Knowing When to Stop
The Perspective of Ralph Kendall, PharmD, Vice President of Clinical Services, Healthesystems
While reading a commentary article in a recent issue of the Journal of Managed Care Pharmacy, I was struck by a very simple, yet powerful statement, “Stopping prescriptions for medicines that patients no longer need is an important part of good prescribing practice,” the author wrote.
This seems fairly obvious, but it’s still not happening across the board.
In fact, it seems we teach the biological processes of disease and injury, proper diagnostic techniques, and how to triage the problems encountered with patients. Yet, medically speaking, what do we do when the complaint is no longer relevant? In many cases, we fall far short of doing the right thing.
In our case history reviews at Healthesystems for example, we’ve seen countless patients who remain on therapies well past the expected recovery time. We see it across almost all therapeutic classes in workers’ compensation injuries. Of course, it doesn’t have to be that way.
As healing and rehabilitation progress, we simply must learn to ask: if the pain is still as severe? Or if the muscle group is still in spasm? Or is the injured tissue still inflamed? Each of these questions, depending on the answers, can represent having reached the point when specific medications should be discontinued.
Yet, more often than not, we still see the medications used to treat the acute phase of an injury continued for months and even years. Of course, patients who fear the return of pain may contribute to this unfortunate trend. Other factors include the transfer of care from a specialist to a primary care physician (without complete directions as to the intended duration of therapy); patients may like the way medications make them feel; or even worse, workers’ compensation patients may be motivated to “extend” their injury status by continuing to use medication. In short, continued use of medication validates the injured worker’s suffering and need for treatment. Continuing medications beyond the intended or expected treatment duration, of course, can lead to medication misadventure, including falls, additional medications to treat side effects, expression of toxicity, dependency, diversion, stockpiling and more.
There are solutions. Perhaps the best strategy to begin answering the question of when to stop starts by documenting in the patient record the expected duration of rehabilitation. Providers should be sure to note what physical signs and symptoms will be present or not present when this end-point is reached. Or ask if some medications require tapering.
Most of all, the most effective approach is to begin with the end in mind. Success is almost always sure to follow.