Prescribing in primary care: art versus algorithm
Authors: Steven Shoptaw, Diep Bich Nguyen, Le Minh Giang
Journal: The Lancet Psychiatry (2019)

In their ambitious mixed-methods analysis reported in The Lancet Psychiatry, John Marsden and colleagues1Marsden J White M Annand F et al.Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England.Lancet Psychiatry. 2019; (published online Oct 3)https://doi.org/10.1016/S2215-0366(19)30331-1PubMed Scopus (21) Google Scholar describe prescribing patterns in England for five classes of medications reportedly associated with dependence or withdrawal (antidepressants, opioids, gabapentinoids, benzodiazepines, and Z-drugs). The authors should be commended for their impressive efforts in compiling different types of data to yield measures of prescribing for these five classes of medications, as well as to describe the adverse experiences of patients who use and discontinue these classes of medications, and the individual, geographical, and economic correlates of prescribing practices. The comprehensive evidence suggests an over-reliance on these medication classes by physicians when treating patients who frequently appear with chronic diseases, especially older patients and patients who face social and economic disadvantages. The finding that sex and age are important factors in medication overuse is not novel. Women see doctors more often and receive more prescriptions than men.2Manteuffel M Williams S Chen W Verbrugge RR Pittman DG Steinkellner A Influence of patient sex and gender on medication use, adherence, and prescribing alignment with guidelines.J Womens Health (Larchmt). 2013; 23: 112-119Crossref PubMed Scopus (175) Google Scholar, 3Waldron I Johnston S Why do women live longer than men?.J Human Stress. 1976; 2: 19-30Crossref PubMed Scopus (65) Google Scholar Additionally, as age increases, so does the prevalence of chronic illness, and thus the number and duration of prescriptions for medications.4Smith SM Wallace E O'Dowd T Fortin M Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.Cochrane Database Syst Rev. 2016; 3CD006560PubMed Google Scholar Short-term use of these medication classes at the population level reflects good common sense and best practices. However, in the setting of chronic diseases or disorders and advancing age, patients frequently conflate the efficacy of a medication to relieve symptoms of their condition with their wish for it to relieve suffering caused by their life circumstances, and will continue seeking medication long after efficacy of the medication has ceased. A key research question not addressed is whether chronic diseases treated with these medication classes over the lifespan are more prevalent in areas with social and economic deprivation, and particularly whether medications are used to reduce discomfort from symptoms or to medicate suffering caused by social and economic disparities. Every day, new patients present for care with medications from these five classes that were initiated by physicians no longer treating that patient. Some doctors will, in consultation with their patients, choose to continue prescribing one or more such medications long after the benefit of the medication is realised, largely because this prescribing gives the physician something to do and is a response to patients' requests. A scenario not addressed by Marsden and colleagues' report1Marsden J White M Annand F et al.Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England.Lancet Psychiatry. 2019; (published online Oct 3)https://doi.org/10.1016/S2215-0366(19)30331-1PubMed Scopus (21) Google Scholar is what, specifically, physicians should do when older patients (often female) seek consultation and care with any of a range of chronic conditions that are unlikely to be cured and have symptoms that are commonly treated using these medications. Another important area for future study is the greater over-prescribing of these medication classes in regions where there are social or economic disparities. Marsden and colleagues1Marsden J White M Annand F et al.Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England.Lancet Psychiatry. 2019; (published online Oct 3)https://doi.org/10.1016/S2215-0366(19)30331-1PubMed Scopus (21) Google Scholar provide well reasoned, actionable, and measurable recommendations for the public health system in England to address over-prescription of medications associated with dependence or withdrawal. From our perspective, however, these recommendations are incomplete. We agree that studies are needed to document best practice for discontinuing patients on long-term antidepressants, especially SSRIs. It might be helpful for labels on antidepressants to indicate the potential for withdrawal symptoms. However, labelling for benzodiazepines and opioids already notes the risk for misuse and the habit-forming nature of these drugs, and similar warnings are in place for gabapentinoids and Z-drugs. What seems to be missing is a recommendation for research and development of decision aids to help guide risk-to-benefit decisions to advise on continued use and discontinuation of these classes of medications—especially when treating patients who are older and who have social or economic disadvantages. The finding that physicians working in deprived areas over-prescribe medication classes associated with dependence or withdrawal points to the need to understand better how physicians negotiate one of the fundamental ethics of medical practice, the do-no-harm ethos. The question remains whether physicians who feel obliged to do something for their patients in the face of pain and suffering follow this ethos and whether, if they do not do so, they feel that they have inflicted further harm. The research that is needed is rooted in discovery science. We need in-depth understanding of what careful, ethical doctors think as they make decisions for and against use (or withdrawal) of these medication classes for patients with unremitting and debilitating conditions, particularly in the setting of advancing age. Cross-cultural5Zhang Q Yu C Feng S et al.Physicians' practice, attitudes toward, and knowledge of cancer pain management in China.Pain Med. 2015; 16: 2195-2203Crossref PubMed Scopus (19) Google Scholar and sociological analyses6Toye F Seers K Barker KL Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain.BMJ Open. 2017; 7e018411Crossref PubMed Scopus (16) Google Scholar could benefit efforts to develop and evaluate a kind of algorithm designed to guide the art of being a doctor, especially in the era of algorithm-driven medical practice. SS has received grants from the US National Institutes of Health outside of the submitted work. DBN and LMG declare no competing interests. Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in EnglandIn 1 year over a quarter of the adult population in England had a prescription dispensed for antidepressants, opioids (for non-cancer pain), gabapentinoids, benzodiazepines, or Z-drugs. Long-term (>12 months) prescribing is common, despite being either not recommended by clinical guidelines or of doubtful efficacy in many cases. Enhanced national and local monitoring, better guidance for personalised care, and better doctor–patient decision making are needed. Full-Text PDF Open Access