213
Drug Prescribing—the
PETER A. PARISH, M.D., M.R.C.G.P.
Senior Research Fellow, Medical Sociology Research
University College, Swansea
DRUG may be defined as any substance which
/~
can alter the structure or function of the living
~ organism. Air pollutants, pesticides, vitamins and
virtuallyany chemical may be regarded as drugs. All
medicines are drugs but not all drugs are medicines.
Those drugs used as medicines have been selected because
they possess or are thought to possess useful properties.
They are, therefore, used to relieve physical or mental
symptoms; produce an altered state of mind; treat, pre-
vent or diagnose disease and to prevent pregnancy.
DRUG EFFECTS
ALTHOUGH DRUGS are classified and marketed accord-
ing to their most prominent effect (e.g. pain relievers), no
drug produces a single effect and no drug is free from
unwanted effects. Most unwanted effects are trivial, some
are serious and a few are fatal: they are usually referred to
as adverse drug reactions-an unintended reaction from a
’normal’ dose. They include side-effects (recognized but
unwanted effects, often dose related); excessive effects
and side-effects from normal dosage (babies, the elderly,
the debilitated and those with physical disorders may
react alarmingly to normal doses of drugs); allergic
reactions; idiosyncratic reactions (reactions peculiar to
certain patients) and reactions secondary to a drug’s
effects. There are numerous diseases produced by doctors
(iatrogenic), many caused by drugs. Some drugs may
react with certain food stuffs or other drugs to produce
reactions (e.g. alcohol with sedatives) some may become
abused leading to drug dependence (addiction). Drugs
may also produce death if taken in overdose.
DRUG PRESCRIBING IN PERSPECTIVE
PRESCRIBING IN medical terms can refer to numerous
actions by a medical practitioner; for example, the order-
ing of any treatment, giving advice, referral of the patient
to hospital or other agency and the issuing of a certificate
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concern of all
Centre,
for unfitness to work. The prescribing of drugs must
therefore be viewed in perspective, within the whole con-
cept of medical care as only one aspect of total prescribing
activity.
TREATMENT DECISIONS
THE GENERAL is often the doctor of first
practitioner
contact for the this role he has to make
patient. In
numerous and varied treatment decisions, many in-
stantly and some without full knowledge of all the factors
which contributed to the patient’s decision to seek
’medical’ help. The patient often presents physical or
mental symptoms for which the doctor follows a routine
procedure which is traditional and conditioned-a dis-
ciplined approach which dates from his teaching in
medical school. But medical school teachers are hospital
based; they see and teach on selected and often rare
diseases. Experienced general practitioners now question
whether such training is suitable for modern general
practice. They realize that general practice is about
people and more about social and mental unease than
disease; they know that commonest diseases are com-
monest ; they accept that they &dquo;can cure rarely, give relief
often, but most comfort alwaysi&dquo; Unfortunately
medical students do not receive the benefit of such
wisdom because of their minimal exposure to general
practitioner teachers.
THE GENERAL PRACTTTIONER’S ROLE
THE GENERAL practitioner’s role is both central and
crucial to any successful medical care programme and
yet he has only a few minutes with each patient in which
to make a treatment decision: although, over time he
may learn much about some of his patients. The doctor
acts because it is expected of him and for many reasons
apart from his clinical findings. The consequences of his
decisions vary markedly in cost: from the issuing of a
214
prescription costing an average 90pl to referral to an out-
patient department at a cost of between £8 and £16 per
new out-patient according to the hospital3. It is, there-
fore, important to remember that a large proportion of
N.H.S. resources are mobilized as the result of these
decisions made under such pressures.
THE COST OF TREATMENTS
ONE OF the most examined and criticized consequences
of a general practitioner’s treatment decisions is the
issuing of a prescription for drugs-yet although some
drug treatments have been subjected to randomized con-
trolled trials of effectiveness4 alternative treatments have
never been costed, examined and compared; for example,
psychotherapy instead of tranquillizers, low calorie diets
instead of appetite suppressants. Further, the general
practitioner is frequently criticized for not providing
sufficient time for his patients yet if he were to provide
15 minutes for every patient who wished to consult him
the service would break down.
AN INFI1~TITY OF DEMAND
IT SEEMS unlikely that more time would alter his
treatment decisions. In countries where the patient pays
and is given more time per consultation, drug prescribing
has increased just as fast as in this country. Further,
although in the past decade the number of doctor-
patient contacts per doctor remained the same or de-
creased5, the number of prescriptions issued, the number
of referrals for pathological tests and X-rays and the
number of referrals to out-patients and other agencies
has actually increased for each doctor 6. Thus treatment
decisions of general practitioners are producing an ever in-
creasing utilization of medical services as well as of drugs.
And this during a time when possible alternatives to drug
treatment, such as the social services, have undergone
inflationary expansion. This is what Enoch PowelP calls
the infinity of demand; he comments &dquo;There is virtually
no limit to the amount of medical care an individual is
capable of absorbing.&dquo; In short, the appetite for medical
treatment is infinite.
WHY FOCUS ON DRUG PRESCRIBING?
DRUGS ARE developed, manufactured, promoted and
supplied by the pharmaceutical industry; they are
prescribed by doctors; dispensed by pharmacists; con-
sumed by patients and through the National Health
Service they are paid for by the taxpayer. Thus there are
numerous agencies interested in prescribing, the critical
link between them being the prescribing doctor who puts
pen to paper. No wonder the prescribing activity of
general practitioners is always under discussion.
Because the cost of drugs is seen to increase annually,
the pharmaceutical industry has come in for much
criticism; yet in terms of human welfare, drugs impose
important responsibilities on all parties concerned. These
go well beyond the accountability of public funds: the
cost of a patient’s ill health can be measured in terms of
morbidity rates, duration of illness, time off work, loss
of production, cost of National Insurance benefit, cost of
hospitalization, profits to the pharmaceutical industry
and many other indices. The cost of the pharmaceutical
service is, therefore, a small fraction of the overall ex-
penditure involved in the process of caring and should
be considered in perspective.
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THE ACT OF DRUG PRESCRIBING
THE ACT of prescribing a drug is one of the most ancient
and visible symbols of the doctor’s knowledge and ex-
perience. It may be viewed in different ways depending
upon the interests of the parties concerned. Very simply
some of these may be listed as follows. The patient sees
it as part of the doctor’s action in response to his con-
sultation and usually but not always as part of his ex-
pectations. The doctor sees drug prescribing in many
ways; as curative, palliative or placebo, as part of the
doctor-patient relationship, as an action expected of
him and as a means of bringing the consultation to an
end. The pharmacist sees it as a list of instructions and
as a source of income. The pharmacologist sees it in
terms of pharmacodynamics and whether the drug can be
proved to be effective in measurable terms. The hospital
doctor sees it as an outcome of investigation and
diagnosis. The social scientist sees the act of prescribing
as part of the doctor-patient transaction, as a social act
with social consequences. The social anthropologist
looks at healing in primitive societies where the admin-
istration of therapy is the core of a magical system. The
Department of Health and Social Security sees prescrib-
ing in terms of cost and safety. Drug companies see it in
terms of market competition and profits-each pre-
scription representing a sale. The politicians see it as a
commitment which periodically needs controlling.
IS DRUG PRESCRIBING EXCESSIVE?
THE THEME of this paper is ’Excessive prescribing and
its social consequences.’ This presumably refers to drug
prescribing and implies that it may be excessive and that
this has social consequences. If excessive means greater
in amount than is right and proper, then in order to
determine whether prescribing is excessive, it is necessary
to state what is the right and proper use of drugs, not in
terms of being above an average quantity or norm but in
terms of what should produce most benefit for that par-
ticular patient at that particular time in those particular
circumstances. The conflicting interest of various parties
concerned in drug prescribing have been discussed and it
is clear that right and proper use of drugs means different
things to different people. For example a psycho-
therapist will often disagree with the psychiatrist on the
use of drugs in mental illness; an osteopath will disagree
with the rheumatologist’s use of drugs; dietitians will dis-
agree with the use of drugs in diabetes and obesity.
Doctors unfortunately interpret examination of their
prescribing as an attempt to challenge their professional
autonomy. Even so there are criteria which can be
applied to any treatment (not only drugs) which will sat-
isfy most of the parties concerned. These criteria are that
prescribing should be responsible and rational.
WHAT IS RESPONSIBLE PRESCRIBING?
THE PRESCRIBING doctor should be answerable for
his actions to his peers and patients and also morally
accountable (note his role in the thalidomide tragedy).
He should have clear cut reasons for the use of drugs
and should be fully aware of a drug’s effects, side-effects
and dangers. He should keep adequate records, supervise
the issuing of prescriptions, provide accurate instructions
to the dispensing pharmacist, and inform the patient. In
short, he must have adequate knowledge of his patient
and the drugs he is prescribing.
However, there is evidence that doctors fail to record

details of all prescriptions issued: some keep no records,
others fail to record repeat prescription data 8, 9. The
issuing of prescriptions without the patient seeing the
doctor is common practice9,10,11 and many pharmacists
complain about the inadequacy of instructions 12. Also,
there is evidence that communication between doctor,
patient and colleagues is poor13; that prescribing is often
symptomatic9 and that there is a great deal of variation in
prescribing from doctor to doctor for similar disorders 14
RATIONALITY IN DRUG PRESCRIBING
I F R A T 1 o N A L means sensible and not extravagant, then
rational drug therapy should preferably be based on what
may be tested by ordinary canons of scientific enquiry
allowing for the mystification which surrounds the heal-
ing process. Sound judgment should result in &dquo;The right
drug for the right patient in the right amounts at the right
time 15&dquo;-However, in everyday general practice the
doctor has to match this ideal of rational prescribing
against the reality of inadequate knowledge of the
patient and his disorder and the pressures of one patient
every few minutes.
There are four main medical criteria which go to form
rational prescribing-these are that drug treatments
should be appropriate, ef~’ective, safe, and economic.
(a) Is drug prescribing appropriate ?
The most appropriate treatment is what will benefit that
patient with that disorder at that time. This must take
into consideration the fact that the patient, his symptoms
and his environment are in a constant state of change.
Any of these may alter over time: a change in the patient’s
family situation or work situation may alter his response
and therefore his symptoms. It is, for example, perfectly
appropriate to afford a bereaved person sleep, but is it
appropriate to ensure that the patient does not sleep
without the use of hypnotics for months or even years
after the event? It is as necessary to know when not to
give a drug and when to stop a drug as it is to start treat-
ment. Unfortunately there is evidence to indicate that
drug prescribing is not always appropriate16, 17, 18.
(b) Is drug prescribing effective ?
To be effective a drug should produce proper and
intended effects-it should alter the natural history of a
particular disease for the better or relieve a symptom:
the least it should do is not make the patient worse.
However, in the natural history of any disease or
unease, improvement or deterioration of the patient may
be totally or partly independent of drug effects. There
are many non-drug factors: the effects of drugs vary
amongst patients (e.g. with age, sex, genetic constitution,
physical and psychological conditions); in the environ-
ment (physical, chemical, social, sexual, marital, occupa-
tional) ; amongst diseases and disorders and amongst
response to placebo (inert) therapy. Patients vary greatly
in whether they take a prescribed drug or not and in their
response to the prescriber. Further, attitudes of the
prescribing doctor may influence a drug’s effects19.
If the term ’effective’ is applied scientifically to the use
of drugs it should indicate a research result of ’treatment’
examined by well controlled trials at different centres
only a few frequently prescribed drugs have been tested
by such methods4. Yet does the absence of such scientific
evidence mean that most drug treatments are ineffective
in terms of benefit to the patient ? The use of new and
expensive brand products does, however, indicate a
misconception that novelty and cost may be related to
effectiveness.
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215
Frequently the prescribing doctor associates any im-
provement in this patient’s condition (and this may be
nothing more than failure to re-attend) with the medica-
tion he has prescribed. This determines the treatment
destiny of others suffering from similar disorders and a
prescribing habit develops which is based on no more than
an assumption. This habit reinforces his beliefs (with the
help of sales promotional activities by the pharma-
ceutical industry) that his medication is effective, yet
without feed-back it is totally impossible to make an
objective assessment of a drug’s effectiveness.
One very important factor in feed-back is whether the
patient ever took the drugs as directed. Drug recovery
programmes have indicated that huge quantities of sur-
plus prescribed drugs accumulate in patients’ homes:
these show that the patient has a considerable autonomy
in the management of his disorder, that communication
between doctor, pharmacist and patient is often deficient
and that prescriptions are given out of all proportion to
their most generously estimated needs2o, 21, 22. One of
the most significant studies of patients’ autonomy with
respect to the taking of prescribed drugs is being under-
taken by Stimson and his colleagues in Swansea. In a
recent paper Stimson commented &dquo;People have a non-
medical perspective for (a) having expectations about
what the doctor should do, (b) for evaluating the doctor’s
actions and instructions, and (c) for making their own
decisions about their use of medications2l.&dquo;
For these reasons: lack of feed-back, non-compliance
and patient’s autonomy, it is difficult to assess the
effectiveness of a drug in general practice.
(c) The risks in drug prescribing ?
Treatment should preferably cause some improvement in
the patient, yet the diseases of medical progress are largely
predictable and preventable complications of treatment-
80 per cent of drug reactions could be prevented without
reducing the therapeutic effects of drugs2°.
It has been estimated that 10 per cent of patients
develop drug reactions23 and three to five per cent of
hospital admissions are because of such reactions24. 18 to
30 per cent of patients in hospital suffer from drug
reactions24 and 30 per cent of patients admitted for a
drug reaction have a reaction to the same or another drug
during the same hospitalization2°. Patients in hospital
have a considerably longer stay because of drug reactions
than those who do not develop reactions24 and it is
estimated that one seventh of hospital days are devoted
to the care of drug reactions2s.
Unfortunately drug reactions are often not recognized,
long-term effects may not be seen for generations and
some drugs accumulate in various body tissues to
produce drug reactions long after commencement or
even after the drug has been stopped. Doctors seem re-
luctant to think that their treatment has contributed to
the patient’s disability. It is easier for the doctor to
attribute the patient’s new symptom to an extension of
his underlying disorder than to drug treatment. This leads
to an additional hazard: the increasing tendency for
doctors to treat the side-effects of one drug with another
drug which may itself produce further side-effects. The
hazards of multiple drug prescribing and taking ought to
be well recognized26 because many patients take alcohol
regularly as well as over-the-counter drugs.
Caution is always required but often not practised in
the drug treatment of certain vulnerable groups-babies,
pregnant women, the elderly and the debilitated. The
most important result of the thalidomide tragedy was the
acceptance that drug reactions are a serious hazard of
modern medicine. This led to the establishment of organ-
izations to ensure adequate and appropriate animal
216
toxicity tests before new drugs were tried on human
beings and the setting up of registries to monitor adverse
drug reactions: although monitoring in this country
must still be regarded as totally marginal to the real
incidence of drug reactions.
As the result of thalidomide, industry and government
now accept mutual responsibility whereas the medical
profession has remained suspiciously silent. On this topic
Wade 21 comments &dquo;Some doctors appear to be too
easily persuaded by drug promotion. Some seem to wish
to prove either to their patients or to themselves that they
are up-to-date and modern by always using ’the latest
drug.’ Some seem to care little about what preparation
they prescribe and may not know what drug it contains
and certainly little about the actions of those drugs.&dquo;
Teeling-Smith28 in discussing pre-market safety tests
on drugs suggests that standards of safety in medicines
are in some cases out of proportion to the risks we accept
in other fields, for example in elective surgical procedures.
However, no matter how stringent are these tests, a drug
still has to be prescribed responsibly and rationally.
(d) Is drug prescribing economic ?
In the field of drug use there has been little work on cost
effectiveness: most studies have centred around the in-
creasing use of brand-name products which account for
about three in five of prescriptions dispensed. Many new
brand products represent no advance over already estab-
lished drugs: they include minor structural variations
(often called molecular roulette), variations in presenta-
tion (e.g. slow-release) and fixed-dose combinations.
These ’pre-packed’ preparations are popular, usually
offer no therapeutic advantage, are expensive and yet easy
to launch because they contain drugs already approved
by the safety committees. They are regarded by most
authoritative opinion as primarily promotional devices.
But it is well to remember that prescription drugs are
directed consumer goods, and for this reason, prescribing
doctors constitute a market. They are, therefore, sub-
jected to the same factors which affect consumer pur-
chase patterns. Sales promotion unquestionably plays a
major part in inducing doctors to prescribe new products
and it is an important feature in the competition between
various companies to sell their products. The drug com-
panies spend about £15 million a year on sales promotion
(excluding the costs of very sophisticated market re-
search) employing one sales representative to every seven
general practitioners. Their efforts are successful; brand-
name prescribing increases annually. Against such in-
fluences the Department of Health and Social Security
concerns itself with costs and safety. To advise on
efficacy is not within its mandate because this could and
would be regarded as clinical direction: a freedom which
the profession’s representatives guard most jealously,
without realizing or admitting that the pharmaceutical
industry’s marketing techniques are based upon clinical
direction.
The fundamental question on drug costs is whether the
prescribing doctor should choose the cheapest product
from amongst a group with equal efficacy. The industry’s
answer is centred around what is called therapeutic
equivalence: this means that the way a drug is prepared
and formulated may affect its availability to the body and
therefore its effectiveness. The industry stresses the high
standards of quality control which ensures predictable
availability and holds that therapeutic equivalence is not
the same for chemically equivalent drugs. The medical
profession is divided: some claim that the whole problem
has been grossly exaggerated by industry because of its
interest in promoting brand-name products as a pro-
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tection against investments on research and development:
others have demonstrated differences and produced
evidence to support the claims of the various drug
companies.
However, these arguments about therapeutic equiv-
alences assume that doctors prescribe and patients take
drugs ’correctly’. This is not so; such arguments neglect
the high amount of drug wastage which is indicated
by compliance studies and drug recovery programmes.
These show that prescribing is not economical regardless
of the drugs being therapeutically equivalent or not.
CONCLUSIONS
(a) Drug prescribing appears excessive
If ideal pharmacological standards are applied to drug
prescribing it would appear that it is not always respon-
sible and rational. Yet if similar standards were applied
to most other types of treatment, these too would not
always meet required criteria. Further, drug taking
follows prescribing and so the criterion of responsibility
should not only be applied to prescribers but also to each
of the other parties involved: pharmaceutical industry,
government, pharmacists, and patients. None of these
is completely responsible in their pressures and demands
upon the prescribing doctor. It is, therefore, wrong to
isolate him for special criticism: his prescribing should
not be judged against criteria which are solely medical;
they must include social ones as well.
(b) Drug prescribing should be the concern of all
The healing process has always been surrounded by
mystification: the consultation process having a mystique
about it which may be beneficial to patient and doctor.
The patient also responds to all manner of treatments,
some more irrational than many drug therapies: the fact
that about two in five patients ’improve’ on dummy
(placebo) drugs and that numerous non-drug factors in-
fluence both the response of patient and doctor indicate
the complexities involved in assessing drug treatments. In
individuals this is especially difficult and often impossible.
Therefore, accepting the mystique that surrounds the
healing process; accepting that recovery often or some-
times takes place, not because of treatment but in spite of
treatment and accepting that it is often impossible to
rationalize in medical scientific terms the ’irrational’
elements in medicine, what ought to be our concern?
The concern of all should be to accept and share re-
sponsibility for drug use-patients and profession,
politicians and pharmacists, industry and government.
There is need for all concerned to engage in meaningful
discussion and action; to accept the limitations of ’treat-
ment’ medicine; to spend more resources on preventive
medicine and health education; and to guard against
exploitation, inequalities of care, inefficiency and over-
enthusiasm for alternatives to drug treatments just
because they are alternatives.
As far as drug treatments are concerned, these should
be used responsibly and rationally in order to obtain
maximum benefits for individuals and society for mini-
mum dangers. Finally it must be accepted that drug
prescribing and drug use are social acts with social
consequences-they are the concern of all.
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SPORT FOR PHYSICALLY HANDICAPPED
continued from page 212
water and a large dining hall for 250 wheelchair users.
Spectator stands for both the main hall and the swimming
pool are included. Moreover, one of the accommodation
huts has been adapted as an indoor bowling green for
use during the winter months for both the able-bodied
and disabled. This has been such a resounding success
that it has been decided to build a six rink indoor bowling
green and an additional accommodation block for a
further 150 beds attached to the existing Sports Stadium
Plans have already been passed and it is hoped to start
building within the next month or two. Since its opening
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217
of the Conference on Continuous Education for Physicians in the
Use of Drugs, Washington, D.C.
17
LEAR, JOHN (1959). Taking the Miracle Out of Miracle Drugs,
The Saturday Review, 42, 35-41 (3 January 1959).
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MACGREGOR, A. (1963). Drugs and the Doctors, Medical
19
Journal of Scotland, 8, 41.
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Perspective, Mind & Medicine Monographs, Tavistock Pub-
20
lications.
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21
STIMSON, G. V. (1972). Obeying Doctor’s Orders: A view from
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22
ology Conference, York, 8 to 10 December.
WILSON, G. M. (1972). Prescribing for Patients Leaving Hos-
23
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MONROE, J. F. and CLUFF, L. E. (1968). Problems with Multiple
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WADE, O. L. (1970). Adverse Reactions to Drugs, William
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This paper was presented at the Pharmaceutical Session of the Health
Congress, Eastbourne, 1973
the Stoke Mandeville Sports Stadium for the Paralysed
and Other Disabled has proved an invaluable contri-
bution not only to furthering sport amongst the disabled
in the whole country, but also to providing better sports
facilities for the local community for able-bodied. Above
all, the Stadium has broken down the barrier which has
existed throughout the centuries between the able-bodied
and the disabled and has shown that integration of the
disabled with the able-bodied in sporting activities is not
only feasible but most beneficial for both sections of the
community. This has proved, beyond any doubt, how
great a part sport can play in the social re-integration of
the disabled into the community.
This paper was presented at a Conference of the Society held in
London, 22 March 1973