The Ethics of Overprescription

Image Citation: [1]

Written by Pratham Rao ‘27

Edited by Yumiko Imai ‘26

Did you know that in 2018, the Infectious Disease Society of America discovered that 46% of 500,000 outpatient antibiotic prescriptions were prescribed by the physician without a diagnosis of infection [2]? This statistic is a glimpse into a very prevalent issue in our healthcare system today: overprescription, and how it relates to patient safety and patient prioritization.

Patients requesting medications and clinicians simply agreeing to them increases the number of concurrent medications they take and also the risk of adverse effects that they experience. Dr. Satya Verma, member of the American Optometric Association (AOA) Ethics and Values Committee, described the current moment as “an explosion of medication overload,” in which during 2018, 42% of adults over the age of 65 are consuming 5 or more concurrent medications, leading to adverse drug events. Furthermore, according to the CDC’s Morbidity and Mortality Weekly Report in 2009, $10.7 billion was spent on antibiotic therapy, equivalent to the U.S economy spending $20 billion in direct health care costs and $35 billion in lost productivity [3]. In the 16 years since this study was conducted, these numbers have likely increased, making the issue even more pressing. Depending on the class of medication being overprescribed, there could be serious consequences for patients constantly intaking new prescriptions, possibly leading to death.

Dr. Daniel J. Safer of the Psychiatry and Pediatrics department in the Johns Hopkins School of Medicine noted in his study that overprescribing was most common in older adults and was related to long-term medication treatment. The four major classes of drugs explored were opioids, Levothyroxine (for subclinical hypothyroidism), antidepressants, and proton pump inhibitors (PPIs) [3]. The main findings were that these drug classes were often overprescribed and caused adverse effects due to adult misuse, broader criterias for prescriptions, withdrawal symptoms, and being the most common primary-care physician prescriptions. If patients are essentially getting an unlimited source of medications through their physicians and don’t have a significant form of resistance to their prescriptions, then should physicians have an increased control in the patient-physician relationship? Also, to what extent should physicians have control in refusing patient requests?

In a study with 271 patients conducted by Dr. Alexia M. Torke and other researchers, 73% practiced healthcare with their own preference being the most important ethical standard. However, it is interesting to note that physicians tended to base their decisions based on patient preferences less when the patient was older, and more when the patient was in the ICU. [4]

This seems to contradict Dr. Safer’s work, but there is an explanation that could combine both of these findings.

Patients that are older in age tend to have more health related issues, and often have an increased need to use more than one patient simultaneously. This is referred to as polypharmacy, or “the simultaneous use of multiple drugs to treat a combination of health conditions”[5]. The kidneys and liver tend to decline in peak function as we get older, and since they are responsible for excreting drugs, there is an increased chance that older patients experience adverse effects due to polypharmacy [5]. Due to the medical conditions of some of these patients, physicians are likely prescribing these medications to take simultaneously as the patient is incapable of making the decision best for their health and the physician feels that the effects of multiple drugs outweighs the risks. Additionally, a single patient may see multiple specialists  which could result in an internal clash between physicians to agree with their colleagues or advocate for something different that they believe to be more effective.

For patients that don’t fall under this demographic, how much say should they have when requesting medications? According to the American College of Physicians Ethics Manual, “the physician's primary commitment must always be to the patient's welfare and best interests, whether in preventing or treating illness or helping patients to cope with illness, disability, and death [6].” By this definition, the physician has the right to intervene and tell patients that they do not need another medication added to their prescription list if there are possible side-effects during consumption. In reality, especially in current times, this right has turned into suggesting what they think is best for their patients, but not necessarily making any definitive choices for them.

Patients deserve to have a voice in their healthcare decisions, especially because it is concerning their bodies and lives. However, the current data suggests that physicians should be more conservative and stubborn in prescribing medications to patients, and should allow polypharmacy to occur only when it is absolutely required or for short periods of time to test patient response. There should be an explicit adherence for prescribing based on the severity of symptoms and how many symptoms the patients are going through, not merely by patient pressure and loose display of symptoms. The National Institute of Drug Abuse suggests that “evidence-based screening tools for nonmedical use of prescription drugs can be incorporated into routine medical visits” and physician recognition that patients may “doctor shop,” or switch physicians to obtain medications/drugs, in orders to decrease overprescribing. [7]

Overall, through the prioritization of patient demands and requests, physicians could be contributing to worse patient safety and measures need to be taken to combat overprescription, polypharmacy, and drug overuse. There needs to be a better balance between physician authority and patient authority to reduce overprescription.

References

1. cwadmin. How Health Care Providers Can Help End the Overprescription of Opioids - October 27, 2017 - USC Schaeffer [Internet]. USC Schaeffer. 2017 [cited 2025 Apr 28]. Available from: https://schaeffer.usc.edu/research/how-health-care-providers-can-help-end-the-overprescription-of-opioids/

2. Do no harm: A case study on overprescribing [Internet]. www.aoa.org. Available from: https://www.aoa.org/news/clinical-eye-care/public-health/case-study-on-overprescribing

3. Safer DJ. Overprescribed Medications for US Adults: Four Major Examples. Journal of Clinical Medicine Research [Internet]. 2019 Sep 1;11(9):617–22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731049/

4. Torke AM, Moloney R, Siegler M, Abalos A, Alexander GC. Physicians’ Views on the Importance of Patient Preferences in Surrogate Decision-Making. Journal of the American Geriatrics Society. 2010 Feb 11;58(3):533–8.

5. 7 Reasons Older Adults Are at Risk for Drug-Related Problems» Online Graduate Programs in Gerontology» College of Medicine» University of Florida [Internet]. Available from: https://online.aging.ufl.edu/2023/11/20/7-reasons-older-adults-are-at-risk-for-drug-related-problems/

6. Sulmasy LS, Bledsoe TA. American College of Physicians Ethics Manual. Annals of Internal Medicine [Internet]. 2019 Jan 15;170(2_Supplement):S1. Available from: https://annals.org/aim/fullarticle/2720883/american-college-physicians-ethics-manual-seventh-edition?_ga=2.104538688.1925068372.1560009571-170876438.1560009571#208346129

7. National Institute on Drug Abuse. How can prescription drug misuse be prevented? [Internet]. National Institute on Drug Abuse. 2020. Available from: https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented