Medicines play a crucial role in our health. They help treat acute and chronic conditions and can also prevent illness. They sometimes save lives. However, there is a growing body of evidence that perhaps doctors are prescribing a little too frequently; the aptly named Too Much Medicine movement or the Choosing Wisely initiative that emphasizes the need to get the fundamentals of prescribing right. PCRS data suggests that 1 in 5 of our over 65-year-old patients are now prescribed 10 or more repeat medicines1. Simultaneously, it is estimated that about 10% of preventable hospital admissions in the elderly are the result of drug related morbidity2.
As a profession we have been routinely informed of the patient safety implications of polypharmacy. There is however a less recognized environmental cost incurred which are now obliged to consider.
The 2019 Health Care Without Harm report of the environmental impact of global healthcare estimated that emissions from healthcare would surpass most countries, bar USA and China. In Ireland we are not obliged to count or consider the carbon emissions of the care that we provide, despite the paradox that this may ultimately lead to harm. Using UK data as a proxy, pharmaceuticals account for approximately 22% of the total NHS England carbon footprint. Notably, 79% of drugs are prescribed in primary care and community services. The NHS Sustainability Development Unit estimates the carbon foot print of a single item on a prescription to be modelled at 7kg of CO2. That has a similar carbon footprint of driving an average vehicle 17 miles or charging 893 smart phones3.
Doctors are taught a lot about prescribing but sadly very little about deprescribing and we have relatively little evidence to support such decisions4,5. We can now prescribe with just the click of a button but have we ever considered the journey triggered by such a quick and sometimes effortless action? Upstream of the action of our pen stroke is a global story of air and shipping miles, packaging, utilization of natural resources and a water, waste and pollution footprint that is hidden from sight. More than 90% of patients are willing to stop a medication if their doctor says it is possible6. With the advent of social prescribing and the evolving field of lifestyle medicine, we may not always need to prescribe as readily or as heavily.
When we do prescribe, fortunately there are some well-known tools to aid us. To help get started below is a summary of these tools, some of the key points and links for further information.
Medication reviews are worthwhile
A cluster randomized controlled trial based in Irish primary care demonstrated that a GP led medication review, where potentially inappropriate prescriptions are identified, did improve prescribing7. Similarly, a large RCT in Scotland, investigating the effectiveness of an intervention designed to alert GPs to high risk prescribing, was effective in improving prescribing and was associated with reduced hospital admissions8.
Polypharmacy and inappropriate prescribing are a major cause of morbidity
A systematic review identified non-steroidal anti-inflammatory drugs, anticoagulants, antiplatelets and diuretics as the four drug groups which are most commonly associated with preventable drug related morbidity8. Similarly, a group in Scotland identified drug groups that are commonly associated with morbidity in the elderly. These include anticholinergics, benzodiazepines and antipsychotics. .
We have tools and guidelines to optimize our prescribing
There is a myriad of tools available to choose from, some examples include;
- the STOPP/START tool
- https://deprescribing.org/ which provides;
- tools to help patients and providers participate in deprescribi
- (information about deprescribing initiatives
- The HSE Medicines Management Programme (MMP) has a number of useful resources on their website
- The Scottish Government Polypharmacy Model of Care Group 2018 provides useful information on deprescribing including a very useful and patient centered 7 step review
Patient buy-in is crucial
The advice is to ask patients “what matters most to you”. Up to half of all patients do not take their medicines as recommended9. Guidelines can be based on numbers as opposed to individuals, however as GPs we have the personal insight into patient motivations and personal circumstances. We have the ability to understand their experience better.
Prescribing has a heavy carbon footprint
A whopping 22% of the NHS carbon footprint is from medications prescribed. So, every item we prescribe has a broader consequence. Unused and unnecessary medication are not only a waste, they are environmentally destructive.
Medicines are central to what we do, they are part of our toolkit. They can also harm us, not just directly but indirectly. Make every prescription count!
HSE Managing Medicines: Information on deprescribing of certain specific drug groups proton pump inhibitors (PPIs), benodiazepines and z drugs.
Benodiazepines and z-drugs: Information on deprescribing benzodiazepines and z-drugs.
General Deprescribing: The Scottish Government Polypharmacy Model of Care Group 2018 document on ‘Polypharmacy Guidance Realistic Prescribing‘ provides useful information on deprescribing. See their accompanying resource too.
- HSE. Primary Care Reimbursement Service Statistical Analysis of Claims and Payments 2018. 2019; Available at: https://www.hse.ie/eng/staff/pcrs/pcrs-publications/annual-report- 2018.pdf. Accessed 23/08, 2019.
- Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br.J.Clin.Pharmacol. 2007 Feb;63(2):136-147.
- Ailabouni NJ et al. General practitioners’ insight into deprescribing for the multimorbid older individual: a qualitative study. Int J Clin Pract 2016; 70: 261-76.
- Welsh Medicines Resource Centre, 2010. Stopping medicines [online]. Available: https://www.wemerec.org/Documents/Bulletins/ StoppingMedicinesBulletinOnline.pdf [Accessed 18 May 2016].
- Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM (2018) “Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States.” JAMA Internal Medicine; Published online 15 Oct
- Clyne B, Smith SM, Hughes CM, Boland F, Bradley MC, Cooper JA, et al. Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A ClusterRandomized Controlled Trial (OPTI-SCRIPT Study). Ann.Fam.Med. 2015 Nov;13(6):545-553. 1
- Br J Clin Pharmacol. 2007 Feb; 63(2): 136–147.
- Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3 rd Edition, 2018. Scottish Government