December brought Christmas, which according to some has its origins in the ancient celebrations of the winter solstice; an expression of longing for the return of light when the year is at its darkest. January brings a fresh start to many, and the promise of longer days in the fullness of time.
A desire for the return to normal also, arguably, plays into why people use medicines. A study published this month in the International Journal of Pharmacy Practice (IJPP) investigates the irrational use of medicines; a systematic review, it focuses on Arabic countries and looks to identify patterns of irrational use of medicines and the leading causes. Systematic reviews aim to examine the scientific evidence on a topic by applying strategies that limit bias in the retrieval, critical appraisal and synthesis of the relevant literature, so it is reassuring to see this paper using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to underpin the work. Additionally, it is good to note that the review protocol was first registered with the International Prospective Register of Systematic Reviews (PROSPERO).
Another strength of the paper is its use of a checklist from the Critical Appraisal Skills Program (CASP) to assess the quality of papers considered for inclusion. This is a large study: while only two databases were used to extract relevant studies, 136 were identified and included in the final paper. The paper did not lend itself to a meta-analysis, but the authors reported high prevalence of polypharmacy, antibiotics prescription and antibiotic self-medication as examples of irrational use of medicines in Arabic countries, which they relate to both patients and health systems, recommending further studies and interventions to address the problem systematically. It makes for an interesting read.
Fall-risk increasing drugs
An adverse effect of medicines use, especially in older adults, is the increased risk of falls. Another paper published in IJPP examines the use of ‘fall-risk increasing drugs’ (FRIDs) in UK patients aged 65 years and over who had broken an arm. Following 100 participants for six months after their initial fall, the researchers found that the percentage of people prescribed one or more FRID decreased from 73% at baseline to 64% at 3 months and 59% at 6 months. The most common FRIDs, they said, were antihypertensives, opioids and antidepressants.
However, changes to FRIDs were not limited to discontinuations; they included new prescriptions or a change from one FRID type to another. The most common changes to FRID prescriptions involved discontinuing opioids and starting antidepressants. Importantly, however, although 14% of the participants had at least one other fall during their 6-month follow-up, this was not linked to them being prescribed one or more FRID. Nonetheless, the authors recommend that future studies focus on exploring the impact of structured medication reviews to identify FRIDs for deprescribing, as part of a multifactorial person-centred intervention targeting older people presenting with upper limb fractures — laudable advice.
Imagine the serendipity, then, in discovering that another paper in IJPP focused specifically on supporting conversations about medicines and deprescribing, collating the view of GPs in Australia on a medicines conversation guide for this purpose. A short communication, the paper describes the guide as having been designed for use by pharmacists during a government-funded Home Medicines Review Programme to support discussions about medicines with older adults and their carers. Of course, as might be expected, GPs identified both strengths and limitations of the tool. But as the authors rightly describe, their work is in line with a shift in deprescribing interventions that focus not only on identifying appropriate medications to stop or reduce, but also the importance of patient involvement in the deprescribing process. Perhaps this guide would be used by those designing deprescribing interventions as described in the previous study.
This recognition of patient views and attitudes is the topic of the final paper I want to highlight this month. Published in the Journal of Pharmaceutical Health Services Research, and based in Jordan, the authors examined the attitudes of individuals, who were fully vaccinated (had received two doses) against COVID-19, towards receiving a booster dose. The authors describe Jordan as the “least willing Arab nation” to receive the COVID-19 vaccine in the first place and argue for the importance of their work based on low uptake of the booster.
The study is a survey conducted online and disseminated through social media, receiving 952 valid responses. It aimed to assess individuals’ attitudes toward the booster dose and to identify predictors of this attitude. The authors report factors that correlate with attitudes toward a COVID-19 booster to include income, educational level, experience of side effects of the vaccine, and whether news about the pandemic was being followed. In contrast, seven other independent factors examined were not associated with attitudes toward a COVID-19 booster, including age, gender, having insurance, working status, social status, living with a child, and smoking. As I read it, I wondered if the authors would design their work, if it were ever repeated, to be led by a priori hypotheses about factors that might predict attitudes to the COVID-19 booster — rather than using multivariate regression analysis, as they did, with all the potential factors included and unadjusted P values. This exploratory approach poses the danger of finding some significant correlations on paper, even if none exist in reality; known as a type I error. Nonetheless, the paper is a novel study, detailing the development of a new survey instrument with a decent measure of internal consistency, which could be used in future studies.
Why does it matter that we measure people’s attitudes to receiving a COVID-19 booster? I invite you to consider comments made by the World Health Organization’s director general in September 2022 about whether the pandemic is over yet: “We’re not there yet, but the end is in sight.” He added that what was needed was “equitable access to COVID-19 vaccines, tests and treatments”.
There is a saying that it is darkest just before dawn. Perhaps the time of maximum danger is right now, just as matters start to improve, and studies of public opinion will help us stay alert to the dangers of laxity, so we can stay on the path to light.
Parastou Donyai is chief scientist at the Royal Pharmaceutical Society