A question of balance: the overconsumption and unavailability of internationally controlled drugs

In developed countries, the prevalence of anxiety and insomnia and the consumption of sedative hypnotics are growing, the elderly being the main group of consumers. The Board notes with concern the frequent long-term use (beyond one year and sometimes indefinitely) of psychotropic substances for treating psychological reactions to social pressure without a diagnosis for a specific disorder. Recent surveys indicate that 70- 95 per cent of illnesses are managed by self-care in many countries and this tendency has an important influence on medical practice and on the clinician-patient relationship in general.

Similar tendencies may be seen in many developing countries and in younger age groups. Correcting mood and behaviour through controlled drugs is becoming widespread. Thus, for Governments, keeping the supply and consumption of drugs, especially controlled drugs, in line with medically justified levels is not only an important public health issue but also an economic issue.

Effects of the drug distribution chain on use

a) Impact of the manufacturing industry

Because of the continuing expansion of free trade, it is of the utmost importance that manufacturers exhibit responsible and ethical behaviour in the promotion of all medicinal products. The regulatory requirements concerning narcotic drugs and psychotropic substances destined for medical purposes represent additional responsibilities for manufacturers. Many manufacturers are in principle convinced that it is in their interest to accept those responsibilities and comply with national and international regulatory requirements. Experience shows, however, that certain policies in company sales and promotion practices may interfere with sound health policy. Examples include the continuing manufacture of, trade in, and promotion of: (a) certain controlled drugs when better treatment options or safer alternative drugs are available (e.g. the continuing promotion of amphetamine-type substances for weight control); and (b) drugs or preparations that have been insufficiently tested on specific target groups of consumers, such as children, pregnant women or the elderly. For ethical reasons, few psychotropic medicines have been adequately tested for safety and efficacy in children, although there are high rates of prescribing. This situation has been the subject of critical review.

In some countries, company sales promotion is often addressed to not only physicians but also the public, circumventing prohibitions on advertising. Direct advertisement frequently portrays drugs as common consumer goods, thus encouraging higher drug consumption. Free promotional samples are distributed through company representatives and company-owned distributors in developed and developing countries alike. The continuing existence of such aggressive sales methods may be a sign of inadequate government regulations and/or of weak enforcement of existing regulations. Such sales promotion characterizes, for example, the medicine markets of countries with quickly changing market structures, such as countries in central and eastern Europe. Other problems include:

• The quality and comprehensiveness of drug-related information made available to doctors and patients by pharmaceutical manufacturers often show unacceptable variations.
• Ethical norms for medicinal drug promotion developed by the pharmaceutical industry and by the World Health Organization (WHO) do not appear to be observed by some companies.
• Drugs, including prescription medicines, are increasingly being advertised on the Internet by a wide range of companies.
• In many countries, unregulated drug markets called "street markets" continue to operate parallel to and often in the absence of licensed pharmacies.

There is a need for concerted international efforts in which bona fide pharmaceutical manufacturers take an active part in eradicating such illegal drug supply channels.

b) Impact of medical practice

The medical profession bears an important responsibility for appropriate drug dispensing in general and for the prescribing of controlled drugs in particular. It is the prescriber who determines the choice of drug, its dosage, duration and termination and, ultimately, the availability of a particular psychoactive drug for a given patient. The clinician enjoys a great degree of professional freedom and discretion in such decisions. The clinician-patient interaction involves responsibilities on the part of both, the extent of which is influenced by the culture of the country in question. Continued education of the public in drug use is indispensable.

Significant cross-national and country-specific variations in psychiatric morbidity and drug use data indicate, inter-alia, that there continue to be considerable variances in medical practice between otherwise similar countries and sometimes even within countries. In spite of the recognition of the urgent need for harmonization and standardization, consensus in these areas has developed rather slowly.

Inappropriate prescription of controlled psycho-active medicines includes uninformed prescribing; inconsistent or lax prescribing; willful and consistent mis-prescribing for abuse; and self-prescribing and self-administration.

Many detailed studies suggest that excessive reliance on pharmacological treatment of mental disorders and psychiatric conditions, with a preference for finding quick solutions exclusively through the use of pharmaceuticals, is a significant contributing factor in countries with overconsumption. Several recent studies, however, show that the use of multiple drugs (polypharmacy), often in irrational combinations, in inadequate dosages and for excessively long treatment periods, continues to be quite common. Such medical practice is contrary to the principles of cost-effectiveness and rational evidence-based therapy and is a waste of resources.

The Board has noted in recent years useful national and international initiatives to promote agreed-on definitions of syndromes, better diagnostic criteria, adequate therapeutic approaches and good prescribing practices for some previously controversial health conditions for which psychoactive drugs are being used. Regional efforts in these areas, including training for health personnel, appear to be increasing.

Telemedicine and Internet prescribing may greatly facilitate access to medical and pharmaceutical services for large segments of society at lower cost. At the same time, the potential for errors and intentional misuse is considerable. Substituting direct patient-doctor contact by electronic communication is problematic, particularly in relation to the diagnosis of psychiatric disorders and the prescription of controlled drugs. Efforts to regulate this quickly developing technical area, which has just started, require close cooperation among countries and the relevant international bodies.

These issues demonstrate the complexity of the problems that need to be addressed in efforts to improve drug-prescribing behaviour. Professional knowledge, personal preferences, interpersonal relationships and the environment in which physicians and patients interact influence such behaviour. Any lasting improvements can only be expected in the long term as a result of coherent and continuing education and training.