Medicines Optimisation and shared decision making are frequently used buzzwords – what do these terms mean in practice?? – here’s some patient stories to reflect on:
These stories are fictitious but based on real events:
Ben’s holiday – (finding out what a medicine does by accident) :
Ben is a 16 year old boy who has been prescribed a drug for a behavioural condition, it’s a powerful drug (called an antipsychotic) which he has taken for over a year. His parents think it helps. Ben hasn’t said what he really thinks, but accepts the tablet.
A few years ago the family went on holiday to Poland. During the holiday there was an air traffic controller’s strike. The family were stuck overseas waiting for the strike to end. They ran out of Ben’s medicine and were unable to obtain any or anything similar. As a result, out of desperation, they gave Ben a saccharin tablet instead, and hoped for the best. He was fine. Over the next few weeks they even noticed an improvement in his mood and behaviour. He seemed to be enjoying life more. When the family returned to the UK they stopped giving him the ‘placebo’ tablets, and he has not needed to take medicines since.
Ian’s secret: (in jargon this is ‘intentional non-adherence’)
Ian is a 35 year old man diagnosed with bipolar disorder. When Ian moved to another part of the country he was allocated a new community psychiatric nurse [CPN] and, as he was unwell at the time, was re-started on medication. Over the next 18 months Ian’s condition improved so his CPN reported a ‘good response to the medication’. It was only after 2 years of knowing him that Ian confided in his CPN that he didn’t take the medication consistently, and never had.
The medicine was lithium, which requires regular blood tests. This is because too much of it is toxic and too little has no effect. Ian revealed that he had only taken it before his blood test days, then always stopped taking it in between.
Ian’s medical notes had stated that he always ‘responded well to lithium’!
As a result of Ian being able to trust his CPN, and let on that he wasn’t taking it, his medical records were corrected to say that he did not want to be prescribed lithium, confirming that other options worked much better. These options include some medicines which he had previously ‘borrowed’ from someone else, or bought on the internet. Of course he didn’t tell medical staff about this at the time.
So his choice is now clearly written up, should he become unwell again.
…and now the ‘science bit’. If you want them I can provide references for medicines geeks like me! firstname.lastname@example.org
Medicines Optimisation is a powerful term because it brings in the:
- Patient’s views and their decision
Clinical people may think they ‘know best’, but in the end it is the patients (you and I) who will decide whether or not we take the medicine, and we will not always tell the doctor or nurse if we don’t feel we can trust them. Statistically around 50% of people, (all ages all types of people), don’t take their medicines as prescribed.
- The ‘human factors’ and health beliefs related to having to take medicines
Medicines aren’t always the answer. We may have strong beliefs in favour or against them; these beliefs are hard to change and need to be respected. Basically we usually know what’s right for us.
- The ‘evidence base’, which means is it known to work?
People who prescribe medicines (usually doctors, pharmacists or nurses who have the qualification) need to offer the medicines which are proven to be most effective. And there is often a choice.
Repeatedly studies have shown that clinicians have a list of medicines they prescribe for various illnesses in their minds, and this list may bear little or no relation to the evidence available on what works best.
Medicines optimisation is not simply another term for ‘medicines management’, which is generally used to refer to the mechanics of the medicines process. This leads us to consider not just the process of selecting, prescribing; ordering; supplying; administering and monitoring, but also whether the person has the capacity and enough knowledge to decide to take a medicine; if they actually take the medicine and indeed whether the medicine is needed in the first place.
Sometimes people need multiple medicines (referred to as polypharmacy) because of the complexity of their illnesses. This can be inappropriate if, for example, a medicine is simply added to counteract the side-effects of another medicine.
I will be speaking on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference
Version 1 Added 12/02/2018 Amended 15/11/2019 & 02/02/2022