DEPRESCRIBING AND TODAY’S PHARMACY REALITY…AN OXYMORON

Deprescribing refers to the reduction in dose and/or stopping of medication that may be causing harm, may no longer be providing benefit, or may be considered inappropriate. The process of deprescribing should be planned and supervised by health care professionals. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life.

Scientist Barb Farrell with the Bruyère Research Institute in Ottawa is an executive member of the Canadian Deprescribing Network, a new national group of health professionals, researchers and patients formed to help the elderly reduce the number of prescription drugs they’re taking.

In a recent article in the Ottawa Citizen written by columnist Don Butler, Butler quotes Farrell:

“We’ve got a four-year plan with a goal of reducing unnecessary or inappropriate medication use in older patients by 50 per cent by 2020.  It’s a lofty goal, but we thought we might as well shoot high.”

I further reference Don Butler below:

The rates of medication use by seniors are “shockingly high,” Farrell says. In 2012, nearly two-thirds of seniors submitted claims for five or more drug classes and 27 per cent had 10 or more, according to the Canadian Institute for Health Information (CIHI).

The simultaneous use of multiple medications, known as polypharmacy, is a growing concern around the world, driven by aging populations and the availability of more and more prescription drugs.

Not only does over-prescription put seniors at risk from side effects and potentially diminish their quality of life, it also drives up costs for governments, which foot much of the drug bill for seniors.

The aim is to develop deprescribing guidelines for the drugs and educate primary care physicians on how to have effective conversations with patients about discontinuing or tapering off medications.

The deprescribing guidelines are the first ever developed. “There are many, many prescribing guidelines that tell you when to start a drug,” Farrell says, “but none of them address when it might be appropriate to stop the drug.”

Interestingly Farrell goes on to say:

“For doctors, one challenge will be to find time to do medication reviews with their patients.”

Not sure where Farrell gets her information that doctors do “medication reviews”.  And if she that doctors any time soon are going to start doing such reviews for which there is no listed compensation to doctors, then she is really out of touch with main stream medical economics.

Too bad Farrell is unaware that the Ontario Government has given the task of doing medication reviews to pharmacists for whom there is, at least in principle, some compensation, skill and motivation to do med reviews.   The quality of these med reviews is another question, which will soon come to haunt the profession of pharmacy.

The really big question however is this one.

If deprescribing ultimately results in less prescriptions being filled (kinda the opposite of medication adherence), and pharmacists are still largely compensated for filling prescriptions, how is this going to work in real life?

Recognize that deprescribing is a cognitive activity requiring pharmacological knowledge and a high level of education and understanding of the interaction among drugs and different disease conditions and all simultaneously.

It will be interesting especially to see how Big Pharmacy Retail (BPR) will respond to this initiative.  The notion of BPR’s employee pharmacists, whom BPR compensates, being compensated to reduce the number of billing units (prescriptions) so that revenues will be reduced in direct proportion to the number of reduced prescriptions.

This sounds like a recipe for retail suicide.

Will there be quotas for the number of prescriptions pharmacists can eliminate?  Will ‘district managers’ soon monitor the number of prescriptions individual pharmacists have cancelled?  The sun will rise in the west before this happens.

It may be good healthcare delivery.  It may be great economics for payers, especially government.  But it’s a recipe for disaster for business.

Hence once again we are confronted by the direct contradiction between pharmacy as a profession (which is practiced by pharmacists), and the business of pharmacy which is overwhelmingly controlled by non-pharmacist corporations, or BPR.

Once again, employee pharmacists are being set up to lose no matter what they do.  And once again we ask, “Where are the regulatory bodies and associations?”  It isn’t even on their radar screen.

 

 

Life is like a movie. There should be few restrictions to changing channels.

This whole subject of assisted dying is getting way beyond the realm of reason and very much immersed in emotion.  The problem is that the subject is constantly being inter weaved with religious overtones, subtle or overt.

Recently the Archbishop of Toronto professed the need for better palliative care as an “option” to assisted dying.  What any kind of palliative care (high quality or low quality) has to do with a person’s right to ‘check out’ is a mystery to me.

Like …if we make dying more fun in a palliative setting, people will want to stick around suffering a little longer?  …or the indignity people are suffering through, will somehow become less undignified?

Apparently the Archbishop is supported by 5,000 doctors who believe in the “sanctity of life” and stand in solidarity against assisted dying.  Has anyone asked what 5,000 plumbers think?  Or what 10,000 carpenters think?

First of all, whether life is imbued with any kind of sanctity or not is a matter of personal perspective/faith/belief etc.  Everyone is entitled to their opinion, but please let us not impose our beliefs on others who may not share them.

Second, what do doctors have to do with any of this?  Doctors are trained to treat disease and to preserve life.  Why on earth have we got them involved with ending life under any circumstances whatsoever?  No wonder there is resistance to assisted dying from doctors, it’s like asking farmers to burn crops, or architects to demolish buildings; they are just not that inclined to do it.

Suicide is not a crime.  For many people with completely rational minds, sometimes they just want out.  Like going to the theatre and finding out that you can’t stand the movie.  Do you sit there and watch the thing to the end just because you paid for the ticket? …or do you cut your losses and get up and leave?

Although admittedly committing suicide is a profound and personal decision, the act of asking someone else to assist in the ending of one’s life is something else.   This is a huge issue, as taking someone else’s life is a highly scrutinized matter in modern society.  This is why we recognize the difference among first & second degree murder and manslaughter as strict qualifiers when a life is taken.  It matters big time how a human life is taken.

To assist someone else in taking his/her life must be characterized, and pass strict 100% scrutiny as the acting out of someone else’s wishes…someone who for some/any reason is unable to do it themselves.

If the state continues to put impediments in front of a person’s choice to decide how or when to end one’s life, this could actually cause a shortening of life in general.  People who have a grave illness will be afraid to let the illness take them to a point where they would be unable to end their own life easily; they could end up terminating their life prematurely whilst they retain the capability to end it when they choose.  This cannot be a desirable consequence of all this meddling in the life/death of others.

The terms of life are especially also ones of personal choice.  Some people adapt heroically to grave disabilities like quadriplegia or blindness and go on to lead happy and productive lives on their own terms.  They are to be congratulated.

But for some people many choose to not live life out under circumstances of their own choosing, especially if they are diagnosed with a chronic deteriorating condition which limits their abilities to live life on their own terms.

Science has done a great job of prolonging life, but it has done a poor job of extending living.  If anything, the last years of life are often anything but living…more like some form of purgatory, but without the pleasures of a committed sin.

The state’s role in the process of dying must be restricted to protect the rights of all its citizens, and at once to ensure that the moral/religious/ethical perspectives of none of its citizens impede on the rights of other citizens.  The Americans have a great expression for this, “The tyranny of the majority”.

Doctors should play no role in the process of assisted dying.  Preserving life under difficult circumstances takes great skill and doctors are critical; ending life is a relatively simple process & doctors are not needed.  There are more effective and simpler solutions.

There are only two legal methods for inducing the end of life:  lethal injection and drinking a specifically designed barbiturates cocktail.  Neither one of these procedures is exactly rocket science.   If anything, they are technical in nature and only require tight protocols and a high degree of professional accuracy.  Clearly pharmacists are much better suited to providing the second procedure at least from an educational perspective.

Point being, there are many other options to effecting the desired results which do not involve physicians, the clergy, or an overabundance of politicians.