Medicines Optimisation in General Practice

Many people, in my opinion, wrongly equate medication review with medicines optimisation. There is a world of difference between the two.
I have carried out many medication reviews in my time. We are used to talk about the older patients who find themselves with 12 medicines on their repeat, but this is not the only patient who needs a review. I have recently seen several patients with a strange mix of painkillers including opiates and antiepileptic medicines alongside PPIs, laxatives and others.
The medication review starts with asking the patient some difficult questions, for example what is the most important thing do you want to achieve from your medicines, followed by a review and usually some changes and reductions. Patients who find themselves on high doses of opiates may require special attention if they do not have a life limiting condition. Anyway, people thing that I am ‘optimising’ medicines – but in reality I am just sorting out a mess.
Medicines optimisation, however, starts with the question – ‘how did we get into this mess’. If you track back in the history, you often find good intentions and ‘symptom responsive care’ and often ‘side-effect responsive care’. Usually each and every medicine has a rationale and some logic to its addition. When all taken together, the prescribing decisions usually represent a long path to nowhere.
Medicines optimisation is the process by which we ensure such prescribing decisions are better. It starts with patient engagement and understanding the patient objective. It is about better selection of medicines that are well placed to achieve the specified objectives. It is about explaining the positives, negatives and alternative approaches. It is about describing the care package or change in behaviours that would support the medicine or support the remaining symptoms. It is about monitoring and review and stepping down as well as stepping up.
You will find me talking about several important issues:
• Managing remaining symptoms. For example: most painkillers for chronic pain will reduce the pain rating scores by 50%. The important question is how to deal with the remaining 50%
• Identifying the real complaint: For example: if you can’t sleep, you feel tired the next day, lack concentration etc – a benzodiazepine or ‘z’ drug is often not a good choice
• Giving patients options and control. For example: prescriptions can be post-dated or issued and not cashed
• Background factors. For example: I have no medicine that treats loneliness, isolation, lack of confidence and feelings of low worth
• Supporting compliance. For example: many people have physical and memory issues that get in the way of good medicines taking
• Failure across an interface. For example: when more than one prescriber gets involved and patients are transferred between organisations
Medicines optimisation is what we deliver in general practice. It starts with good organisational processes, medicines reconciliation, prescribing policies, medication review. It is driven by training, education, development and discussion. It helps patients and prescribers plot a sensible approach to medicines.


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