D-11 Competency in the use of drugs
Ensuring the appropriate use of drugs is crucial in rehabilitation because patients with long-term disorders tend to accumulate prescribed medications. Many of the drugs are unnecessary, and some will cause harm. Deprescription is important. A doctor or pharmacist often undertakes it, but all team members should consider it and raise the issue if it is not considered. At the same time, previous medical teams may have yet to be aware of medications that might alleviate impairment or distress, may have used inappropriate drugs, or may not have used an appropriate dose. The team should know when drugs may be helpful and should be aware of the benefits and the potential side effects of commonly used medications. Although a doctor may be the only person legally able to prescribe or deprescribe medication, all professions must be aware of this competency. Some doctors are attached to a rehabilitation team despite lacking any expertise in rehabilitation; patients may discuss problems with non-doctors more readily, other professions may consider a drug helpful, etc. A knowledgeable team can contribute ideas, question the need for drugs, and be more realistic in their medication expectations.
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The competency in the Rehabilitation Medicine syllabus for doctors is “The rehabilitation expert is able to review critically, and to prescribe and deprescribe and monitor appropriately, the drugs used by patients with long-term disability, including liaising with all parties.”
To be appropriate for all professions, it could be modified to being “able to evaluate critically the drugs used by a patient, suggest appropriate changes, and identify appropriate medication for commonly met problems in rehabilitation patients.” The competency is already relevant to all professions and will be especially relevant to non-medical prescribers. The expected, indicative behaviours, knowledge, and skills doctors require are given here; they can be adapted to any profession.
Adverse effects from medication are common, and patients with long-term disabling conditions and multiple diseases are particularly vulnerable. Often, several specialists see patients, each prescribing drugs for the problems they know about without necessarily considering the whole situation. Rehabilitation services are responsible for thinking about the person holistically, which includes ensuring the safe, appropriate, and parsimonious use of medications.
Rehabilitation services also prescribe drugs for impairments such as pain, spasticity, musculoskeletal stiffness or joint problems, and many other symptoms. They also risk overprescribing.
The need to review and reduce the drugs prescribed is widely acknowledged. Geriatricians were the first speciality to highlight medication risks, but it is now recognised in most specialities. I frequently see:
- Extensive use of anti-spasticity medication (e.g. baclofen) causing drowsiness, swallowing difficulties, constipation etc., with little or no evidence of benefit;
- Routine prescription of anti-depressants also with no apparent indication or benefit;
- Allegedly prophylactic prescription of anti-convulsant medication when there is no good evidence that the policy is effective after one week, for example, after a stroke, traumatic brain injury, or craniectomy.
- Long-term prescription of opioid drugs.
The American Geriatrics have published a more systematic and evidence-based list of medications requiring caution and review, which applies to rehabilitation patients.
Last, non-medical prescribing has been developing since the 1960s in the United States and in 2006 in the UK, and it is likely to expand further. Currently, nurses, pharmacists, and other professionals are involved, and all are integral to rehabilitation teams.
Rehabilitation competency in the use of drugs
The rehabilitation team must have expertise in medications for many reasons. The expertise should focus on when not to use medication, drug limitations and adverse effects, and how to tailor drug regimes to the person’s needs and preferences.
The team should know about the disease-modifying drugs used in their patient caseload, particularly awareness of adverse effects that should be reported to the person prescribing the medication and an understanding of the benefits sufficient to give good advice to the patients. With other drugs seen only occasionally, they should be familiar with dependable sources of information such as the British National Formulary.
The team should be experts in all interventions aimed at minimising impairments associated with the conditions seen, knowing when and how to use medication, monitoring effectiveness, side effects etc. This applies to all team members because the patient will discuss medication-related issues with whomever they see.
The prescriber should also be familiar with the off-label use of drugs and whether one drug can treat more than one impairment. For example, amitriptyline may help bladder urgency, chronic pain and sleep in addition to its effects on mood; it can also cause drowsiness, hallucinations, and seizures!
Last, the team should be able to review all medication taken critically, looking for opportunities to rationalise and reduce medication.
The advantages of team competency.
I highlighted the benefits of moving from individual to team competency in the introduction to this section.
Patients in rehabilitation usually take many drugs for different reasons over a long time. Any new medication started will usually be introduced gradually and may take weeks or months to show effects. The primary prescribers, doctors, are rarely in continuous close contact with their patients to assess benefits and harms. Moreover, remaining continually and sufficiently aware of all drugs to detect gradual changes is challenging.
The patients frequently contact the team and usually communicate with the team members they see. Thus, team members are ideally placed to learn about changes, worries, side effects etc. With a sufficient understanding of medications, team members may appreciate the relevance of incidental questions or comments made by the patient.
The team members may also learn of new or worsening problems that could be improved by adding or changing a drug. If they have limited awareness of drug use, these opportunities for active help are lost.
Thus, a team whose members have appropriate knowledge and understanding of drug use in their patients can significantly enhance to use of medication. While doctors remain the primary prescribers, the team can nonetheless contribute to the better use of drugs.
Despite the evidence of overprescription, reviewing, reducing, and withdrawing medication is not widely undertaken. There is inertia, often for understandable reasons such as the additional time and effort needed to consider and discuss the question with the patient, the perceived risk of stopping a medication, and the patient’s perceived reluctance.
Ian Scott and colleagues suggest that deprescription, the process of reducing inappropriate polypharmacy, has five steps:
- Determine all drugs the person takesPriori and the indication for each
- Evaluate the overall risk of drug-induced harm
- Assess for each drug both the current and the future risks and benefits
- Prioritise the drugs for deprescription based on the risk-benefit ratio and risk of withdrawal
- Start deprescription, monitoring improvements and adverse effects
Philippe Martin and colleagues undertook a cluster-randomised trial of a pharmacist-led educational intervention. Their paper showed that it was associated with a higher discontinuation rate of prescriptions for inappropriate medication. It gives links to resources used within the study.
Alec Petersen and colleagues undertook a pilot study of an evidence-based protocol for reducing polypharmacy (five or more prescribed drugs), Shed-MEDS. The critical component was the evaluation of medications for deprescribing. The paper gives details, but the stages were to review:
- The indication and the appropriateness of that indication
- Potential for reduction or removal
- Wrong dose
- No longer indicated
- Not effective for the patients
- Duplicate medication
- High-risk medication
- Inconsistent with the person’s goals of care
- Risk greater than benefit
- Evidence of poor adherence
- Suggested method
- Reduce over time until stopped
- Reduce to a lower dose
As Emily Page found in her systematic review, many other tools and guidelines are available.
Evidence on deprescription
Despite the apparent common-sense rationale for deprescribing, the evidence of significant effectiveness is limited.
Charissa Ee and colleagues reported a randomised trial in a Singapore rehabilitation hospital investigating the deprescription of some specific drugs:
- Proton-pump inhibitors
- Analgesics (all classes)
The trial included 200 people.
Their data suggested:
- No cost savings
- No reduction in medication
- No alteration in the frequency of constipation
- The mean additional time needed for each patient by the pharmacist and doctor is 19 minutes.
Hannah Bloomfield and colleagues reviewed the evidence for reducing overprescription in community-dwelling older adults. Data from the 38 trials found suggested small reductions in mortality and the use of potentially inappropriate medication. Amy Page and colleagues studied all studies involving older adults. At the same time, non-randomised studies did suggest benefits; the randomised trials did not find any reduction in mortality in the outcome studies.
These studies are disappointing. However, the outcome studied, mainly mortality, is probably insensitive given this population’s relatively short follow-up and base mortality rate. The likelihood of cost reduction being sufficient to detect is also low.
More positively, the rehabilitation study showed that the time involved is not extensive.
The team should include doctors and pharmacists able to manage the patient’s medication or know when further advice is needed from another specialist. The rehabilitation expert should critically review all medication, leading to deprescription (i.e. reducing and stopping the medication) when appropriate. There are protocols and guidelines. The evidence of effectiveness is currently weak; there is no evidence of harm. The rehabilitation team should include a pharmacist who can assist in reviewing medications, focusing on rationalising and minimising them. All team members should be familiar with the drugs used by their patient population.