CHAPTER
3
RATIONALITY OF DRUGS
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CHAPTER
3 |
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The Oxford English Dictionary defines "rational" as that which is based on reason, which is sensible, sane or moderate. Rational Drug Therapy is described as "Ordering the right medicine for the right patient at the right time and in the right amount with due consideration of costs" (1). Rationality is also to be looked at within a particular medical system. In this book, we are concerned with rationality within the allopathic medical system only. (Rationality of use of two or more systems is a knotty if unresolved issue. A recent hearing of the Supreme Court (1996) prohibits prescribers trained in one system to prescribe medicines of another system in which the prescriber is not trained.) |
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Rational
drug therapy means the use of drugs which are efficient, safe, low-cost
and easy to administer. It requires that health practitioners have adequate
medical knowledge and appropriate skill for correct diagnosis and treatment
They would also be required to have time and concern for their patients.
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Irrational
use occurs owing to:
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1.
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1.
Lack of knowledge: Or when prescribers have no scientific knowledge.
This happens in the case of so-called quacks or when doctors have not
kept abreast of current developments in medicine. (It is indeed debatable
whether any formally trained doctor with a medical degree who does not
have knowledge to treat even simple problems, or treats common problems
irrationally, should be considered a 'quack';
likewise, should a well-trained village health worker knowing how to prescribe
for specific conditions be considered 'practising'
medicine unethically and illegally?). Lack of knowledge also occurs when
patients treat themselves without sufficient knowledge about the drug.
Most OTC drugs have instructions for use in English - a language understood
only by a minority of the Indian population. Moreover, very often instructions
are couched in technical jargon (and often in small, unreadable print)
which cannot be understood by lay persons. In addition, people tend to
recommend drugs based on their personal experience.
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2.
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Inaccurate diagnosis: This occurs due to lack of interest, lack of time, over-crowded OPDs, inadequate health personnel and lack of diagnostic aids. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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3.
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Lack
of objective drug information: It is doubtful whether a majority of
doctors in India are in the habit of referring to standard textbooks or
standard medical journals. So they probably tend to take the easy way
out by relying on information supplied by medical representatives and
drug companies which can be very biased and selective (see Chapter 4).
Also, doctors are led to believe a lot of new products are being marketed
every day. Many of these are not new discoveries which radically alter
the course of treatment. Therefore to say that it is difficult to keep
up with new knowledge is not quite correct. Thirdly, absence of compulsory
recertification of medical degrees and continuing education programmes
is another drawback in updating whatever relevant new knowledge that does
come out.
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4.
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Aggressive
drug promotion influencing doctors: As mentioned in the earlier chapter,
there are more than 100,000 formulations (at five products per company
for the estimated 20,000 manufacturing units in India) in the Indian market,
many of which are similar except for different brand names or for a few
unnecessary additional ingredients. Pharmaceutical companies therefore
indulge in aggressive marketing to promote the sale of their brands. Sometimes,
it results in unethical marketing practices such as bribing doctors with
diaries, calendars, posters, gifts and even foreign trips and vacations
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5.
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Over/under-prescribing
by doctors: Over-prescribing occurs when doctors prescribe too large
quantities, for too long duration, too many at the same time for the same
problem, or sometimes even unnecessary drugs. This causes wastage of money,
drugs, adverse reactions due to drug interaction, and saddest of all,
is that the patient's
condition does not improve, and in fact may have deteriorated. Doctors
over-prescribe because they may not be able to diagnose the patient's
condition and hope to "hit or miss" with a wide range of drugs.
They may also be influenced by the pharmaceutical companies which supply
doctors with excessive samples. In addition, doctors may not be able to
resist the clamour of patients'
demand for more medicines, lest they lose their practice to a competing
private practitioner.Under-prescribing occurs, among other reasons, due
to lack of knowledge on the part of the prescriber, non-availability of
drugs as in the case of long-term, regular treatment necessary for the
treatment of diseases like tuberculosis and leprosy, and patients'
inability to purchase drugs.
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6.
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Cut-Practice:
Another reason irrational and often expensive treatment occurs is due
to the presence of cut practice, that is, kickbacks offered by specialists,
pathologists, X-ray clinics, CAT scan centres, etc., to prescribers who
refer patients to them.
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*
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Prescribing
antibiotics for ailments like diarrhoea or viral infection where they
are useless, thus causing antibiotic resistance by the body when needed
for dangerous diseases.
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*
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Prescribing
combination products where one medicine is sufficient..
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*
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Prescribing
unnecessary expensive vitamins or tonics, virtually regardless of the
condition being treated.
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*
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Prescribing
expensive new drugs in preference to established, less expensive ones.
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*
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Ordering of
unnecessary investigations.
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