Introduction

Jack E. Fincham

Health professionals are given significant responsibilities in our healthcare system. These roles may be taken for granted by patients until a pharmacist, nurse practitioner, physician assistant, physician, or others perform assigned tasks that make major positive impacts upon patients and patients’ families lives in countless ways. The exemplary manner in which health professionals provide necessary care to patients is a hallmark of health professional practice and delivery of US health care. Patients are thus well served, and fellow health professionals share knowledge and expertise specific to their profession.

However, there are significant problems remaining in the US healthcare system from a structural standpoint. In 2018, the United States spent twice as much as comparative countries on health care, yet the United States ranks 11th in the list that considers increased hospitalization from preventable causes and an increase in avoidable deaths.¹ Keehan and colleagues² from the US Centers for Medicare and Medicaid Services (CMS) projected the costs of health care through 2028 and estimate that by 2028, US healthcare expenditures will exceed $6.2 trillion with prescription drug spending estimated to be $560.3 billion. This prescription drug spending amounts to a projected increase in spending of 74% between 2016 and 2028.

A significant issue in the United States is that countless Americans in our midst are uninsured or underinsured. They may have partial coverage after a fashion, but, for these Americans, the high price of deductibles, co-pays, and monthly payments for insurance create an economic dilemma each time they seek care or pay premiums. The Coronavirus Disease (COVID-19) pandemic has amplified the lack of health insurance for many in this country.³ The swelling of the ranks of the unemployed also means many with prior health insurance through an employer are now not only out of work but also without health insurance. In addition, many other social determinants of care impact who receives health care or not.

The use of medications in the healthcare system provides enormous benefit to many; lives are saved or enhanced, and lifespans are lengthened. Many other uses of medications lead to significant side effects, worsening states of health, and premature deaths. So, how to separate these disparate pictures of drug use outcomes? You, within your practices and within your networks in the healthcare workplace, can help to promote the former and diminish the latter. The authors of the chapters in this book have written informative, current, and superb chapters that can empower you to positively influence medication use.

The following are issues that will impact you as you develop as a healthcare professional or impact your patients as they use medications. These are important issues to consider as you enhance your knowledge concerning medications and how they can impact your patients.

The COVID-19 pandemic has wreaked havoc globally upon economic, social, and health structures. Healthcare practitioners have been stressed as never before. Driggin and colleagues⁴ have written of the risks heathcare workers are exposed to when providing cardiovascular care and become hosts or vectors of COVID-19 transmission. Much has been written of the fear healthcare workers are experiencing since they fear for their coworkers, their family and friends, and their communities.^5,6 Rose⁷ has noted the rapid change of teaching techniques from traditional pre-clerkship course delivery to online learning applications that are now required for health professional curricula during this pandemic.

The general public has experienced significant detrimental emotional impacts due to the COVID-19 pandemic. Pfefferbaum and North⁸ have written of the trauma, including post-traumatic stress disorders (PTSD), patients are experiencing due to concerns related to their health, safety, well-being, economic status, and stress disorders. You will have an enormous opportunity to positively impact patients and families in your practices.

Prescription medications are used daily and problems occurring with the use of drugs can include:

• Medication errors

• Suboptimal drug, dose, regimen, dosage form, and duration of use

• Unnecessary drug therapy

• Therapeutic duplication

• Drug–drug, drug–disease, drug–food, or drug–nutrient interactions

• Drug allergies

• 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

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 Issues

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.

Drug Use by the Elderly

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.

Medication Errors

There is a tremendous opportunity in medication use and monitoring to reduce medication errors. Untold morbidity and mortality occur due to the many errors occurring in medication use. The increasing availability of artificial intelligence applications, and increased usage by healthcare professionals can enhance the proper provision of patient care for all patients.¹¹

Avoiding Prescribing Cascades

Prescribing cascades occur in healthcare when the side effect from a medication is interpreted as a new condition—and a second drug is prescribed to “treat” the side effect. Prescribing cascades are important because they can be prevented.¹²

Impacting the Opioid Crisis

The use and misuse of prescription opioid analgesic medications are at an all-time high and are increasing, and the negative consequences of this epidemic are many.¹³ Health professionals will play a key, vital role in reversing this epidemic and enhancing the health of many and society as well.

Health professionals are at a crucial juncture facing an uncertain, yet promising future. The skills and knowledge that enable effective practice have never been more daunting among the numerous health professions. Technology can further empower health professionals to play an effective role in helping patients and fellow health professionals to practice safe and effective medicine. Continuing healthcare reforms will have the potential to dramatically impact your practices in the healthcare system for the length of your careers.

The use of this text, which incorporates materials written by the finest minds in pharmacy practice and education, can enable the reader to play a crucial role in improving the drug use process for patients, providers, payers, and society. The thorough analysis of common disease states, discussion of therapies to treat these conditions, and specific advice for patients will help you in your practices. The purpose of this book is to help you make a real improvement in the therapies you provide to your patients. Current and future clinicians can rely on the information laid out here to enhance your knowledge and allow you to assist your patients with the sound advice that they expect you to provide. Use the text, case histories, and numerous examples here to expand your therapeutic skills, and to help positively impact your patients in the years to come.

You can help to reverse medication-related problems, improve outcomes of care both clinically and economically, and enable drug use to meet stated goals and objectives. This text provides a thorough analysis and summary of treatment options for commonly occurring diseases and the medications or alternative therapies used to successfully treat these conditions.