1 Problems of Irrational Drug Use. 2 Problems of Irrational Drug Use: Objectives Identify magnitude and nature of inappropriate drug utilizationIdentify

1

Problems of Irrational Problems of Irrational Drug UseDrug Use

Problems of Irrational Drug Use 2

Problems of Irrational Drug Use:Problems of Irrational Drug Use:ObjectivesObjectives

• Identify magnitude and nature of inappropriate Identify magnitude and nature of inappropriate drug utilizationdrug utilization

• Understand the adverse impacts of Understand the adverse impacts of inappropriate use of drugsinappropriate use of drugs

• Describe factors which influence the decision-Describe factors which influence the decision-making processmaking process

• Identify factors which influence the behavior of Identify factors which influence the behavior of prescribers and patientsprescribers and patients

• Discuss specific medication use problemsDiscuss specific medication use problems


What is Rational Use of Drugs?What is Rational Use of Drugs?

The rational use of drugs requires that patients receive medicines The rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individual appropriate to their clinical needs, in doses that meet their own individual

requirements, for an adequate period of time, and at the lowest cost to requirements, for an adequate period of time, and at the lowest cost to them and the community.them and the community.

(WHO 1988)(WHO 1988)

Appropriate indicationAppropriate indication Appropriate drugAppropriate drug Appropriate administration, dosage, and durationAppropriate administration, dosage, and duration Appropriate patientAppropriate patient Appropriate patient informationAppropriate patient information Appropriate evaluationAppropriate evaluation


Irrational Use of Drugs = Pathology Irrational Use of Drugs = Pathology of Prescribingof Prescribing

• The use of drugs when no drug therapy is indicatedThe use of drugs when no drug therapy is indicated

• The use of wrong drugs for a specific condition The use of wrong drugs for a specific condition requiring drug therapyrequiring drug therapy

• The use of drugs with doubtful or unproven efficacyThe use of drugs with doubtful or unproven efficacy

• The use of drugs of uncertain safety statusThe use of drugs of uncertain safety status

• Failure to prescribe available, safe, & effective drugsFailure to prescribe available, safe, & effective drugs

• Incorrect administration, dosages, or durationIncorrect administration, dosages, or duration


Examples of Common Inappropriate Examples of Common Inappropriate Prescribing PracticesPrescribing Practices

• The overuse of antibiotics and antidiarrheals for The overuse of antibiotics and antidiarrheals for nonspecific childhood diarrheanonspecific childhood diarrhea

• Indiscriminate use of injections for malariaIndiscriminate use of injections for malaria• Multiple or over-prescriptionMultiple or over-prescription• Use of antibiotics for mild, non-bacterial Use of antibiotics for mild, non-bacterial

infection, e.g., URIinfection, e.g., URI• Tonics and multivitamins for malnutritionTonics and multivitamins for malnutrition• Unnecessary use of expensive Unnecessary use of expensive

antihypertensivesantihypertensives


Components of the Drug Use Components of the Drug Use SystemSystem

Drug ImportsDrug ImportsLocalLocal

ManufactureManufacture

HospitalHospital or or HealthHealth CenteCenterr

Private Physician orPrivate Physician or Other PractitionerOther Practitioner Pharmacist orPharmacist or

Drug TraderDrug Trader

The DrugThe Drug SupplySupply ProcessProcess

Provider andProvider and Consumer BehaviorConsumer Behavior

Illness PatternsIllness Patterns

++

PublicPublic


Factors Underlying Irrational Use Factors Underlying Irrational Use of Drugsof Drugs

• inefficient inefficient managementmanagement

• non-availability non-availability of required of required drugsdrugs

Drug SupplyDrug SupplyDrug SupplyDrug Supply

• availability of availability of unsafe drugsunsafe drugs

• informal informal prescribersprescribers

• etc.etc.

Drug RegulationDrug RegulationDrug RegulationDrug Regulation

• promotionpromotion• misleading misleading

claimsclaims

IndustryIndustryIndustryIndustry

• lack of education lack of education and trainingand training

• lack of drug lack of drug informationinformation

• heavy patient loadheavy patient load• pressure to pressure to

prescribeprescribe• generalization of generalization of

limited beliefslimited beliefs• misleading beliefs misleading beliefs

about efficacyabout efficacy

PrescribersPrescribersPrescribersPrescribers• drug drug

misinformationmisinformation

• misleading misleading beliefsbeliefs

• inability to inability to communicate communicate problemsproblems

PatientsPatientsPatientsPatients


Impact of InappropriateImpact of InappropriateUse of DrugsUse of Drugs

Reduced Reduced quality of quality of therapytherapy

•morbiditymorbidity•mortalitymortality

Waste of Waste of resourcesresources Risk of Risk of

unwanted unwanted effectseffects

•patients rely on patients rely on unnecessary drugsunnecessary drugs

Psycho-social Psycho-social impactsimpacts

•Reduced availabilityReduced availability•increased costincreased cost

•adverse reactionsadverse reactions•bacterial resistancebacterial resistance


Activity 1Activity 1

Meaning of Appropriate UseMeaning of Appropriate Use


Drugs per Case by Age Group:Drugs per Case by Age Group: E. Java & W. Kalimantan, Indonesia, 1987E. Java & W. Kalimantan, Indonesia, 1987

OneOne3%3%

TwoTwo14%14%

ThreeThree27%27%

FourFour26%26%

FiveFive17%17%

SixSix++13%13%

OneOne1%1%

TwoTwo9%9%

ThreeThree29%29%

FourFour35%35%

FiveFive19%19%

SixSix + +6%6%

Under 5Under 5 Five & OverFive & Over


All CasesAll CasesDiarrheaDiarrhea Resp.Dis.Resp.Dis. SkinSkin G.I.G.I. MusculoskelMusculoskel.00

11

22

33

44

55

# Drugs per Case# Drugs per Case

Under FiveUnder Five

Five & OverFive & Over

Drugs Per Case By DiagnosisDrugs Per Case By DiagnosisE. Java & W. Kalimantan, Indonesia, 1987E. Java & W. Kalimantan, Indonesia, 1987


NoneNone12%

OneOne

56%

TwoTwo

29%

Three/MoreThree/More3%

NoneNone35%

OneOne36%

TwoTwo27%

Three/MoreThree/More2%

5 & Over5 & Over Under 5Under 5

% Of Patients Receiving % Of Patients Receiving AntibioticsAntibioticsE. Java & W. Kalimantan, Indonesia, 1987E. Java & W. Kalimantan, Indonesia, 1987


NoneNone56%

OneOne34%

Two or MoreTwo or More10%

NoneNone26%

OneOne

54%

Two or MoreTwo or More20%

Under 5Under 5 5 & Over5 & Over

% Of Patients Receiving Injections% Of Patients Receiving InjectionsE. Java & W. Kalimantan, Indonesia, 1987E. Java & W. Kalimantan, Indonesia, 1987


AntibioticsAntibiotics AnalgesicAnalgesic Cough/ColdCough/Cold Antihist.Antihist. OthersOthers00

0.20.2

0.40.4

0.60.6

0.80.8

11

1.21.2

1.41.4

Average # of Drugs Per CaseAverage # of Drugs Per Case

Under FiveUnder Five

Five & OverFive & Over

ARI Treatment PatternARI Treatment PatternE. Java & W. Kalimantan, Indonesia, 1987E. Java & W. Kalimantan, Indonesia, 1987


Other Drug Use ProblemsOther Drug Use Problems

• Incorrect treatment of malariaIncorrect treatment of malaria– incorrect use of chloroquin injectionincorrect use of chloroquin injection

• Poor compliance with TB therapyPoor compliance with TB therapy– causes treatment failure and resistant causes treatment failure and resistant

organismsorganisms• Underuse of effective drugsUnderuse of effective drugs

– hypertensionhypertension– depressiondepression

• Hospital drug use problemsHospital drug use problems– antibiotic misuse for surgical prophylaxisantibiotic misuse for surgical prophylaxis


YemenYemenUgandaUganda

SudanSudanMalawiMalawi

IndonesiaIndonesiaBangladeshBangladesh

ZimbabweZimbabweTanzaniaTanzania

NigeriaNigeriaNepalNepal

EcuadorEcuadorGuatemalaGuatemala

Eastern CaribbeanEastern CaribbeanJamaicaJamaica

GhanaGhanaCameroonCameroon

El SalvadorEl Salvador

00 11 22 33 44 55

Average Number of DrugsAverage Number of Drugs

Average Number of Drugs per Average Number of Drugs per PatientPatientPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


SudanSudan

IndonesiaIndonesia

ZimbabweZimbabwe

TanzaniaTanzania

NigeriaNigeria

NepalNepal

EcuadorEcuador

GuatemalaGuatemala

Eastern CaribbeanEastern Caribbean

GhanaGhana

CameroonCameroon


JamaicaJamaica

00 2020 4040 6060 8080 100100% Generic% Generic

% Prescribed as Generics% Prescribed as GenericsPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993











00 2020 4040 6060 8080 100100% of encounters receiving antibiotics% of encounters receiving antibiotics

% Receiving Antibiotics% Receiving AntibioticsPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993











00 2020 4040 6060 8080 100100

% of encounters receiving injections% of encounters receiving injections

% Receiving Injections% Receiving InjectionsPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


MalawiMalawi

IndonesiaIndonesia

TanzaniaTanzania

NigeriaNigeria

NepalNepal

00 11 22 33 44 55 66 77

Average Consultation Time (mins)Average Consultation Time (mins)

Average Consultation TimeAverage Consultation TimePublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


TanzaniaTanzania

NigeriaNigeria

NepalNepal

Eastern CarribeanEastern Carribean

GhanaGhana

00 5050 100100 150150 200200

Average Dispensing Time (seconds)Average Dispensing Time (seconds)

Average Dispensing TimeAverage Dispensing TimePublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


MalawiMalawi

IndonesiaIndonesia

BangladeshBangladesh

TanzaniaTanzania

NigeriaNigeria

NepalNepal

Eastern CaribbeanEastern Caribbean

GhanaGhana

00 2020 4040 6060 8080 100100% patients w/ dosing knowledge% patients w/ dosing knowledge

% Patients Knowing Drug Dosing% Patients Knowing Drug DosingPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


MalawiMalawi

TanzaniaTanzania

NigeriaNigeria

NepalNepal

EcuadorEcuador

CameroonCameroon

GhanaGhana


GuatemalaGuatemala

JamaicaJamaica

00 2020 4040 6060 8080 100100% of key drugs in stock% of key drugs in stock

% of Key Drugs in Stock% of Key Drugs in StockPublic Sector Drug Use Indicator Studies 1990-1993Public Sector Drug Use Indicator Studies 1990-1993


Activity 2Activity 2

Identifying a Priority ProblemIdentifying a Priority Problem


ConclusionConclusion

• Drug use is the end of the therapeutic Drug use is the end of the therapeutic consultation.consultation.

• Health professionals have a responsibility to Health professionals have a responsibility to ensure that the right drug is prescribed, ensure that the right drug is prescribed, dispensed and taken.dispensed and taken.

• Methods exist to measure drug use and to Methods exist to measure drug use and to change practices.change practices.

• Improving drug use improves the quality of Improving drug use improves the quality of care and frequently lowers cost.care and frequently lowers cost.

Documents

1 Problems of Irrational Drug Use. 2 Problems of Irrational Drug Use: Objectives Identify magnitude and nature of inappropriate drug utilizationIdentify