Rules For Safe Drug Use

Ten Rules for Safer Drug Use

Rule 1: Have "Brown Bag Sessions" With Your Primary Doctor and Fill Out A Drug Worksheet.

It is impossible to overemphasize the importance of this first and most crucial step in preventing adverse drug reactions. Whenever you go to a doctor you have not previously seen or to one with whom you have never had a brown bag session, put all prescription and over-the-counter drugs you are using, have used in the last month, or are likely to use in a bag, and bring them to the doctor so a list can be made and you can start to fill out your drug worksheet.

Doctors should never prescribe a drug or renew a prescription nor should you be willing to get a new prescription, without full up-to-date knowledge of all drugs already being taken or likely to be taken.

Before your brown bag session with the doctor, your neighborhood pharmacist may help you to fill out some of the blanks on your drug worksheet.

Once you have brought in all the drugs you are taking, ask your doctor to help you fill out the drug worksheet. You will probably be able to fill out more of the information concerning over-the-counter drugs yourself, since doctors often do not know that you are taking them or for what purpose. The doctor will be able to help you to fill out most of the information concerning prescription drugs, at least the ones that he or she has prescribed for you.

Do Not Use Drugs

If a drug already being used or being considered for use is one of the 160 drugs that we list as Do Not Use, Do Not Use Until Seven Years After Release, or Last Choice, ask your doctor about alternative therapy which could be either nondrug therapy or a safer drug. If the drug you are using is listed in this book as Limited Use, it may also be a good idea to discuss the drug with your doctor to see if a better alternative might be found.

Talk to your doctor before deciding to make
any change in your prescription drugs.

Rule 2: Find Out If You Are Having Any Adverse Drug Reactions.

Even before you have a brown bag session with your doctor, if you develop any of the following reactions after beginning to use any drug, contact your doctor. Ask if you really need a drug in the first place and, if you do, whether a safer drug can be substituted or whether a lower dose could be used to reduce or eliminate the adverse effect. Look in Chapter 2, Adverse Drug Reactions for the lists of widely used drugs that can cause each of these adverse effects.

Mental adverse drug reactions: depression, hallucinations, confusion, delirium, memory loss, impaired thinking, and insomnia
Nervous system adverse drug reactions: parkinsonism, involuntary movements of the face, arms, and legs (tardive dyskinesia), dizziness on standing, falls (which can sometimes result in hip fractures), automobile accidents that result in injury because of sedation, and sexual dysfunction
Gastrointestinal adverse drug reactions: loss of appetite, nausea, vomiting, abdominal pain, bleeding, constipation, and diarrhea
Urinary tract adverse drug reactions: difficulty urinating or loss of bladder control (incontinence)

If you or a relative or friend have any of the above problems or develop other problems arising after starting a new drug notify your doctor or tell your friend or relative to notify his or hers.

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The remaining rules for safer drug use (or nonuse) were compiled from a number of lists, but particularly from the World Health Organization's General Prescribing Principles for the Elderly. These rules, however, apply to all age groups--and all doctors and patients who are involved in drug therapy should know them.

Rule 3: Assume That Any New Symptom You Develop After Starting a New Drug Might Be Caused By the Drug.

If you have a new symptom, report it to your doctor.

Rule 4: Make Sure Drug Therapy Is Really Needed.

Often, drugs are prescribed to treat situational problems such as loneliness, isolation, and confusion. Whenever possible, nondrug approaches to these problems should be tried. These include hobbies, socializing with others, and getting out of the house. When a person is suffering from an understandable depression after losing a loved one, for example, support from friends, relatives, or a psychotherapist is preferable to drugs such as antidepressants.

Nondrug therapy such as weight loss and exercise is preferable to drugs for such problems as mild high blood pressure and adult-onset diabetes. Increasing fiber and liquid in the diet is preferable to using laxatives. For swollen legs due to "bad" veins in the legs (not due to heart disease), wearing support hose is less expensive, safer, and probably more effective than taking heart pills or water pills.

Anxiety or difficulty sleeping are two situations for which drugs should rarely, if ever, be prescribed, particularly in older adults.

A last category of "disease" for which drug therapy is rarely, if ever, appropriate is drug-induced disease or adverse drug reactions. The proper treatment for drug-induced parkinsonism is not a second drug to treat the problem caused by the first drug, but stopping the first drug.

For any condition, always consider and discuss with the doctor whether the drug that is being selected may cause problems (side effects) worse than the disease being treated. A very common example of this is the extraordinary over- treatment of older people with slightly high blood pressure but without any symptoms of or problems caused by high blood pressure. In most cases, the person will feel worse because of the treatment, without any evidence of benefit. Always consider the seriousness of the condition which your doctor is considering treating, and try to make sure that the treatment is not worse than the disease.

The guiding principle is to use as few drugs as possible, in order to reduce adverse reactions and increase the odds of properly taking the ones that are really necessary.

Rule 5: If Drug Therapy Is Indicated, In Most Cases, Especially in Older Adults, It Is Safer To Start With a Dose That Is Lower Than the Usual Adult Dose.

"Start low, go slow." The lowest effective dose in any patient is always the best, because a lower dose will cause fewer adverse effects, which are almost always related to dose. In the elderly, some experts suggest starting with one-third to one-half of the usual adult dose for most drugs and watching for side effects, increasing the dose slowly and only if necessary to get the desired effect.

Rule 6: When Adding a New Drug, See If It Is Possible to Discontinue Another Drug.

If your doctor is considering the addition of a new drug, this should always be used as an opportunity to reevaluate existing drugs and eliminate those that are not absolutely essential. The possibility of an adverse drug interaction between the new drug and one of the old ones may force dropping or changing a drug.

Rule 7: Stopping a Drug Is As Important As Starting It.

Regularly review with your doctor, at least every three to six months, the need to continue each drug being taken. For many mind-affecting drugs, such as sleeping pills, tranquilizers, and antidepressants, and for antibiotics, this reevaluation should be more frequent and sooner. The prevailing principle for doctors and patients should be to discontinue any drug unless it is essential. Many adverse drug reactions are caused by drugs which were continued long after any rational duration of use ended. Many drugs such as antidepressants, sleeping pills, tranquilizers, digoxin and others that are prescribed for an acute problem are not needed beyond a short period, and cause risks without providing benefits. Slow and careful weaning off these drugs may significantly improve the user's health. In addition to considering whether to stop the drug, you and your doctor should discuss the possibility of lowering the dose.

Rule 8: Make Sure Your Drug-Using Instructions Are As Clear As Possible To You and At Least One Other Person.

Regardless of how old someone is, the chance of adverse reactions is high enough that at least one other person--a spouse, child, or friend--should know about these possibilities. In the presence of such adverse reactions as confusion and memory loss, this is especially critical. For older adults, the complexities of drug use may be greater, especially for people taking more than one drug and people with physical or mental disabilities. In these cases, it is even more important to inform another person about possible adverse drug reactions.

Ask your doctor to make sure that the label on the drug states, if at all possible, the purpose for which the drug is being used. This is especially important when you are using multiple drugs, but is always important as a way of increasing your and your family's or friend's participation. All information concerning the proper use of the drug should also be on the label. In addition to the label, you should get a separate instruction sheet and have it explained to you.

Rule 9: Discard All Old Drugs Carefully.

Many people are tempted to keep and reuse drugs obtained in the past, even though reasons for their use have changed. Additional drugs used may make the earlier drugs much more dangerous. In addition, you may be tempted to give drugs to a friend or relative whom you believe may benefit from them. Resist these temptations and avoid further problems caused by using outdated drugs, by throwing them away when you are done with your course of therapy.

Rule 10: Ask Your Primary Doctor to Coordinate Your Care and Drugs.

If you see a specialist and he or she wants to start you on new medicines in addition to the ones you are on, check with your primary doctor first--usually an internist or general or family practitioner. It is equally important to use one pharmacist, if possible.

Special Problems in Nursing Homes

All of the problems of dangerous misprescribing of drugs for people living in the community are even worse in many nursing homes. For example, one study found that almost 40% of nursing home residents were being given antipsychotic drugs even though only a small fraction of them actually were psychotic. Another study found that one third of people in nursing homes were getting seven or more prescription drugs. Most of the above rules for safer drug use apply in all situations, including the nursing home situation, but there are some differences. The main one is that for patients in nursing homes, the brown bag session and filling out the Drug Worksheet should be done by the nursing home staff, including the nurse, doctor, and pharmacist.

If you are the child, other relative, or friend of a nursing home resident, you have the right, with his or her permission, to demand and receive a completed Drug Worksheet for that person and an explanation of the reasons for each drug being used. The process of obtaining this information, with the help of your own pharmacist and possibly your own doctor, will very likely lead to a reduced number of drugs being given and, where appropriate, reduced doses of those still judged to be necessary. By taking care of these matters, you will have made a major contribution to the health and well-being of your loved one(s) in nursing homes.

COMPLIMENTS OF Public Citizen, www.citizen.org. & www.worstpills.org