Of drugs – The role of patients

'Rational use of drugs requires that patients receive drug appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to their community' – [WHO,1985] Rational drug use requires active participation by:

* The prescriber: A trained professional who gives a recommendation for treatment( Medical doctor, dentist, medical assistant, pharmacist)

* The dispenser: A trained professional who gives out drugs to a patient in accordance with the wishes of a prescriber, as indicated on a valid prescription (Pharmacist, dispensing technician, nurse)

* The patient: The final recipient of the prescribed drug; the person for whom the drug was prescribed. This suggests that, though a drug will ultimately be used by a patient, it can only be said to have been used rationally if the prescriber and dispenser also play their role efficiently. Let me explain using the following illustrations.

* Dr. Flames failed to conduct the necessary tests on a patient. He made a wrong diagnosis and wrote a prescription for this patient to purchase some drugs at a pharmacy. At the pharmacy, the pharmacist simply interpreted the prescription, picked the indicated drugs from his shelves and taught the patient how to take his drugs (as stated on the prescription). The 'obedient' patient followed the pharmacist's instructions and took the drugs accordingly.

* Dr. West conducted the necessary tests on a patient, made a correct diagnosis but wrote a wrong dose – a wrong dose could be a higher than required dose (over dose), a lower than required dose (under dose), a longer than required duration of treatment, or a shorter than required duration of treatment – of a drug on a prescription. At the pharmacy, the pharmacist simply interpreted the prescription, picked the indicated drugs from his shelves and taught the patient how to take his drugs (as stated on the prescription). The 'obedient' patient followed the pharmacist's instructions and took the drugs accordingly.

* Dr. Night conducted the necessary tests on a patient, made a correct diagnosis and prescribed the correct drug. However he wrote an expensive brand of the drug on the prescription and instructed the patient to only purchase the brand he has indicated on the prescription. The doctor's real motive was to promote the use of this new brand of the drug, in fulfilment of his 'contractual obligations' with a pharmaceutical company. There were equally effective and less expensive brands of the drug on the market. The patient couldn't afford that brand of the drug; he therefore didn't take any drug, hence his condition worsened.

* Dr. Ten conducted the necessary tests on a patient, made a correct diagnosis and prescribed the correct drug. At the pharmacy, Pharm. Brown picked the wrong drug from the shelf and taught the patient how to take the drug (as stated on the prescription). The 'obedient' patient followed the pharmacist's instructions and took the drugs accordingly.

* Dr. Rhymes conducted the necessary tests on a patient, made a correct diagnosis and prescribed the correct drug. At the pharmacy, Pharm. Green decided to sell an expensive brand of the drug stated on the prescription, though equally effective and less expensive brands were in stock. The patient could not afford that brand. He left the pharmacy with an excuse of going home to pick additional money. He didn't return to the pharmacy. He never bought his prescribed drug.

* Dr. Cool conducted the necessary tests on a patient, made a correct diagnosis and prescribed the correct drug. At the pharmacy, Pharm. Grey selected the prescribed drug from the shelf and taught the patient how to take his drug. He forgot to label the drug. The patient got home and couldn't remember the pharmacist's instructions. He decided to refer to the drug label. There was no label, and the direction on the original package of the drug read: 'Take as directed by physician'. The patient used his discretion, but unfortunately took a wrong dose of his drug.

* Another doctor conducted the necessary tests on a patient, made a correct diagnosis and prescribed the correct drug. At the pharmacy, Pharm. White collected three prescriptions from three different patients and went to the dispensary to select the drug. The pharmacy was very busy at that time. Pharm. White inadvertently swapped drugs for two patients. He labelled the drug appropriately and taught each patient how to take his drug. The patients left the pharmacy and followed the pharmacist's instructions appropriately. The two patients consumed the wrong drug.

In the above illustrations, I have tried to explain the commonest sources of irrational drug use. These are only a few of the various errors from prescribers and dispensers of drugs which ultimately result in irrational drug use. The most important result of irrational drug use is therapeutic failure. This is when a treatment regimen fails to achieve its intended purpose; or when the set objectives (of prescribers) that guide the prescribing process are not met. In all the above illustrations, the most probable outcome is therapeutic failure.

Another important example is the prescribing, dispensing or use of drug when no drug is indicated or required. I must emphasize that not all conditions require drug or pharmacological therapy. In fact, certain conditions require no drug at all. Instead, non-pharmacological interventions such as rest, exercise, diet and life style changes such as smoking cessation, alcohol reduction etc are the remedy to such clinical conditions.

The final source of irrational drug use is from the patient. A patient's role is to take his or her drug in accordance with the instructions of prescribers and dispensers, and to follow all non-pharmacological counseling instructions. Concordance refers to the ability and desire of the patient to take the drug in a way that will promote an agreed therapeutic outcome.

Self-medication – when a patient independently decides what his/her drug needs are, and ultimately administers the drug to himself /herself – is an example of irrational drug use. This term captures anyone who potentially has a drug need, including health professionals like doctors and pharmacists. Most of us (health professionals) confuse our roles when we fall sick. There is no such thing as a patient who doubles as doctor or pharmacist. Remember, once you fall sick you temporarily cease to be a doctor, pharmacist etc, and become a patient. What is the right thing to do? Do as you preach! – Do not self-medicate! Seek medical attention [from a colleague].

Common examples of irrational drug use by patients include: * Increasing the dose of a drug in order to increase the 'desired' effect of the drug. Most patients believe 'the higher the dose the higher the effect of the drug'. Unfortunately it's not as simple as that.

* Doubling the dose of a drug to make up/ compensate for a missed dose.

* Consuming (ingesting) more than the prescribed dose of a drug (especially syrups) because it is palatable.

* Taking less than the prescribed dose of drug because of unpleasant taste.

* Abrupt discontinuation of drug due to unpleasant taste, unbearable side effects.

* Failure to complete your drug course or discontinuation of drug because initial condition has improved.

As patients, never alter your dosage regimen (how you've been instructed to take your drug) without consulting your doctor or pharmacist. If your condition improves before you complete your course, continue taking your drug till completion. Always report any side effects or strange occurrences (while taking your drug) to your doctor or pharmacist. When you miss a dose, take it as soon as you remember. If you remember at a time that is close to your next scheduled dose, ignore the previous dose and carry on with the current dose – this instruction may differ for certain drugs, therefore always seek clarification from your doctor or pharmacist. Always take your drug on schedule. Several missed doses will lead to treatment failure and in the case of antibiotics, may lead to drug resistance. Follow label instructions to the latter. If the label says 'one hour before food', do just that. There is always a pharmacological basis for such instructions. Doing otherwise can affect the outcome of your treatment.

Your drug is intended for you only. Never give your drug to anyone else to take, even if you think the person has the same medical condition or symptoms as you do. Drug that is good for you may harm someone else who seemingly has the same problem.

Finally, always ask questions when you visit your doctor. When you visit a pharmacy, ask for the pharmacist! Ensure that a pharmacist attends to you or at least supervises who ever attends to you.

Remember, the name is PHARMACY and not PHARMACY SHOP. The Practice of pharmacy has evolved into a patient-centered rather than a drug-centered discipline, which lays minimum emphasis on profit maximization. At a pharmacy, pharmaceutical (health) services are offered and these include free patient counseling. However, the use of the word 'shop' in describing such a premise defeats its purpose and reduces it to a place where only mere buying and selling takes place.

Take control of your health. Eschew all forms of irrational drug use.