To help you enhance your practice and increase your bottom line, we ask practicing doctors of chiropractic, like you, for ideas and solutions that have been tested in real-world environments. In this issue, we asked: "How do you assess and then deal with patients who are likely taking unnecessary prescription and over-the-counter drugs?" Based on your responses, there are some common philosophies regarding patient drug use.
The improper or unnecessary use of prescription and over-the-counter medication is a growing problem in the United States. According to a report published by the World Health Organization (WHO) in 2010, more than 50 percent of all medicines are prescribed, dispensed or sold inappropriately and half of all patients fail to take medicines correctly. This incorrect use may take the form of overuse, under use and misuse of prescription and over-the-counter medications. The WHO also believes that a combination of health care provider education and supervision, consumer education and an adequate medicines supply is effective in improving the use of medicines, while any of these interventions alone has a limited impact. Inappropriate self medication is on the rise and has a potentially high financial effect as well. According to the WHO report, between 10 and 40 percent of national health budgets are spent on medicine.
There are can be severe consequences to the incorrect or unnecessary use of medications and chiropractors often deal with some of the them when attempting to educate their patients about potential side effects and alternative treatment options. There is a growing concern over antimicrobial resistance. An overuse of antibiotics increases resistance and the number of medicines that are no longer effective against infectious disease. Chiropractors often deal with contra indications and harmful side effects when attempting to understand a patient's health and medical history. Adverse drug reactions have been estimated to cost millions of dollars each year, according to the WHO study. Patients can also waste money in over-the-counter medicine purchases. The WHO study estimates that billions of public and personal funds are wasted each year in unnecessary drug purchases.
According to most responses, unnecessary drug use (both prescription and over-the-counter) is not uncommon and communication with both the patient and their primary care physician was the key in dealing with this issue.
Scope of Practice Question
Several chiropractors urge caution when talking to patients about their prescription drug use. "The DC should not comment on the patient's taking of prescription drugs, whether necessary or unnecessary. Anytime a DC thinks that drug is incorrect for a patient, he/she should refer the patient back to his primary care physician for their expertise on the drugs," said Dr. Pete Fernandez. "If the DC tells the patient not to take the drugs, take less of the drugs or that the drugs are unnecessary, they are practicing outside of their scope of practice and probably guilty of malpractice....and definitely illegally interfering with the doctor-patient relationship of the MD and their patient."
However, Dr. Fernandez believes a different conversation can occur when over-the-counter drugs are the issue. "If the patient is taking over-the-counter drugs not prescribed by their MD, I would recommend the patient discontinue the use of these over-the-counter medications until they make an appointment with their primary care physician regarding these drugs. I would make a big point of the interaction between drugs and the many contra indications of taking conflicting medications or taking too much of the same type of drug (i.e. Indocin prescribed by an MD and aspirin/ibuprofen that the patient purchases over-the-counter)," said Dr. Fernandez.
Dr. Forest Mapes of Lyons, Ill. says, "if the drug is a non-prescription type, the answer is simple. The state of Illinois allows me to discontinue the drug. If it is a prescription drug, by law I am not allowed to interfere with it. However, I am able to make statements such as, 'If it were me, I would not take it.'"
Simple Patient Conversations
For many chiropractors, it just takes having a simple and honest conversation with your patients to help them understand what they are doing in taking these unnecessary drugs and what your philosophy is in approaching their treatment. Dr. Stephen Oetzel from Wilmington, Ohio, believes that "almost all prescription and OTCs are unnecessary, so I frequently remind patients that drugs do not nurture the body to heal, although if used temporarily they may save a life on an emergency basis. I have many patients who have taken themselves or their children off drugs while becoming healthy."
[pb]Dr. John Watson from Smithfield, Utah is currently retired but remembers the conversations he had with his patients. "I asked directly what drugs were being used. I instructed my patients that pharmacology was not the area of my training but that I had become knowledgeable in dealing with health issues. I shared the concept that there are no 'side effects,' only direct wanted effects and direct unwanted effects. I shared the contra indications from the PDR and the Pill Book and attempted to get patients to think. I never interfered with medications but tried to educate my patients and get them to make good choices."
Dr. Robert Gear from Phoenix has found that "my patients automatically stop taking medication as I correct their spinal subluxations. Correction allows proper blood flow to the spinal nerves which then allows normalization of blood flow in the gastrointestinal and endocrine organs. This then allows the chemistry of the body to function in proper biochemical harmony. Most medication is necessary due to disharmony of biochemical function."
Patient Education
Educating patients was a recurring theme with chiropractors across the nation. Dr. Denise Primavera from Telford, Penn. says that she "often discovers in the course of an exam that a patient is taking a great many prescription drugs, some of which may be causing some of their presenting complaints, for example dizziness, fatigue or weakness. I never advise a patient to discontinue a drug on their own but I do share information about the drug's actions and side effects and I discuss possible less harsh alternatives. I then suggest they discuss my recommendations with their provider who prescribed the drug and often the regime can be modified or a different drug prescribed."
Dr. Arno Sullivan from Pine Grove, Calif. believes "the treating physician should be alerted to contra indications that may be due to medications they are taking, either prescription or over-the-counter. And depending on the doctor's level of education and experience they might contact the patient's MD suggesting a review of their medications and consider alternatives or discontinuation altogether. If the DC has prescribing privileges they can remove the patient from the medications in question and/or provide an alternative medication or homeopathic substitute in conjunction with their adjustive procedures."
Dr. Kelli Pearson of Spokane, Wash. believes "the number of drugs a person is on is diagnostic of how hard it will be to reduce their pain and see improved function. The more drugs, the longer the treatment time needed. I begin on day one discussing food is medicine and let them know that I will be adjusting their spine and their diet or we will get nowhere quickly. It is a trend over the 30 years that I have been practicing that folks are harder to treat, in part to the toxicity of the environment but more so related to what they put in their mouth, what they choose to do (or not do) with their body and how much courage they have to move beyond the pain and not take pain killers for a short term fix."
Many chiropractors believe it is first important to establish a respectful relationship with patients before the education can really begin. Dr. Paul Marston of New Jersey says "the outcome is usually an agreement for the patient to reduce or change the medication they are taking with the blessing of the MD, if the medication was not necessary. Advising the patient to discuss the over-the-counter use of medication and nutritional supplements with their primary care physician is also recommended. This concern for the patient's health and wellbeing aids in the establishment of a sincere doctor-patient relationship with the DC and the patient, as well as the MD."
Dr. Jared Leath from Tennessee believes "many of our patients come to us because they are looking for a way to take less medication. Others who are obviously being over-medicated or taking too many over-the-counter drugs, we simply try to educate." He continues, "Our education consists of taking the information directly from the drug manufacturers web site or WebMD if appropriate, printing out the information and going over the potential side effects. We are constantly amazed that many of our patients complaints resolve by simply taking that information back to their MD and asking for a change. Side effects from medication is a possible cause for our patient complaints and should not be overlooked in treatment."
One thing to consider is the population you are treating. For example, according the National Institute of Drug Abuse (part of the National Institutes of Health) persons aged 65 years and older comprise only 13 percent of the population, yet account for more than one-third of total outpatient spending on prescription medications in the United States. If you serve an aging population, you should consider this statistic as you educate your patients.
The bottom line seems to be that chiropractors will inevitably deal with patients using unnecessary prescription or over-the-counter medications. Opening the doors of communication with primary care physicians and establishing good relationships with them and with patients appears to be the most successful route in dealing with this unfortunately growing trend.
