Prescription medications are used daily and problems occurring with the use of drugs can include:
Suboptimal drug, dose, regimen, dosage form, and duration of use
Unnecessary drug therapy
Drug–drug, drug–disease, drug–food, or drug–nutrient interactions
Adverse drug effects, some of which are preventable
Clinicians are often called upon to resolve problems that occur due to undertreatment, overtreatment, or inappropriate treatment. Individuals can purchase medications through numerous outlets. Over-the-counter (OTC) medications can be purchased virtually anywhere. OTCs are widely used by all age groups. Prescription medications can be purchased through traditional channels (community chain and independent pharmacies), from mail-order pharmacies, through the Internet, from physicians, from healthcare institutions, and elsewhere. Herbal remedies and countless cannabidiol (CBD) products are marketed and sold in numerous outlets. The monitoring of the positive and negative outcomes of the use of these drugs, both prescription and OTC, can be disjointed and incomplete. Clinicians and health professionals need to take ownership of these problems and improve patient outcomes resulting from drug use.
Although clinicians are the gatekeepers for patients to obtain prescription drugs, patients obtain prescription medications from numerous sources. Patients may also borrow from friends, relatives, or even casual acquaintances. In addition, patients obtain OTC medications from physicians through prescriptions, on advice from pharmacists and other health professionals, through self-selection, or through the recommendations of friends or acquaintances. Through all of this, it must be recognized that there are both formal (structural) and informal (word-of-mouth) components at play. Health professionals may or may not be consulted regarding the use of medications, and in some cases are unaware of the drugs patients are taking.
External variables may greatly influence patients and their drug-taking behaviors. Coverage for prescribed drugs allows those with coverage to obtain medications with varying cost-sharing requirements. However, many do not have insurance coverage for drugs or other health-related needs.
Self-medication can be broadly defined as a decision made by a patient to consume a drug with or without the approval or direction of a health professional. The self-medication activities of patients have increased dramatically in the late 20th and early 21st centuries. Many factors affecting patients have continued to fuel this increase in self-medication. There have been many prescription items switched to OTC classification in the last 50 years, which is dramatically and significantly fueling the rapid expansion of OTC drug usage. In addition, patients are increasingly comfortable with self-diagnosing and self-selection of OTC remedies.
Through the rational use of drugs, patients may avoid more costly therapies or expenditures for other professional services. Self-limiting conditions, and even some chronic health conditions (e.g., allergies and dermatologic conditions), if appropriately treated through patient self-medication, allow the patient to have a degree of autonomy in healthcare decisions.
Non-adherence is not taking a prescribed medication or not taking it as prescribed and is one of the most understated problems in the healthcare system.9 Reasons can include not being able to get the medication in a timely manner because of insurance requirements such as a prior approval from the insurance being denied or delayed, the prescribed drug may not be covered under the patient’s insurance, the patient cannot afford to pay the drug cost or the copay, regimens are complicated or not understood by the patient, etc. The effects of non-adherence have enormous ramifications for patients, caregivers, and health professionals. Non-adherence is a multifaceted problem with a need for interprofessional, multidisciplinary solutions. Interventions that are organizational (how clinics are structured), educational (patient counseling, supportive approach), and behavioral (impacting health beliefs and expectations) are necessary. Compliant behavior can be enhanced through your actions with the patients for whom you provide care. Sometimes what is necessary is referral to specific clinicians for individualized treatment and monitoring to enhance compliance. The case histories provided in this textbook will allow you to follow what others have done in similar situations to optimally help patients succeed in improving adherence rates and subsequent positive health outcomes.
The major source of payment for prescription drugs for those age 65 years and older in the United States is the Medicare Part D Drug Benefit. Seniors have benefitted tremendously from this component. Estimates place the expenditure for Medicare Part D to be $88 billion in 2020.10
A joint effort by health professionals working together is the best approach to aiding seniors in achieving optimal drug therapy. Evaluation of all medications taken by seniors at each patient visit can help prevent polypharmacy from occurring.