately prescribed in pain management, or over- or under-used, with potential for significant harms. Schiff et al. propose, “Conservative prescribing also embodies an important new construct — the precautionary principle — an ecologic paradigm that stresses forecaring, the practice of anticipating potential adverse effects, even when cause-effect relationships are not fully established scientifically.”

It is important to note that conservative prescribing is not about avoiding drug therapy or withholding medications that might help patients, including those with pain; rather, the focus is on a more prudent, selective, evidence-based approach. Experienced healthcare providers will find that the principles are familiar and are good commonsense reminders. Newer practitioners, especially those just entering the pain management field, will find the list helpful for sensible and safe prescribing. Here is a synopsis of principles to ponder from the article…

A) Think Beyond Drugs…

  1. Seek Nondrug Alternatives First — clinicians should broaden their repertoire to become more skilled and effective at patient counseling and prescribing exercise, physical therapy, diet changes, and other helpful modalities.

  2. Consider Potentially Treatable Underlying Causes of Problems Rather Than Just Treating the Symptoms With a Drug — for example, could suspected arthritis pain actually represent osteomalacia that is treatable with vitamin D, or occupational trauma requiring workplace redesign, or an adverse effect of a medication?

  3. Look for Opportunities for Prevention Rather Than Focusing on Treating Symptoms or Advanced Disease — time and effort spent on prevention, such as lifestyle interventions, often result in greater positive impact on outcomes at lower cost.

  4. Use the Test of Time as a Diagnostic and Therapeutic Trial Whenever Possible — especially when dealing with nonspecific symptoms or potentially self-limiting conditions, such as lower back pain, use restraint rather than reflex prescribing to avoid giving drugs that can confuse the clinical picture and compound uncertainties.

B) Practice More Strategic Prescribing…

  1. Use Only a Few Drugs and Learn to Use Them Well — by becoming familiar with a limited number of medications, one's knowledge and experience with those increase dramatically, and the chances of adverse effects, drug interactions, and prescribing errors decrease.

  2. Avoid Frequent Switching to New Drugs Without Clear, Compelling Evidence-Based Reasons — have a clear plan with specific parameters and end points to monitor as the basis for decisions about maintaining or modifying therapy. In some cases, more time rather than a new drug regimen is needed.

  3. Be Skeptical About Individualizing Therapy — while this principle seems contrary to patient-centered care, individualizing therapy can also be a code word for unscientific trial-and-error, experimental medicine.

  4. Whenever Possible, Start Treatment With Only One Drug at a Time — temper the urge to start treatment with multiple medications for multiple symptoms or disorders at a single visit.

C) Maintain Heightened Vigilance Regarding Adverse Effects…

  1. Have a High Index of Suspicion for Adverse Drug Effects — anticipate, ask about, and monitor for common and even rarer but important adverse reactions from medication therapy. For example, could suspected fibromyalgia pain actually be statin-induced myopathy?

  2. Educate Patients About Possible Adverse Effects to Ensure That They Are Recognized as Early as Possible — better informed patients make for better care when it comes to medication therapy.

  3. Be Alert to Clues That You May Be Treating or Risking Withdrawal Symptoms — there is a long history of drugs being promoted as curative when they actually may perpetuate or exacerbate the problem. For example, caffeine, butalbital, or other analgesics used to treat headaches may cause chronic daily headaches via cycles of chronic overuse and withdrawal.

D) Approach New Drugs and New Indications Cautiously and Skeptically…

  1. Learn About New Drugs and New Indications From Trustworthy, Unbiased Sources — evaluate claims for new drugs skeptically, insisting on evidence that they are demonstrably better than existing treatments, whether drug or nondrug.

  2. Do Not Rush to Use Newly Marketed Drugs — even when new drugs seem safer or more effective, experience with them is generally limited and there is initially a paucity of data studying patients in typical clinical settings.

  3. Be Certain That the Drug Improves Actual Patient-Centered Clinical Outcomes Rather Than Just Treating or Masking a Surrogate Marker — many clinical trials show statistically significant improvements in laboratory, radiologic, or other markers of disease risk, severity, or prognosis but lack proof of meaningful clinical benefits. There is a growing body of literature demonstrating situations where such surrogate improvements do not translate into clinical benefits (eg, quality of life, functionality, disease regression) and may even worsen outcomes.

  4. Be Vigilant About Indications Creep — prescribers need to better understand the precise niche for each drug: eg, Which patients with headaches should receive a triptan? Making seemingly logical leaps to different indications for the same drug — eg, gabapentin works for postherpetic neuralgia; so, it is worth trying for migraines — moves away from evidence-based prescribing.

  5. Do Not Be Seduced by Elegant Molecular Pharmacology or Drug Physiology — the notion that the sophisticated molecular structure or mechanism of action of a new drug can reliably predict its effectiveness and safety in humans has led to some “nasty surprises.” Prescribers should await clinical evidence of benefit before succumbing to theoretical promises of new drug advantages, no matter how compelling.

  6. Beware of Selective Reporting of Studies — research studies may actually yield a mixture of positive and not so positive findings; yet, often only the positive results are promoted or published.

E) Work with Patients for a More Deliberative Shared Agenda…

  1. Do Not Hastily or Uncritically Succumb to Patient Requests for Drugs, Especially Drugs That They Have Heard Advertised — rather than taking the path of least resistance, consider that writing prescriptions for questionable drugs violates many of the safety and precautionary principles detailed above, and opportunities are lost for educating patients to become better-informed drug consumers.

  2. Avoid Mistakenly Prescribing Additional Drugs for Refractory Problems, Failing to Appreciate the Potential for Patient Nonadherence — do not automatically increase drug doses or add new drugs without strongly considering patient adherence issues with the current medication regimen.

  3. Avoid Repeating Prescriptions for Drugs That a Patient Has Previously Tried Unsuccessfully or That Caused an Adverse Reaction — without a complete medication history (including reasons for starting and stopping drug treatments), prescribers risk writing wasteful and potentially harmful prescriptions for drugs that have previously failed.

  4. Discontinue Treatment With Drugs That Are Not Working or Are No Longer Needed — by identifying patients who are not benefiting, they can be spared the expense and adverse effects of continuing treatment with an ineffective medication. The timing of such decisions can be difficult because there may be the hope of a delayed response, but often this is wishful thinking.

  5. Work With Patients’ Desires to Be Conservative With Medications — take advantage of patients’ healthy skepticism about drug therapy, when it exists, engaging them in a dialogue that aligns your own concerns with theirs via honest education, negotiation, and cautiousness about prescribing.

F) Consider Longer-Term, Broader Effects…

  1. Think Beyond Short-Term Beneficial Drug Effects to Consider Longer-Term Benefits and Risks — certain drugs may be effective in the short run but may not be as effective long-term or even produce detrimental effects over time.

  2. Look for Opportunities to Improve Prescribing Systems, Changes That Can Make Prescribing and Medication Use Safer — implementing computerized prescriber order entry or improved patient or laboratory monitoring has been shown to improve drug treatment, often more than the marginal impact of many new "breakthrough" drugs.

Of course, the full article provides more details and illustrative examples regarding each principle, and Schiff et al. concede that none of the points is particularly novel or terribly controversial. Taken together, however, they do represent a shift in the prescribing paradigm from “newer and more is better” to “fewer and more time-tested is best.” Along with that, an essential component of any successful drug regimen is an informed patient who fully knows why, when, and how to take a medication and is well-educated about adverse effects and safety.

REFERENCE: Schiff GD, Galanter WL, Duhig J, et al. Principles of Conservative Prescribing. Arch Intern Med. 2011(Sep);171(16):1433-1440 [abstract here].