Dr. Howland is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.
The author has disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Robert H. Howland, MD, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: HowlandRH@upmc.edu.
The effectiveness of a drug treatment is gauged not only on efficacy, but also on tolerability, safety, and acceptability. Effective medication management implies that the overall process of selecting and managing prescribed drugs results in an optimal patient outcome, and nurses have an important collaborative role with physicians in this process.
Mastering Drug Knowledge
Depending on the scope of practice, medication management will often encompass a therapeutic armamentarium of “favorite” drugs by indication or class. An important aspect of effective medication management is acquiring knowledge about the drugs you use or are likely to use, including their basic pharmacology, labeled indications as well as potential off-label uses, dosing parameters, and short- and long-term tolerability and safety profiles. Detailed knowledge about these drugs should be used to guide decisions about when to use them (labeled and off-label indications), how to use them (within or beyond the recommended dosage range and for how long), what to expect (clinical response rates and side effects), and whether to switch or combine medications (to improve responses or manage side effects). Acquiring extensive knowledge about these aspects of a drug takes time, effort, and experience, but will enable clinicians, especially nurses, to counsel and support patients, as well as answer their questions.
A good place to start is by reviewing the product package insert approved by the U.S. Food and Drug Administration (FDA), although this should not be the sole source of information about a drug. The package insert would not ordinarily include information about off-label uses, use in patient populations that did not participate in the studies conducted for drug approval (e.g., pediatric or geriatric patients, pregnant women), using doses outside of the recommended range, long-term use, or comparative effectiveness with other drugs. Product labeling information can become dated, especially for drugs that have been on the market for a long time or for those that have generic formulations. Many common side effects and some potentially serious effects of a marketed drug may become apparent only with the passage of time, when a larger and more diverse patient population is exposed to the drug. Although labels can be revised after initial approval, typically this would only occur when there is a new indication for the drug or for certain FDA-mandated reasons (e.g., new serious adverse events warnings). Additional research on a drug after its initial marketing approval may lead to a different or more refined understanding of its clinical pharmacology. Newer clinical studies or pharmacological information about a drug’s mechanism of action may be clinically relevant for justifying its use for off-label indications or using higher-than-recommended doses, for helping explain newly identified side effects, and for recognizing or anticipating drug-drug interactions. This new knowledge would not necessarily be found in the product label.
For these reasons, reviewing the product label should be supplemented with information from published literature and/or other trustworthy sources. Experienced clinicians may believe that after years of use, they know all that they need to know about a drug or drug class. Knowledge based on personal experience certainly is important but obviously has its limits. Exposure to a broader perspective from the research world, as well as from other clinical practitioners, is conducive to effective medication management. Reading for updates or consulting with other clinicians should be done periodically. Patients also can access a considerable amount of drug information beyond what their pharmacist might give them, including information from sources that are not necessarily reputable. Being prepared to discuss with patients information that is not included in the package insert will foster communication and trust. When patients present me with information that I am not familiar with, I encourage them to show me copies of what they have read or tell me how they accessed the information.
Nuts and Bolts of Medication Management
Effective medication management means translating drug knowledge into clinical practice. The selection of medication should be individually tailored by taking into account factors such as patient expectations, perceptions, and preferences; the expected efficacy and tolerability profile; existing treatment regimen (including treatment for other conditions); and cost considerations. The drug dosage and duration of treatment is critical. The target dose should strive to achieve an acceptable balance between efficacy and tolerability. Dosing a drug too low may result in a suboptimal outcome. Some patients require dosages beyond what is recommended. Based on knowledge of the drug and its pharmacology, prescribing off-label doses is certainly appropriate and defensible. Some patients may require a slower titration schedule to be able to tolerate escalating doses. Sufficient time at any dose is important to assess efficacy, as well as to determine whether tolerance develops to early side effects. Doses increased too quickly may cause needlessly intolerable side effects, lead to unnecessarily high doses, prompt the premature addition of medication to treat side effects, or result in a potentially avoidable discontinuation of the drug due to side effects.
Prescribing medication combinations may be appropriate and necessary for some patients to achieve an optimal treatment response, but this assumes that each drug clearly has a beneficial role. Combining medications may enhance efficacy or treat side effects but could be costly, can be associated with additional side effects, and will increase the burden of treatment. Overprescribing multiple medications can occur when there is urgency (real or perceived) to treating associated symptoms (e.g., sleep or anxiety) or side effects, rather than patiently allowing time for the primary treatment to “kick in” to improve symptoms or for side effects to diminish. On the other hand, patient perceptions that they are suffering needlessly—when they have expectations of how long it should take to feel better or when they know they could possibly take something to help with sleep or anxiety—may trump parsimony and patience. Out of anger, frustration, or dissatisfaction, patients can simply stop medication or not return for follow-up visits. Knowing whether and when to combine medications is a critical decision point in treatment that is unique to each patient.
Similar to making medication changes too quickly, making two or more changes at once can obscure a later assessment of cause and effect at subsequent visits. Ideally, medication changes (adjusting doses and switching, combining, or stopping medications) should be done one at a time to determine what the effect is on clinical response or side effects. Not doing so can lead to confusion. Explaining this to patients usually makes sense to them.
An important issue related to prescribing multiple medications is the need to be aware of all other drug products a patient is taking, including other prescription medications, over-the-counter drugs, herbal preparations, and dietary supplements. Moreover, an increased number of foods and beverages also contain various dietary supplements or other potentially psychoactive additives. Interactions with certain ingredients in these products may blunt therapeutic efficacy, exacerbate side effects, create new side effects, or lead to toxicity. Taking multiple drugs is associated with poor treatment adherence and also represents a cost burden to patients (Howland, 2007).
Psychotherapeutic and Psychoeducational Aspects of Medication Management
Ultimately, effective medication management is a psychotherapeutic and psychoeducational process. For each patient, this process must evolve from the earliest stages of acute treatment, when patients are mostly symptomatic and the goal is to find something that works, to the later stages of treatment, when patients are better and the objective is to maintain stability or perhaps focus on recovery of function.
Throughout the course of treatment, if a patient does not think the medication is effective, he or she will communicate this to the clinician in some way, either overtly or covertly. Patients have beliefs, opinions, perspectives, and expectations about medications that should be recognized and respected. Each patient also has his or her own repository of medication facts, fantasies, and fallacies, which may be derived from family, friends, and neighbors; television and other popular media; other health care practitioners; and/or a multitude of Internet resources. The only way of knowing what patients think and why is to listen to them and recognize that what they think about taking medications may change over time. It would be especially wise to ask whether a friend or family member has had a particular drug(s) prescribed and whether they have perceived bad outcomes.
Understanding patients’ expectations for taking medication is a central component of effective medication management. Not surprisingly, what patients expect during acute treatment may be different from what they expect when they are feeling well again. Unrealistic or misguided expectations throughout treatment should be addressed in such a way that the patient is not demoralized. During acute treatment, helping patients to be patient with medication therapy—giving it time to work and avoiding changes too quickly or too often—requires appropriate and consistent support, with practical advice on coping skills and ancillary resources. During the maintenance phase of treatment, the focus usually shifts to monitoring for signs of relapse, managing long-term side effects, discussing whether the patient should stay on the medication and why, and when necessary, facilitating social and vocational recovery. Medication nonadherence throughout treatment should be addressed by seeking the underlying reasons and working with the patient to address the issue.
For a significant minority of patients, maximum benefit is achieved with less-than-optimal effectiveness, despite multiple trials of various medications or medication combinations. Although there might always be something new to try, it is important to recognize when and why more medications or more medication changes are likely to be futile, and to help patients understand and accept that their current progress might be “as good as it gets” without giving up and dropping out of treatment. Maintaining a reasonably acceptable medication regimen should be supplemented with other interventions, including psychosocial therapeutic or rehabilitative programs, lifestyle changes, exercise, and other nonpharmacological strategies.
Effectively prescribing medications broadly encompasses gaining a mastery of drug knowledge, learning the nuts and bolts of treatment with medication, and appreciating the fundamental importance of psychotherapeutic and psychoeducational processes in medication management. Nurses have an essential role in providing effective medication management, given their direct level of patient contact and their collaborative relationship with physicians.
- Howland, R.H. (2007). Medication adherence. Journal of Psychosocial Nursing and Mental Health Services, 45(9), 15–19.