Social pharmacology and diabetes.

Dear Madam,

We appreciate the comprehensive review article Social Pharmacology: Expanding horizons, which explores the complex concepts which merge together to form this subspecialty of clinical pharmacology.[1]

Social pharmacology is central to pharmacotherapeutics in chronic disease, especially diabetes mellitus. While newer drugs have been developed to address the various pathophysiological defects in diabetes, their availability has not necessarily meant automatic accessibility or acceptance. Neither has this translated into improved glycemic control at a public health level. The reasons for this can be analyzed by the discipline of social pharmacology.

Psychosociocultural factors play an important role in influencing acceptance of, and adherence to chronic therapy, especially injectable drugs.[2] An understanding of these factors is key to encourage persons with diabetes to join health care professionals in a successful ‘therapeutic alliance’. Appropriate rational therapy to achieve targets and goals, decided through a process of shared decision making, can be instituted only if the patient is motivated. A person- centered framework, therefore, should be used to describe social pharmacology, instead of the drug- centered model proposed by Maiti and Alloza.[1]

Social pharmacology should also include the study of motivational skills, which are necessary to ensure optimal drug usage. We propose the 3I strategy (Inform- Incubate-Initiate) to encourage use of injectable therapy including insulin and glucagon-like peptide 1 receptor agonists (GLP1RA) in diabetes. This approach is based upon Prochaska's therapy of motivation which proposes that one must move from pre-contemplation to contemplation (that is, incubation), before action (initiation) can take place.[3] For example: Initiation of insulin in a diabetic patient, who is uncontrolled on diabetes. A patient may not readily accept the advice for insulin initiation instantly, if he is not acutely ill or severely symptomatic. Such patients can be informed regarding need for insulin for glycaemic control, postponed till the next visit. This moves them from pre-contemplation (No thought for insulin therapy) phase to contemplation phase (thoughts for insulin therapy), which we call the incubation period. Such patients while trying their maximum effort for glycaemic control, also gets ready for insulin, if their glucose control is not good at the next visit. The initiation of insulin then becomes easier, and the relapse rates (moving back to oral anti-diabetic agents) decreases.

Social pharmacology must involve family and community as well, as these are important stakeholders in diabetes care.[4] The need for well-made educational materials for persons with diabetes and their family members is also covered in this field.

Social pharmacology, already a well-developed field,[1] can be further strengthened by involving diabetes care professionals, people with diabetes, and their family members. The Indian Journal of Pharmacology should be appreciated for providing a platform to achieve better utilization of available drugs using validated socio-pharmacological approaches.