RATIONAL USE OF DRUGS

Medicines are to be used in an appropriate and safe way and only when needed. A policy on rational use of drugs is an extremely important part of a national drug policy. Its aim is to contribute to the health of the country's population by improving the use of medicines by health workers and consumers, and by encouraging the activities of government, industry and the media in support of rational drug use.

They may involve therapeutic committees responsible for the development of standard treatment guideliness; professional associations, which establish standards of professional practice and continuing education; academic institutions, which are responsible for basic training, research and practice support; industry; and consumer groups.

The factors influencing drug use are many and interrelated. No single approach is likely to work.

Objective drug information

A medicinal product must be accompanied by appropriate information. The quality of information accompanying the drug is as important as the quality of the active substance. Information about drugs and drug promotion can greatly influence the way in which drugs are used.

Drug information

Drug information is the basis for the development of tools essential for rational prescribing and use such as formularies, standard treatment guidelines and consumer information.

Drug information for health personnel

Regulatory information

Information material in the form of drug information sheets and labels is provided by manufacturers as required by regulators.

Other sources of information

Comparative, independent, reliable and objective information is also needed for appropriate therapeutic decisions. This can be provided in the following ways:

* Establishing a drug information centre

* Participation in the development of treatment guidelines and drug formularies, the formation of  drug and therapeutic committees, involvement in teaching and clinical meetings, surveys of practice, and outreach services by staff from the drug information centre.
* Developing a national drug information bulletin or newsletter.
* Disseminating independent scientific literature on the rational use of drugs and on therapeutic advances.
* The organization of training programmes, symposia, and lectures for the various groups of health personnel.

* The development of treatment guidelines and educational material on the appropriate use of drugs by community health workers or paramedical personnel at the primary health care levels.

Drug information for consumers

Information similar to prescriber information, but in language that is understandable for the non-health professional, should be provided to consumers. This is done through patient information sheets and drug labeling. These should be regulated to ensure accuracy. Other information may be provided in the form of brochures, through compaigns and, most importantly, through patient counselling.

Rational use of drugs by health personnel

The therapeutic encounter between the patient and the prescriber/dispenser has a major impact on the quality of care. Even if drug supply and diagnostic services are excellent, treatment may be inadequate. For the patient to receive correct treatment, the overall prescribing and dispensing environment must be supportive. Strategies include the investigation and monitoring of drug use practices, leading to appropriate interventions to address identified problems.

Drug use practices by health personnel can be investigated relatively easily utilizing quantitative techniques. When a significant problem is identified, an intervention should be developed to remedy the situation.

Requirement for rational drug use

Adequate diagnosis

For a correct diagnosis to be made, the prescriber must have adequate knowledge and motivation, private examination facilities, and sufficient time to take a history, perform an examination, and explain to the patient the diagnosis and treatment.

Correct prescribing

To prescribe correctly, the prescriber must know which drug to prescribe for which diagnosis or complaint and when treatment without drugs is appropriate.

Appropriate dispensing

For correct dispensing to occur, the dispenser must be trained, have adequate time, have the necessary materials (containers, labels), and have a dispensary where it is possible to communicate with patients.

Patient adherence to treatment (compliance)

Patient adherence to treatment is dependent on understanding and acceptance of the treatment; this results from effective communication between prescriber, dispenser and patient.
Measuring drug use

In any situation, measurement of present practices, followed by investigation of the underlying reasons for practices that represent problems, should precede the development of interventions. Other methods may utilize aggregated information combining drug procurement and morbidity data to calculate consumption/morbidity ratios. Computers are increasingly used to exchange drug utilization data, there is a need to standardize coding systems, for example for health problems, dosage forms, and the description of adverse drug reactions.

Once the priority problem has been identified, further investigations utilizing qualitative techniques such as observation, focus group discussions, in-depth interviews, questionnaires and simulated patients are required.

Action to promote rational drug use

Any intervention should be focused on a specific problem behaviour and targeted at those individuals or facilities that exhibit the problem behaviour. In the development of interventions the participation of the target group in all phases of the activity is necessary to achieve the desired outcome.

Educational approaches

The education and training of health professionals and health workers form a major strategy to achieve rational drug use. The essential drugs concept and its practical application should be included in the curriculum of all health professionals and health workers.

Teaching medical students to prescribe rationally has a strong impact on the future. Traditional medical education concentrates too much on instilling a growing quantity of facts, rather than teaching the student techniques of problem-solving and making rational choices between drug treatment alternatives, which includes the skill to evaluate new drugs critically.

This implies that the objectives of pharmacotherapy training need to be defined better, with more emphasis on the practical needs of the future prescriber. An undergraduate course in clinical pharmacology and therapeutics should teach the principles of rational evaluation of therapeutic alternatives before the students enter the wards.

Teaching hospitals have an ethical responsibility towards society to promote rational prescribing through the example of their teaching staff, which will then be followed by future generations of doctors. The best approach appears to be for clinical departments in teaching hospitals to develop departmental prescribing policies for common conditions, within the national list of essential drugs, through a process of consultation and consensus building. Such treatment guidelines can later be integrated into a hospital formulary and should be used, and enforced, as the basis for prescribing, teaching, examinations and medical audit.
Post-qualification training for prescribers is required in order to maintain and update knowledge and practice, and to correct identified deficiencies in practice. Whenever possible such training should occur on site and in small group or one-on-one interactions. Conferences and symposia offer further opportunities for education.

The prescriber is an important factor in patient education, a function that is often neglected.

Managerial action

Options for managerial action to promote rational drug use can occur throughout the drug procurement cycle. The essential drugs list should be organized. Estimates of procurement quantities should be based on morbidity rather than past consumption data.

Prescribing and dispensing can be improved managerially by audit and feedback (including the use of "exit" interviews of patients); structured drug order forms; standard diagnostic and treatment guidelines for different levels of health care; packaging in quantities required for a course of therapy and mandatory consultations or justifications.

The option of audit and feedback has been shown to be among, the most effective strategies progressively to improve prescribing.

Regulatory interventions

Regulatory interventions may be rapidly effective but can have unintended impacts. Thus they should be used with caution. Fixing priorities in the registration of drugs on the basis of medical need; restrictions on the level of use for both prescribing and distribution; dispensing controls, which can include limiting the quantities of drugs dispensed for some categories; and the use of convenient packaging, such as blister packs.

Combining actions

Interventions of different categories should be combined either simultaneously or sequentially. Such combinations have shown synergistic impact when evaluated.

Evaluation and selection of approaches

To determine which approaches have the greatest chance of success, careful evaluation is required. Such evaluations require good methodology, and a recognition that information is gained even from a negative outcome. At present the most successful interventions appear to be:

* Audit and feedback.
* Focused and targeted education, particularly when this includes face-to-face training in small groups, ideally involving an opinion leader.
* Developing essential drugs lists and standard treatment guidelines combined with focused training.

* Distribution of level-specific drugs combined with training and supervision.
* Structured drug order forms.

Rational use of drugs by consumers

Public education in drug use

Public education in the appropriate use of drugs is needed because without it people lack the skills and knowledge they require to make informed decisions about how to use drugs (and when not to use them and to understand the role of drugs in health care. However, public education is frequently treated as a marginal activity or one that should only be tackled when the other elements of drug policy have been dealt with. There is a need to increase the priority given to public education.

Irrational drug use has been well documented and includes problems of overuse, underuse and inappropriate use. Improving public understanding of medicines will not resolve all of these issues.

Principles to guide public education in rational drug use include the following:

* Drug use should be seen within the overall context of a society, community, family and individual. Public education on drugs should recognize and take into account cultural diversity and the influence of social factors such as poverty, disadvantages and power relations that can influence drug use.
* Public education should be part of national drug policies.
* Public education should encourage informed decision-making by individuals, families and communities on the use of drugs and non-drug solutions.
* Public education should be based on the best available scientific information on drugs, their efficacy and side-effects.
* Non-Government organizations, community groups, teachers, and consumer and professional organizations have an important role to play in public education programmes and should be involved in the planning and implementation of educational activities.
* Communications training of health care providers and reorientation of their attitudes to patients are necessary.

Education about drug use should begin at an early age; schools and the home have a key role to play in this respect. It is important that people understand some basic concepts relating to drug action and realize that drugs involve risks as well as benefits.

People should also receive information about the positive value of therapeutic medicines and how to choose when to self-medicate and when to seek medical advice.

People need to understand the correct use, benefits, and limitations of the drugs they take. They also need to understand that drugs can mask serious conditions.
Constraints and facilitating factors

Factors that can act as constraints to public education include: a lack of policies on both drug use and public education: commercial interests; professional interests; weak infrastructures; lack of  resources; and economic, social and cultural influences.

Factors that can facilitate public education include: a rise in levels of education and literacy in the country; increased awareness of the need for drug education; improvements in health infrastructures; and the expanding coverage of the world's population by mass media.

Self-medication

Self-medication is widely practised in both developed and developing countries. In some chronic or recurring illnesses self-medication is possible after initial diagnosis and prescription, the doctor retaining an advisory role.

Responsible self-medication can:

* help to prevent and treat symptoms and ailments that do not require medical consultation;
* reduce the increasing pressure on medical services for the relief of minor ailments, especially when resources and human resources are limited;
* increase the availability of health care to populations living in rural or remote areas where access to medical advice may be difficult;
* enable patients to control their own chronic conditions.

Promotional activities

Drugs have a potential for harm as well as benefit that makes them different from other commodities. Their promotion and sale require special controls. Hence the aim is to support and encourage the improvement of health care through the rational use of medicinal drugs. All promotion-making claims concerning medicinal drugs should be reliable, accurate, truthful, informative, balanced, up-to-date, capable of substantiation and in good taste. They should not contain misleading or unverifiable statements or omissions likely to induce medically unjustifiable drug use or to give rise to undue risks. The word "safe" should only be used if properly qualified. Comparison of products should be factual, fair and capable of substantiation. Promotional material should not be designed so as to disguise its real nature"