Chapter 1 Medicines in society today and tomorrow

Medicines have an impact on the lives of people of all ages. In the main, the impact is beneficial, enhancing lifestyles and prolonging, and often saving, lives. However, in developing countries neither the benefits nor the hazards of modern drug therapy are experienced. Thanks to the innovative work of the global pharmaceutical industry, prescribers and their patients have access to a range of effective drugs and delivery systems that could scarcely be imagined when the NHS was established in 1948. The therapeutic explosion comes, however, with a hefty price tag for both the industry and the consumer. In developing a new drug, thousands of compounds are screened for therapeutic activity and safety. To bring a new drug to the market requires massive expenditure over a period of many years. The importance of the research and development effort involved to the global economy is vast. Pharmaceutical companies target their research efforts to those therapeutic areas in which the returns are likely to be profitable. One major drug can generate sales of billions of pounds per annum. The problem of research priorities remains unresolved, but the ultimate aim is to develop medicines designed to meet the needs of individual patients. Few resources can be diverted to finding treatments for very rare diseases, because of the low returns (profits) generated. Orphan drugs need to be adopted. Prescription medicines are vitally important, but it should not be forgotten that over-the-counter medicines play an important role in self-care, thus releasing resources for the NHS. By making some potent medicines available without prescription, access to medicines has been improved for those who can afford them. It is important that this deregulation is carried out within carefully defined conditions. Medicines are not just commodities; they are potent therapeutic agents that should be treated with the respect they merit.

Despite the progress made in the development of new drugs, massive problems remain, especially in addressing the needs of the developing world. New pandemics threaten the world, in particular avian influenza. The availability of effective antiviral drugs and new vaccines should not cause complacency. In confronting the unmet needs in the treatment of cancer, the AIDS crisis, tuberculosis, tropical diseases, Alzheimer’s disease, respiratory and cardiovascular diseases, and diabetes, innovative global research programs will be required. The problems of resistance to antibiotic therapy, especially in hospitals, require constant vigilance, as does the need to reduce the side-effects of drug treatment.

Not only will appropriate drug treatment make people feel better, but also links between ill health and poverty will, in time, be broken. In the UK and other countries, drug costs have long been a cause for concern for politicians. There are no signs that the financial and other tensions created by the introduction of new drugs will abate. In some ways, this is to be welcomed because it is a sign that there is a dynamic research environment producing valuable drugs. The establishment of bodies charged with the assessment of new drugs (the National Institute for Health and Clinical Excellence) has brought into sharp focus the need to manage the introduction of new drugs on an equitable basis. ‘Postcode prescribing’ is an evil that must be eliminated.

Controversy will always be associated with the development and introduction of new drugs. The actions of the pharmaceutical companies in aggressive marketing, price fixing, profiteering (alleged), and the use of uninformed human volunteers and laboratory animals in drug testing are often criticised (and worse). It is beyond any doubt that the benefits of modern drugs in both the treatment and the prevention of disease are here to stay. Safety issues relating to the introduction of new drugs remain a cause for concern, as recent events relating to the withdrawal of rofecoxib illustrate. There are real possibilities that some drugs may be replaced by treatments such as stem cells (regenerative medicine), organ transplantation, and even using organs grown in the laboratory. In time, the present research methods, like some of our drugs, will become redundant. Several important drugs in use today are derived from plants. This source of effective medicines is by no means exhausted.

Information technology will play an even more important role in both the discovery and the manage-ment of medicines. Electronic prescribing, automation and improved communications will all help to ensure that the benefits of modern drug therapy will be available to more people than ever before. Evidence-based prescribing decisions are increasingly being supported by IT. Delays in introducing an NHS-wide IT system are currently a cause for concern, as are the escalating costs of the system.

Healthcare professionals are adapting their practice to meet the higher expectations of patients and those who pay for health services. Greater specialisation, increased responsibilities and improved joint working will all develop in the years ahead. Along with these increased responsibilities (such as prescribing) will go the need for continuing professional development, further education and participation in research programmes. The need to maintain the highest professional, ethical standards during times of great change both in society and in the clinical environment cannot be overemphasised. Worries about possible litigation should be responded to by ensuring com-pliance with current standards and being aware of the need to be accountable for one’s actions. Ethical dilemmas such as the issue of assisted dying may arise in the context of drug therapy. As the boundaries of practice expand, ethical issues will be ever present. In the 1990s, a policy decision by the Crown Prosecution Service has led to an increasing number of doctors being prosecuted for gross negligence or recklessness at work.

Since the publication of the Shipman report (2005), GPs in small practices have expressed their concerns regarding the administration of powerful narcotics to patients in terminal care. If the ‘Shipman effect’ has an adverse impact on patient care, this is to be deplored.

There is more attention given in the media to issues relating to drug use (legal and otherwise) than ever before. Bad news is reported more often than good. Newspapers have always been a source of information on drugs and medical research (Fig. 1.1). If the story involves sex, it is more likely to be reported than a story involving the overuse of vitamins.

Fig. 1.1 Medicines are in the news almost every day.

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