Creative Commons/C.L. Frost

Conservative prescribing: Going beyond ‘first, do no harm’

The Archives of Internal Medicine published a remarkable report this week that should be required reading by every physician.

And every health consumer.

The report, whose lead author is Dr. Gordon D. Schiff, associate director of the nonprofit Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, calls for physicians to make a “radical shift in prescribing attitudes and behaviors” toward a new and “alternative paradigm” that Schiff and his colleagues are calling “conservative prescribing.”

“[C]onservative prescribing conveys an approach that goes beyond the oft-repeated physician’s mantra, ‘first, do no harm,’” the report explains. “The concept sums up lessons from past experience as well as from recent studies demonstrating that medications are commonly used inappropriately, overused, and associated with significant harm — suggesting the need to more thoughtfully weigh claims for drugs, especially new drugs. … This approach places the burden of proving safety on the proponents of introducing a new chemical into the human ecosystem and thus encourages exploring alternatives to new drugs.”

Physicians don’t receive enough training in the “skill” of drug prescribing, which is one reason their prescribing practices tend to be driven by the marketing efforts of drug companies, including those aimed at consumers, the report adds.

Yet, as the report also notes, “substantial literature supports initiating nonpharmacologic measures as initial or preferred therapy for a range of conditions commonly treated with drugs, such as hypertension, diabetes, insomnia, back pain, arthritis, and headache.”

Powerful tips

There are so many good and detailed (with footnotes) tips in this report, it’s difficult to know what to pull out and highlight. Here are a few of the tips and supporting arguments that jumped out at me:

• Under “Be Skeptical About Individualizing Therapy”: “[I]ndividualizing therapy can also be a code word for unscientific trial-and-error medicine. Individualization is a mantra of the pharmaceutical industry when it wishes to dismiss disappointing trial results, arguing that they apply only to average patients and not necessarily to the individual patient.”

• Under “Approach New Drugs and New Indications Cautiously and Skeptically”: “Avoid education from pharmaceutical representatives or “experts” with conflicts of interest. … Evaluate claims for new drugs skeptically, insisting on evidence that they are demonstrably better than existing (drug or nondrug) therapy.”

• Under “Do Not Rush to Use Newly Marketed Drugs”: “Generic, hence older, drugs are generally safer owing to their longer track record. Some have advocated a 7-year rule (ie, wait 7 years before using a new drug), based on data showing that it often takes 5 to 10 years to identify significant adverse effects.”

• Under “Be Certain That the Drug Improves Actual Patient-Centered Clinical Outcomes Rather Than Just Treating or Masking a Surrogate Marker”: “Many well-designed randomized trials show statistically significant improvement in laboratory, radiologic, or other markers of disease risk, severity, or prognosis but may lack proof of a meaningful clinical benefit. Improving these markers may not improve clinical outcomes. There is a growing body of literature demonstrating situations where such surrogate improvements do not translate into clinical benefits (eg, survival, quality of life, complications, mortality) and may even worsen outcomes.”

Give a copy to your doctor
“Individually, none of these principles is particularly novel, nor should any of them be terribly controversial. But taken together, they represent a shift in prescribing paradigm from “newer and more is better” to “fewer and more time tested is best,” the report concludes.

It’s a shame this report is behind a pay wall. But if you can get your hands on a copy, I recommend you read it carefully — and then give it to your physician.

(Hat tip: Gary Schwitzer's Health News Review blog)