Trial’ Prescriptions to Reduce Drug Wastage
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Despite the fact that prescribed medications are often not used by patients, current statutes in most clinical settings do not allow patients to return unused medications for reissue to other patients. Hence, if a patient tries a medication, and is dissatisfied with it, does not tolerate it, no longer needs it, or is directed by a health professional to discontinue it for any reason, remainder medication is generally wasted. Canada has tested a concept of allowing pharmacists to initially fill prescriptions for intended long-term medication with a "trial" amount first—allowing the patient to administer a small quantity of the medication, for instance 7-14 days supply—followed by the "full" balance of the prescription if both the patient and clinician were satisfied with the initial applicability of the prescription.
The overwhelming majority of patients (n = 249) who were offered "trial" prescriptions (86%) were content to receive that instead of a "full" prescription initially. More than half of the minority of patients who did not elect to receive a trial prescription reported sensible obstacles like the fact that they were leaving town, or that geographic limitations precluded ready return for a "full" prescription. Between 14-52% of "trial" prescriptions were ultimately discontinued. Overall, using trial prescriptions saved Canada $5.50 per trial prescription issued. American clinicians might similarly save important financial resources in some settings by the consideration of prescriptions of "trial" duration.
Paterson JM, Anderson GM. Am J Manag Care. 2002;8:151-158.
Cognitive Functioning of Long-Term Heavy Cannabis Users Seeking Treatment
Whether long-term heavy cannabis (LHC) use is associated with persistent impairment of cognitive function (COG) is an important public health issue not only because of the ponderous number of chronic marijuana users, but also because of potential employment by the medical profession as a therapeutic tool. This study looked at a population of LHC users who sought treatment because of cannabis dependence. Participants must have not used cannabis for at least 12 hours. Data obtained through neurophysiologic testing were compared with a control population of age-matched nonuser controls. Most LHC users used cannabis essentially every day, approximately 2 joints daily.
LHC users had poorer word recall, poorer performance on increasingly complex executive function tasks, and a trend toward attentional dysfunction, in addition to deficits in other monitored functions. The LHC most prominently affected learning, retention, and retrieval as measured by the Rey Auditory Verbal Learning Test.
Despite deficits detected with these measurement tools, the results do not indicate a severe COG problem, and may require as long as 10-20 years of consistent LHC to occur. That the study is retrospective, and the population highly selected, may limit the generalizability of the findings. Additionally, whether sustained abstinence from LHC would ameliorate the detected dysfunctions is unknown.
Solowij N, et al. JAMA. 2002;287: 1123-1131.
A Randomized, Placebo-Controlled, Double-Blind, Flexible-Dose Study of Fluoxetine in the Treatment of Women with Fibromyalgia
Best management of fibromyalgia (FMG) remains a difficult challenge for most clinicians. Although meta-analyses suggest that tricyclic antidepressants are moderately effective, trials using selective serotonin reuptake inhibitors (SSRIs) have provided conflicting results. Since some positive results have been found with various SSRIs, a prospective placebo controlled trial of fluoxetine was felt to be of merit.
Study subjects (n = 60) were adult women with FMG, who received placebo or fluoxetine (FXT) once daily, titrated in 10-20 mg increments every 2 weeks to a maximum dose of 80 mg/d. Outcomes were assessed using the Fibromyalgia Impact Questionnaire and the McGill Pain Questionnaire. Both the Impact and Pain Questionnaires showed statistically significant improvements in patients receiving fluoxetine. More than twice as many FXT recipients than placebo recipients experienced at least a 25% improvement in Fibromyalgia Impact Questionnaire score.
FXT was generally well tolerated. Perhaps the more favorable effects seen in this trial may be attributed to the higher doses of FXT used—earlier controlled trials used only 20 mg/d. Based on these results, clinicians may wish to consider flexibly dosed FXT for symptomatic management of female patients with FMG.
Arnold LM, et al. Am J Med. 2002; 112:191-197.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.