As a GP, a solid understanding of the principles and practice of drug use is essential. At the same time, you must also be aware that often drugs are neither the only nor the best solution to many of your patients’ problems. You need to have a good working knowledge of the range of drugs used to treat the common and important conditions for which GPs take primary responsibility and which are discussed in the chapters of this book. But you also need to be aware of the much broader range of drugs that your patients will be on following various secondary care interventions. As the doctor responsible for coordinating the patient’s overall care, you need to be aware of the potential for interaction between drugs prescribed by different specialties perhaps working in ignorance of each other. Nowhere is this more common than in prescribing for the elderly, where multiple pathologies often require multiple therapeutic interventions and an enhanced risk of problems.
Before you reach for your prescription pad, consider the following seven questions.
1Is a drug necessary? The ‘pill for every ill’ culture has caused more problems than solutions. Treating social problems with diazepam (popular in the 1960s) produced addiction without resolving the underlying problems. Be clear about the nature of the problem you are treating and the potential for a drug to solve it. Medication may be used to cure an underlying problem (e.g. antibiotics), control a chronic problem (e.g. antihypertensives) or manage symptoms (e.g. opiates in end stage breathlessness). Non-drug approaches involve physical therapy (e.g. physiotherapy for musculoskeletal problems, exercise for mild depression), psychological therapies (of which brief intervention by the GP is one example), self-help through support groups or individual exertion (often helped by books or other written information – pretentiously labelled ‘bibliotherapy’) often with the aim of lifestyle change.
2Is the drug effective? The rise of evidence-based medicine has made a large body of evidence available to GPs on the effectiveness of therapy. Persuading patients of the ineffectiveness of favoured remedies (which may have been promoted by other doctors) is a challenge (e.g. the lack of benefit of antibiotics in minor infections such as otitis media). At the same time, applying evidence to individual patients who may not conform to the exclusions and inclusions of the original trials requires clinical judgement, which may sometimes be little more than an educated guess.
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