The issue of non-doctor prescription of medicines has not been studied enough and to our knowledge an article focusing on the prescription of medicines by medical students in particular has never been published. However there has been tremendous research on the issue of self medication which in many ways has similar implications as non-doctor prescription of medicines. However, we consider the inappropriate prescription of medicines to others as the 'bigger evil'. It puts others and society in a greater danger than self medication alone. The following discussion focuses on the prescription of medicines by non-doctors, particularly medical students. As no similar study was found in this regard it was not possible to comment upon the practices in other parts of the world.
It was very distressing to find out that every other medical student had independently prescribed medicines to someone. We had expected that a large number would be doing so but the fact that so many of them were doing it was surprising. This implies that thousands of medical students are prescribing medicines in Karachi alone. We doubt that the rates would be much different in other parts of the country however, this needs to be studied. It was overwhelming to find that non-medical students, those with an even lesser amount of knowledge regarding the complex nature of drugs, were prescribing medicines at an equal rate also. This shows that the total number of non-qualified people prescribing medicines in Pakistan, and most probably in this region, is tremendously high. This is a very serious issue.
Prescription of medicines by non-doctors is an issue of grave concern and similar to self medication it can lead to a multitude of problems including the global emergence of Multi- Drug Resistant pathogens [9], drug dependence and addiction [10], masking of malignant and potentially fatal diseases [11], hazard of misdiagnosis[12], problems relating to over and under dosaging [13], drug interactions [14] and tragedies relating to the side effect profile of specific drugs[15].
In our study the most common medicines prescribed were analgesics, antipyretics, anti-allergics and antibiotics. This can have serious implications to the individual in the form of masking of serious illnesses by analgesics and antipyretics. It could also lead to devastating effects on society especially if resilient endemic infectious diseases such as tuberculosis are harbored and treatment is delayed while symptoms are controlled by inappropriate medicines.
The issue of anti microbial resistance is one of the greatest challenges of modern times [16]. Much research and effort has been done to limit this growing menace [17]. Drug resistance is known to develop when antibiotics are taken in inappropriate doses or for inappropriate lengths of time [17]. It can also develop if the choice of antibiotics in inappropriate [17]. This study has shown that medical students prescribe antibiotics 3.5 times more than non-medical students and it has been previously demonstrated that medical students are not skilled enough to make the appropriate choice [8]. There is no doubt that non-medical students are also not knowledgeable enough to prescribe antibiotics. In this era of globalization, where intercontinental travel is rampant, the development of anti-microbial resistance in one city can have devastating effects all around the world. Hence this is not only a local concern but is an issue of great international importance.
The great respect that exists for medical professionals in society has given a helping hand to this issue. Many of our respondents stated that they would follow the advice of a medical student without consulting a doctor and many more of them said that it is alright for medical students to diagnose and treat illnesses. Our sample was derived from a highly educated slice of society and if this is what they think then it is very disturbing to imagine what the uneducated 70% of the population thinks about this. This should be a topic for further research.
There is no doubt in the fact that the issue of illegal drug prescription is a major concern and should not be neglected anymore. This situation needs to be stopped before it escalates into an insurmountable feat. A holistic multidisciplinary approach should be taken to combat this growing hidden problem. Based on the findings of our study and that of previous studies we propose four areas of intervention that should be studied and implemented as soon as possible.
First of all strict rules and regulations need to be put in place to prevent pharmacy shop owners from selling non-over the counter drugs without a doctors prescription. This is a common feature in many developing countries[6] and should not be neglected anymore. It has been shown that easy access to pharmaceuticals is a determinant for self medication [4]. Why pharmacists do not adhere to the rules should be researched further as there is paucity of literature in this regard. However, it is widely known that In Pakistan the records of pharmacy shop owners are never checked. It is up to the pharmacies own sense of ethical practice whether to sells drugs on a prescription only basis or not. Considering the fact that more sales would lead to a greater profit and in a developing country like Pakistan where the earnings by the common man are already so low and competition with other similar stores is so fierce no one would willingly give up a huge bulk of their profit. The problem is that even if they do follow the rules, the pharmacist a few shops away from them is not and thus all the customers will go to him as a matter of convenience. Another problem is that many pharmacies are not registered and thus definitely not regulated [18]. Majority of the people do not even know whether the pharmacy they go to is licensed or not [19]. A system of checks and balances should be made and brought into practice in order to ensure adequate implementation of the rules.
Secondly, there needs to be a system of similar rules and regulations to prevent robust advertising by pharmaceutical companies of their products. This includes aggressive advertising and un-ethical marketing. At present there are many weaknesses in the drug policies of Pakistan, ranging from weaknesses in the legislation to inadequate implementation of the law leading to unchecked marketing practices and the production of substandard and spurious medicines [18]. Even though direct to consumer advertising is prohibited in Pakistan there are lapses in the implementation of this law, which need to be reported and addressed. At present there is no mechanism to monitor the drug promotional campaigns by the pharmaceutical industry in Pakistan [20]. This is important as advertising directly influences the self medication practices of the people. It has been shown that familiarity with medicines leads to higher rates of self medication [4]. In a recent study it was seen that the majority of college students used at least one of the advertised products, without discussing this with their physicians[21].
Thirdly awareness regarding this issue needs to be created. The general public including non-medical students can be approached via awareness programs and/or by the media. They should be told about the serious hazardous consequences of taking medicines without a doctor's approval. For medical students, this issue needs to be addressed in the medical curriculum of medical colleges. Medical ethics should start as early as the first year as it was seen in our study that majority of students who prescribed these medicines belonged to the junior years. Many students thought that it was alright for them to diagnose and treat medical illness without the supervision of a medical doctor. This form of attitude needs to be eliminated. Students should also be taught on how to turn down a person asking for a prescription as majority of medical students said that they were asked to prescribe the medicine and conversely majority of the non-medical students said that they had indeed asked the medical student to prescribe them a drug. The effectiveness of teaching of medical ethics early on is a proven intervention [22] but sadly not many institutions in Pakistan practice this [23].
The removal of the 'barriers to health care' is the fourth intervention we propose. The availability of hassle free quality health care at an affordable price is the right of every individual and this should be protected by the state. In a poor country like Pakistan where it is so difficult to obtain quality health care the common man has no choice but to approach other avenues for the treatment of their problems. A previous study revealed that households with a lower income are more likely to seek alternate avenues for medical treatment[19]. An understanding of the exact reasons as to why people choose alternate sources of medication needs to be further studied [5].
There are a few limitations of this study that need to be taken into account. Firstly the findings of our study were based on data collected by a self reported questionnaire; hence the practices regarding drug prescription were subjectively explored. This could lead to under-reporting of the problem as social desirability bias is a common problem with this type of questionnaires. Objective studies in this regard should be carried out although they would require a great many resources, which was difficult for us to gather. The second limitation of this study lies in the sampling method. Although the sites were representative, we had taken a convenient sample of participants from these sites. This sampling method is inferior to probability sampling in its representativeness to the population. However, we feel that as the size of our sample was large its generalization to other such populations is possible. Even though the findings cannot be as accurate as those of a probability sample, we are confident that they are not far from the true findings.
