Prescriber in the USA

The one hundred ethical drugs most frequently prescribed in the USA in 1974 (J.C. Stokes, 1975) may be divided into three chemical classes ... 

Phenacetin is no longer prescribed in the USA and has been removed from many over-the-counter analgesic combinations. However, it is still present in a number of proprietary analgesics in this country and is in common use in many other parts of the world. The association between the excessive use of analgesic combinations—especially those that contain phenacetin—and the development of renal failure has been recognized for almost 30 years. 

Permission granted by an acceptance authority to supply product or service that does not meet the prescribed requirements. (Note the term waiver is used in the USA and has the same meaning.)... 

Pesticide mutagenic activities are usually ascertained much later than the inception of active use in agriculture and forestry [3]. This is because pesticide-producing companies are not interested in detecting mutagenic affects in their products, and do not conduct the long, expensive, comprehensive research needed to do so. In the best case, they comply with the prescribed health test standards for mutagenic activities in new pesticides - which normally use only three test systems (as is done, for example, in the USA). 

More recently, large databases have been used to estimate the effect of drug co-payment in the USA under different insurance schemes.10 The conclusion reached is that there is a significant interaction effect between the behaviour of demand and prescriber incentives. Thus, larger prescription drug copayments are associated with lower expenditure when the doctor does not share the financial risk of the cost of the drugs (that is, practises in an independent practice association) but this effect is barely perceived in managed care models in which the doctor has incentives for cost containment. 

Lithium is the simplest therapeutic agent for the treatment of depression and has been used for over 100 years—lithium carbonate and citrate were described in the British Pharmacopoeia of 1885. Lithium therapy went through periods when it was in common use, and periods when it was discouraged. Finally, in 1949, J.J.F. Cade reported that lithium carbonate could reverse the symptoms of patients with bipolar disorder (manic-depression), a chronic disorder that affects between 1% and 2% of the population. The disease is characterized by episodic periods of elevated or depressed mood, severely reduces the patients quality of life and dramatically increases their likelihood of committing suicide. Today, it is the standard treatment, often combined with other drugs, for bipolar disorder and is prescribed in over 50% of bipolar disorder patients. It has clearly been shown to reduce the risk of suicide in mood disorder patients, and its socioeconomic impact is considerable—it is estimated to have saved around 9 billion in the USA alone in 1881. 

Adverse reactions include nausea, nervousness, headache, insomnia, anxiety. Sexual dysfunction with loss of libido is a common complaint. Insomnia can be a problem. Urticaria and rashes have been described. Venlafaxine may significantly increase the risk of suicide and is therefore not recommended as a first line treatment of depression. The view that also fluoxetine and other SSRIs can lead to suicide is under debate for quite some time now. In most countries SSRIs are not approved for use in pediatric populations. In the UK and in the USA only fluoxetine can be prescribed for children. 

The example of other health workers in the USA nurse practitioners, physician assistants and optometrists demonstrates that non-medical professionals can be trained to adequately prescribe drugs within their area of expertise. Pilot projects, e.g. in the state of California, with psychologists prescribing psychopharmaceuticals with appropriate training and supervision were successful in that both the patients and supervising physicians were comfortable with the clinical performance of the trainees (De Leon and Wiggins, 1996, p. 226). 

Treatment with a leukotriene-receptor antagonist, particularly montelukast, is widely prescribed, especially by primary care providers. Taken orally, leukotriene-receptor antagonists are easy to use and appear to be used more regularly than inhaled corticosteroids. They are rarely associated with troublesome side effects. Maintenance therapy with a leukotriene antagonist or with cromolyn or nedocromil appears to be roughly as effective as maintenance therapy with theophylline. Because of concerns over the possible long-term toxicity of systemic absorption of inhaled corticosteroids, this maintenance therapy is widely used for treating children in the USA. 

According to a 2007 report by the Centers for Disease Control and Prevention, antidepressant drugs were the most commonly prescribed medications in the USA at the time of the survey. The wisdom of such widespread use of antidepressants is debated. However, it is clear that American physicians have been increasingly inclined to use antidepressants to treat a host of conditions and that patients have been increasingly receptive to their use. 

Mandatory drug product selection on the basis of price is common practice in the USA because third-party payers (insurance companies, health maintenance organizations, etc) enforce money-saving regulations. If outside a managed care organization, the prescriber can sometimes override these controls by writing "dispense as written" on a prescription... 

In the USA, evidence showing that it was ineffective for its intended purpose appeared by the 1950s. However, conclusions based on animal experiments, as well as a major double-blind, controlled clinical trial (18), remained unheeded, partly because prescribing physicians trusted their collegial loyalty more than data that implicitly threw doubt on their practice. 

Note Ivermectin is approved for use in the USA for the treatment of onchocerciasis and strongyloidiasis. See Chapter 66 Rational Prescribing Prescription Writing for comment on the unlabeled use of drugs. 

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