TABLE 2.-SELECTED PSYCHOACTIVE AGENTS OF QUESTIONABLE VALUE FOUND ON FORMULARIES OF PRIVATE HOSPITALS WITH 500 BEDS OR MORE Ingredients Meprobamate, 300 mg; d-amphetamine, 15 mg. Phenobarbital,4 gr; vitamin B-1, 1.5 mg; vitamin B-2, 1 mg; vitamin d-Amphetamine, 5 mg; amobarbital, 1⁄2 gr; ASA, 21⁄2 gr; phenace- Meprobamate, 400 mg; benactyzine, 1 mg. Methamphetamine, 5, 10, or 15 mg; pentobarbital, 30, 60, or 90 mg. gr; ASA, 2 gr.. Secobarbital sodium, 50 mg; butabarbital sodium, 30 mg; phenobarbital, 50 mg. Dihydroergocornine, 0.167 mg; dihydroergocristine, 0.167 mg; di- Secobarbital sodium, 25 mg; pentobarbital sodium, 25 mg; buta- Expectorant with sedative. Treatment of obesity.. Phenytoin, 100 mg; phenobarbital, 30 mg; methamphetamine, 2.5 Epilepsy. Conjugated estrogens, 0.4 mg; meprobamate, 200 or 400 mg. Meprobamate, 100 or 200 mg; promazine, 125 or 25 mg. Relief from anxiety and tension during menopause. Climacteric and its nervous mani- Control of emotional disturbances. 1 Products withdrawn from the market since 1976. TABLE 3.-Selected Psychoactive Drugs Listed on 1 or More Medicaid Formularies But Not on Any of 52 Hospital Formularies Tranquilizers Benactyzine HCl Cytran Promazine/Meprobamate Sedatives and Hypnotics Acetabar Acetamin/Butabarb/Salicylamide Amobarb/Secobarb/PB Butabarbital/Homatropine HBr Chloral Hydrate/Aminoacetic Acid Ephedrine/Secobarbital Fello-Sed Pentobarbital Sod Pyrilamine Mal Sebella Tab The above data indicate that some and perhaps many practitioners have considerable difficulty in obtaining adequate information to effectively discriminate in the drug selection process. Part of this problem, though, may be traced to the tendency of certain prescribers to rely upon an excessive number of different products. Although the following illustration is now a decade old, Becker and associates (9) found that general practitioners, on the average, used 270 different drug entities during the course of a single year (the range extended from 100 to almost 500). While the optimum number of drugs that can be employed effectively by a given physician will vary due to type of practice, years of experience, etc., the statistical probability of achieving this objective would seem to fall sharply once the limit of 60-100 is exceeded. Indeed, the hospital formulary study cited above revealed that an unusually strong correlation (.94) obtained between the increased size of formularies and the proportion of inferior preparations carried. While the relationship between number of unique drugs ordered per year by a practitioner and the quality of those selections remains unknown, it seems foolish to disregard the negative relationship observed in the hospital survey. Because of the time constraint, my analysis of prescribing practices has been restricted to the top of our therapeutic iceberg. Let me conclude this descriptive section by noting that I am unaware of a single study in the literature which has been able to document that prescriptions for psychoactive agents corresponded with the standards of rational use established by the investigator. Since most surveys of prescribing behavior have been implemented within medical school environments, where care supposedly is superior to that provided in alternative settings, it seems reasonable to conclude that the general situation can only be worse than perceived. It would seem to be more productive, therefore, if the legislative bodies and researchers would devote less resources to the task of problem measurement and more to the development of constructive techniques that are likely to minimize it. In my view, efforts to mitigate the irrational prescribing of psychoactive drugs are unlikely to be very effective (except perhaps in the imposition of production controls on amphetamines) if the problem is approached as a special case. Thus it is necessary for society to establish a comprehensive, coordinated program that is designed to support the rational prescribing of all marketed pharmaceuticals. If this basic strategy is sound. it then becomes essential to identify those impediments that inhibit the attainment of that goal. While the causes of suboptimum prescribing are numerous and their relative importance subject to disagreement, the three most significant, along with the corresponding recommendation, are: (1) The absence of a comprehensive, current and unbiased system of drug information that is readily available to support practitioner decision-making. In this connection, I have proposed the establishment of an integrated model in the form of a National Drug Education Foundation (10) whose major objec tive is to help ensure that prescribing decisions are made in an environment of enlightened neutrality. (2) The second factor is manifest in the posture of casual empiricism exhibited by many practitioners in evaluating the results of their prescription orders. This propensity is prevalent in the area of psychoactive agents where "an excessive reliance on 'clinical judgment' seems to contribute to doctors' overestimation on the benefits and underestimation of the risks of drug use." (11) In order that these subjective elements may be replaced with more objective techniques, the two recommendations put forward today are thought to be essential in achieving that end. (3) The third factor is the lack of a coordinated, efficient means of record generation and retrieval pertaining to prescribing, dispensing and consumption in general. (12) Since a basic objective here is to furnish practitioners with a self-correcting mechanism for reviewing many prescribing decisions before the patient leaves the treatment setting, the role of an advanced, computerized record-network becomes a critical prerequisite for any program designed to improve drug use. In addition, this same system would serve as the foundation for carrying out more systematic quality assurance activities on a retrospective basis. It should be of concern that many auto junkyards, pecan parlors and hamburger stands-among others have established computerized data systems on a nationwide basis for controlling their inventory. This technology, however, has not been harnessed effectively in health care because both the professions and Federal Government construe the problem to be one of microincrementalism rather than one of macro development and coordination. Given the major information gaps that characterize drug prescribing and use in our society, it should be apparent that professional schools of medicine, dentistry, podiatry and pharmacy will continue to train practitioners without a full understanding of the limitations of their previous graduates. A model information network, though, could incorporate a feedback function that would enable interested students to test experience data against their academic training. In conclusion, until the nation and practitioners are willing to address fundamental methods for improving prescribing practices in general, such as sketched above, little progress is likely to be recorded. In considering holistic legislative programs, though, no intervention strategy should be adopted if it seems likely to perpetuate or aggravate the problem. This task, then, represents a challenge for us all. REFERENCES 1. Greenblatt, D. J. and Shader, R. I. "Benzodiazepines," NEJMed 291:1011–15; 1239-43 (Nov. 7 and Dec. 5, 1974). 2. Manheimer, D. I., et. al., "Popular Attitudes and Beliefs About Tranquilizers," Am J Psychiatry 130:1246-53 (Nov., 1973). 3. Parry, H. J., et. al., "National Patterns of Psychotherapeutic Drug Use," Arch Gen Psychiatry 28:769-83 (June, 1973). 4. Mellinger, G. D., et. al., “An Overview of Psychotherapeutic Drug Use in the United States." In: Drug Use: Epidemiological and Sociological Approaches, (edited by Eric Josephson and E. E. Carroll), Washington, Hemisphere Publishing Corp., 1974. p. 364. 5. Rucker, T. D. and Visconti, J. A. A Descriptive and Normative Study of Drug Formularies Columbus, OH, College of Pharmacy-OSU, June/August 1978, 213 pages. 6. Ibid., p. 13. 7. Ibid., pp. 176–85. 8. Waldron, Ingrid. "Increased Prescribing of Valium, Librium and Other Drugs..." Int J Health Services 7:40 (1977). 9. Becker, M. H., et. al., Correlates of Physicians' Prescribing Behavior," Inquiry 9:33 (Sept., 1972). 10. Rucker, T. D. "Drug Information for Prescribers and Dispensers: Toward a Model System," Medical Care 14:156-65 (Feb., 1976). 11. Waldron, op. cit., p. 53. 12. Rucker, T. D. "Public Policy Considerations in the Use of Psychotherapeutic Drugs," Drugs in Health Care 1:10-11 (Summer, 1974). |