Drug utilization review of analgesics in the management of pain in accordance with the South African Standard Treatment Guidelines at a hospital level in Limpopo, South Africa.

Abstract

Background One of the aims of the National Drug Policy (NDP) of South Africa was to promote the rational use of medicines and to achieve this goal, the Essential Medicines Programme (formerly EMP), which included an Essential Medicines List (EML) and Standard Treatment Guidelines (STGs), was developed. The STGs offer guidance on the rational use of medicines for the most common conditions including pain management. A perceived marked increase in the use of tramadol for pain management requires that research be undertaken to confirm if there is use of tramadol outside of prescribed guidelines, and to determine the contributing factors for this.

Study aim The overall aim of the research was to review the use of analgesics in the management of pain in terms of compliance with STGs by prescribers and to determine the cost implication of failure to follow STGs in pain management for the district hospital. Prescriber awareness and use of the guidelines for pain management and the associated cost implications of nonadherence to guidelines was also assessed. Finally the study sought to ascertain prescriber experience on the misuse of tramadol when treating patients for pain.

Methods This was a quantitative study in which the records of patients admitted and being treated for chronic mild to moderate pain at a district hospital in Limpopo from the 1st of April to the 30th of September 2021 were reviewed to determine whether the Hospital Level Adults STG/EML (2019) was followed when patients commenced with treatment. An Excel spreadsheet was used to record patient demographics; diagnosis; pain medication prescribed; dosage regimen; prescriber post and prescriber compliance with recommended STG. The treatment regimens for pain that were captured included paracetamol; ibuprofen; and tramadol as single prescribed therapies as well as combinations of paracetamol and ibuprofen; paracetamol and tramadol; and a combination of all three, viz. paracetamol, ibuprofen and tramadol. The recorded prescriptions were assessed for compliance in terms of the stepwise process of pain management as outlined in the Hospital Level Adults STG/EML (2019). Descriptive statistics and Excel were used for data analysis. The cost of analgesics was obtained from the Limpopo Province Pharmaceutical Depot (LPPD). A questionnaire was used to determine prescribers’ awareness of STGs, compliance with guidelines for the management of chronic mild to moderate pain, and awareness of the cost implications of non-compliance among prescribers assigned to the general ward for the period of data collection. Full ethical approval was obtained before commencement with the study.

Results A total of 224 prescriptions were recorded for the 6-month period. Patients initiated on paracetamol as first-line treatment for pain were 129 (57.5 %). Nineteen patients (8.5%) were initiated on tramadol and 54 patients (24 %) on paracetamol and tramadol. Patients initiated on paracetamol and ibuprofen were 12 (5.4%); those on ibuprofen were 3 (1.3%) and 7 (3%) were switched between pain regimens. The prescription compliance rate in terms of the stepwise process of pain management as outlined in the STGs/EML was 90.6% and 9.4% were noncompliant. The total cost for both compliant and non-compliant prescriptions was R1128,10. Compliance to STGs when prescribing analgesics as reported by prescribers was 33%. Half of the prescribers (50%) stated that they only follow guidelines occasionally. Only 33% followed STGs when prescribing tramadol although 83% stated that they prescribe paracetamol for pain. All prescribers had encountered tramadol misuse by patients but only 50% monitored patients after the medicine was prescribed. The study found that 67% of prescribers had poor knowledge of the cost implication associated with non-compliance to STG.

Conclusion This study has identified that there is a prescription compliance rate of 90.6% among prescribers in prescribing analgesics according to the STG/EML. There is however still room for improvement because non-compliance to guidelines has cost implications. In the South African setting where there are resource constraints, compliance is critical for the purpose of efficient use of health care resources. There is also a need for educating prescribers on the importance of compliance to guidelines.