Problems of Irrational Drug Use 24 February 2019 Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Problems of Irrational Drug Use: Objectives Identify magnitude and nature of inappropriate drug utilization Understand the adverse impacts of inappropriate use of drugs Describe factors that influence the decision-making process Identify factors that influence the behavior of prescribers and patients Discuss specific medication use problems Problems of Irrational Drug Use

What Is Rational Use of Drugs? 24 February 2019 What Is Rational Use of Drugs? The rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and the community. (WHO 1988) Appropriate indication Appropriate drug Appropriate administration, dosage, and duration Appropriate patient Appropriate patient information Appropriate evaluation Emphasize that this is medical model. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Irrational Use of Drugs = Pathology of Prescribing 24 February 2019 Irrational Use of Drugs = Pathology of Prescribing The use of drugs when no drug therapy is indicated The use of wrong drugs for a specific condition requiring drug therapy The use of drugs with doubtful or unproven efficacy The use of drugs of uncertain safety status Failure to prescribe available, safe, & effective drugs Incorrect administration, dosages, or duration Request an example of each practice from participants. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Examples of Common Inappropriate Prescribing Practices 24 February 2019 Examples of Common Inappropriate Prescribing Practices Overuse of antibiotics and antidiarrheals for nonspecific childhood diarrhea Indiscriminate use of injections for malaria Multiple or overprescription Use of antibiotics for mild, nonbacterial infection, e.g., ARI Tonics and multivitamins for malnutrition Unnecessary use of expensive antihypertensives Elicit 2-3 others from participants. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Components of the Drug Use System 24 February 2019 Components of the Drug Use System Local Drug Imports Manufacture The Drug Supply Process Key points: relationship of demand and supply multiple outlets for drugs many decision-makers effect system Provider and + Consumer Behavior Private Physician or Hospital or Pharmacist or Other Practitioner Health Center Drug Trader Illness Patterns Public Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Factors Underlying Irrational Use of Drugs 24 February 2019 Factors Underlying Irrational Use of Drugs drug misinformation misleading beliefs inability to communicate problems Patients promotion misleading claims Industry availability of non-essential drugs informal prescribers Drug Regulation lack of education and training lack of drug information heavy patient load pressure to prescribe generalization of limited beliefs misleading beliefs about efficacy Prescribers inefficient management nonavailability of required drugs Drug Supply Emphasize interrelationship of factors and that problems rarely have single cause. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Impact of Inappropriate Use of Drugs 24 February 2019 Impact of Inappropriate Use of Drugs Reduced quality of therapy Waste of resources Risk of unwanted effects Psychosocial impacts reduced availability increased cost morbidity mortality patients rely on unnecessary drugs adverse reactions bacterial resistance Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Meaning of Appropriate Use 24 February 2019 Activity 1 Meaning of Appropriate Use Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Drugs per Case, by Age Group E. Java & W. Kalimantan, Indonesia, 1987 24 February 2019 Drugs per Case, by Age Group E. Java & W. Kalimantan, Indonesia, 1987 One 3% Two 14% Three 27% Four 26% Five 17% Six+ 13% 1% 9% 29% 35% 19% Six + 6% Under Age Five Age Five and Over Average for both Adults and Children =3.8 Drugs. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Drugs per Case, by Diagnosis E. Java & W. Kalimantan, Indonesia, 1987 24 February 2019 Drugs per Case, by Diagnosis E. Java & W. Kalimantan, Indonesia, 1987 All Cases . 1 2 3 4 5 # Drugs per Case Under Five Five and Over Possible discussion: Why are there such small differences by diagnosis? Diarrhea Resp.Dis. Skin G.I. Musculoskel Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % of Patients Receiving Antibiotics E. Java & W. Kalimantan, Indonesia, 1987 None 12% One 56% Two 29% Three/More 3% 35% 36% 27% 2% Age Five and Over Under Age Five Possible discussion: What would you expect the real need for antibiotics to be? Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % of Patients Receiving Injections E. Java & W. Kalimantan, Indonesia, 1987 None 56% None 26% One 54% Two or More Possible discussion: Why is use of injections higher in adults than children? 10% Two or More 20% One 34% Under Age Five Age Five and Over Problems of Irrational Drug Use Problems of Irrational Use of Drugs

ARI Treatment Pattern E. Java & W. Kalimantan, Indonesia, 1987 24 February 2019 ARI Treatment Pattern E. Java & W. Kalimantan, Indonesia, 1987 Antibiotics Analgesic Cough/Cold Antihist. Others 0.2 0.4 0.6 0.8 1 1.2 1.4 Average # of Drugs Per Case Under Five Five and Over Possible Discussion: Which drugs are appropriate for ARI? Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Other Drug Use Problems 24 February 2019 Other Drug Use Problems Incorrect treatment of malaria Incorrect use of chloroquin injection Poor compliance with TB therapy Causes treatment failure and resistant organisms Underuse of effective drugs Hypertension Depression Hospital drug use problems Antibiotic misuse for surgical prophylaxis Ask participants which other problems are important in their environment. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 Average Number of Drugs per Patient Public Sector Drug Use Indicator Studies, 1990–1993 Yemen Uganda Sudan Malawi Indonesia Bangladesh Zimbabwe Tanzania Nigeria Nepal Ecuador Guatemala Eastern Caribbean Jamaica Ghana Cameroon El Salvador 1 2 3 4 5 Average Number of Drugs Possible discussion for all indicator slides: 1.) Why are countries different? 2.) What is gold standard value? Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % Prescribed as Generics Public Sector Drug Use Indicator Studies 1990-1993 Sudan Indonesia Zimbabwe Tanzania Nigeria Nepal Ecuador Guatemala Eastern Caribbean Ghana Cameroon El Salvador Jamaica 20 40 60 80 100 % Generic Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % Receiving Antibiotics Public Sector Drug Use Indicator Studies 1990-1993 Yemen Uganda Sudan Malawi Indonesia Bangladesh Zimbabwe Tanzania Nigeria Nepal Ecuador Guatemala Eastern Caribbean Jamaica Ghana Cameroon El Salvador 20 40 60 80 100 % of Encounters Receiving Antibiotics Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % Receiving Injections Public Sector Drug Use Indicator Studies 1990-1993 Yemen Uganda Sudan Malawi Indonesia Bangladesh Zimbabwe Tanzania Nigeria Nepal Ecuador Guatemala Eastern Caribbean Jamaica Ghana Cameroon El Salvador 20 40 60 80 100 % of Encounters Receiving Injections Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 Average Consultation Time Public Sector Drug Use Indicator Studies 1990-1993 Malawi Indonesia Tanzania Nigeria Nepal 1 2 3 4 5 6 7 Average Consultation Time (in minutes) Discuss reasons for short consultation times when the workload is low. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 Average Dispensing Time Public Sector Drug Use Indicator Studies 1990-1993 Tanzania Nigeria Nepal Eastern Caribbean Ghana 50 100 150 200 Average Dispensing Time (in seconds) Point out that times are measured in seconds not minutes and that training of dispensers can have good effects. Begin to discuss that dispensing time includes both preparation of drugs to dispense and dispensing communication. Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % Patients with Drug Dosing Knowledge Public Sector Drug Use Indicator Studies 1990-1993 Malawi Indonesia Bangladesh Tanzania Nigeria Nepal Eastern Caribbean Ghana 20 40 60 80 100 % Patients with Dosing Knowledge Possible discussion: What should patients know about their drugs? Problems of Irrational Drug Use Problems of Irrational Use of Drugs

24 February 2019 % of Key Drugs in Stock Public Sector Drug Use Indicator Studies 1990-1993 Malawi Tanzania Nigeria Nepal Ecuador Cameroon Ghana El Salvador Guatemala Jamaica 20 40 60 80 100 % of Key Drugs in Stock Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Identifying a Priority Problem 24 February 2019 Activity 2 Identifying a Priority Problem Problems of Irrational Drug Use Problems of Irrational Use of Drugs

Conclusion Drug use is the end of the therapeutic consultation 24 February 2019 Conclusion Drug use is the end of the therapeutic consultation Health professionals have responsibility to ensure that the right drug is prescribed, dispensed, and taken Methods exist to measure drug use and to change practices Improving drug use improves the quality of care and frequently lowers cost Problems of Irrational Drug Use Problems of Irrational Use of Drugs