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overuse of prescription drugs

The Drugging of America: Deprescribing

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Over the past couple of weeks here at FaM we’ve seen evidence that Americans have been sucked into a vortex of unnecessary prescription and nonprescription drug treatment. About all most of us have heard of this comes from the flap over the spreading addiction to opioids — largely blamed on the habit of prescribing addictive drugs for discomfort that could be handled with over-the-counter or nonaddictive prescription pain-killers. But in fact there is a larger, quieter movement afoot. It’s called deprescribing.

Its purpose is to bring a stop to putting everybody and his little brother and sister on handsful of long-term, sometimes redundant, sometimes conflicting drug therapies.

Deprescribing is “the process of tapering, stopping, discontinuing, or withdrawing drugs.” The goals are to reduce the widespread use of “polypharmacy” — in which a person regularly takes five or more drugs — and to improve health and outcomes for patients who actually do need medication. As polypharmacy has become an international problem afflicting most developed nations, so deprescribing is being taken up worldwide.

The Canadians in particular pursue the issue with some vigor. Two invaluable sites from that country are Deprescribing.org, operated by Dr. Barbara Farrell, a research pharmacist, and Dr. Cara Tannenbaum, a research geriatrician; and the Canadian Deprescribing Network, which explains the issue and what you can do about it in words of one syllable. As the latter site points out, overprescribing affects older people more acutely than younger ones: “…[E]ach year in Canada 1 in 200 seniors are hospitalized due to harmful effects of their medication. Seniors are hospitalized five times more often than people under the age of 65 because of harmful medication effects.” Nevertheless, overuse of medications affects everyone. Women, older men and women, and people with more than one chronic condition are at the greatest risk. The site, on two pages, offers a total of fourteen safety tips for people who have to take prescription drugs:

Track your meds. It’s up to you or your family to keep track of the drugs you are taking. Your medication list is unlikely to be available to all health professionals online! Electronic medical records systems often don’t “talk” to one another.

Keep a list. For your safety, carry your own UPDATED list and keep one on your fridge. Make sure to include over-the-counter (OTC) drugs. Make sure drugs prescribed by specialists that you see are listed.

Stick to one pharmacy. Try to fill prescriptions from one pharmacy so drug interactions are easily checked. Any pharmacy’s list will only show what their pharmacy has dispensed to you and won’t include everything you take.

Don’t start a new drug when you’re alone. It’s rare, but if you have a severe allergic reaction you’ll need immediate help. Never take a prescription drug that was prescribed to someone else.

Check your prescription. When you pick up your prescription order, check both your name and the drug name on the bottle. At times, people who have the same name have received the other person’s drug.

Be aware of side effects and adverse effects. If you have a new symptom after taking a new drug, don’t assume it’s a “new condition” or “old age”. Tell your doctor or pharmacist right away. It could be adverse effects from the drug itself or an interaction with another drug you already take.

Beware of the prescription cascade. Sometimes new drugs might be prescribed to deal with symptoms caused by a drug you are already taking. This is called the “prescription cascade” – a common example is being prescribed a new drug for stomach upset, which may be caused by a drug you are already taking. Ask your doctor to consider whether new symptoms could be the result of the drugs and whether you should consider stopping a medication or reducing the dose, also known as deprescribing.

Look out for changes. Tell your doctor how new drugs affect you and whether there’s been a change for better or worse. Doctors may be depending on you to report and may not be actively monitoring the effects. If you SEE something (or feel something), SAY something (just like at the airport!). You do not have to be “right” in order to bring forward concerns about adverse reactions from a drug.

Seniors are more sensitive to medications. Older people are more sensitive to medications because of changes in their liver and kidney function as they age. In many cases, drugs for seniors should be prescribed at a reduced dose. The more medications used, the greater the chance of drug interactions.  Drugs commonly prescribed to older adults can cause dizziness and loss of balance, leading to falls or fractures and hospitalization, as well as cognitive and memory problems. Adverse drug reactions can start even if you have been taking a drug for a long time. Your doctor depends on you to raise issues of concern and to begin to talk about deprescribing some drugs: www.deprescribingnetwork.ca/starting-a-conversation

Ask for a medication review. Ask your doctor or pharmacist to review all your medications, especially if you are taking several or if different doctors prescribed them. This means reviewing your complete medication list to make sure all are needed and not causing problems as you grow older. List drugs prescribed by specialists and over the counter drugs too. Often, doctors are able to give you an appointment that is longer than the usual 10 minutes to have a consultation about your medications. It is up to you to ask for a review of your medication: don’t assume that your drugs will be reviewed on an annual basis. Remember to ask your doctor if you can either stop taking some medications or lower the doses of others as a result of the medication review.

Medication issues in nursing home settings need to be addressed quickly. In a nursing home setting, get answers quickly if you have concerns about your medications or a family member’s. Patients can lose function and mobility if bedridden from a drug interaction. Delirium (a reversible state of disorientation, agitation or drowsiness) or unusual behaviour can be caused by medications and it may be mistaken for a serious chronic illness such as dementia. Alert your family members and be prepared to go, with your family, to management, if you have serious concerns or can’t get an answer. If you feel anxious bringing up medication issues, ask a family member to make an appointment with nursing home staff and have them accompany you.

Avoid anticholinergic drugs.* Older adults are often prescribed anticholinergic medications (medicines that affect acetylcholine, a neurotransmitter) for common conditions such as overactive bladder, allergies, gastrointestinal problems, Parkinson’s and depression. Seniors are highly sensitive to the harmful effects of anticholinergic drugs. These drugs can have a negative impact on the brain by causing delirium, confusion and memory problems as well as physical effects such as dry mouth, constipation and blurred vision. Recent research is exploring whether these drugs have a role in dementia. While this link is still being explored, seniors should avoid these drugs whenever possible or ask for a safer alternative.

Ask questions and be wary. When your doctor suggests a new drug, you have the right to ask what the drug is for, what its benefits are and the risks of harm. Is the drug being prescribed for prevention? How likely is it that you would become ill in the future if you didn’t take it? Could the side effects outweigh any benefit the drug may have? It may not be worthwhile feeling unwell every day because of a drug to gain a small chance of having a little less risk of future illness.

Ask if deprescribing is appropriate for you. If a drug is bothering you, ask your doctor or pharmacist about the possibility of a “drug holiday” or a trial of stopping or tapering the drug and carefully monitoring the results. It is reasonable to see if a drug is causing problems if it is not a life-saving drug. You may find more information here.

* Anticholinergic drugs include a wide variety of commonly prescribed and over-the-counter nostrums, among them Benadryl, Dramamine, Advil PM, tricyclic antidepressants, and a variety of smoking cessation drugs.

A major problem with trying to get off one or more drugs is that many medications — both over-the-counter and prescription — can cause uncomfortable and sometimes dangerous kickbacks if you stop taking the stuff abruptly. For this reason, you need to talk with a pharmacist and, ideally, with your doctor about tapering off the drugs you’re taking, or stopping altogether.

Getting people off these drugs can be a complicated matter. Some sites that provide potentially useful information hide that information behind paywalls or demand private data and an e-mail address in exchange for access. Criteria for limiting drug use and helping people ease off  drugs can be challenging. The STOPP-START set of criteria, for example, is extremely complex. However, unlike the 2003 Beers criteria, the STOPP-START criteria list medications that have been shown to have significant adverse effects, and the STOPP-START approach has been shown to improve outcomes.

The American Geriatric Society offers updated Beers drug guidelines in relatively easy-to-access table form. Note than many of these drugs are readily available over the counter: Benadryl and its generic versions, for example. Proton pump inhibitors? Those are the pills you take for real or supposed GERD: omeprazole, for example. Some people will drop one of these drugs for ordinary indigestion, easily amenable to a couple of Rolaids. Estrogen? Mercifully doctors have stopped trying to put every middle-aged woman in the country on that stuff, but it still is frequently prescribed for any number of real or imagined ailments. Run your eyes down the list and you come to aspirin, ibuprofen, naproxen, famotidine, pseudoephedrine (Sudafed)…holy sh!t!!! In the U.S., any of us can buy any or all of these drugs at any time, with no advice or feedback from a doctor or a pharmacist. So, even if your doctors are not guilty of piling med on top of med, you yourself could inflict any number of potentially dangerous individual drugs or combinations of drugs upon yourself.

Two useful tools  for consumers are Medstopper, a Web-based program that disgorges guidelines for quitting specific drugs, and Worst Pills, Best Pills, which exists both as a Website and as indispensable reference work.

So what can each of us do about this state of affairs?

  • First, and most obvious: question authority. When a doctor wants to put you on some drug now and evermore, look it up. Learn all you can about the diagnosed condition, about all the approaches to treatment, and about the available medications. Seek a second or even a third opinion before agreeing to go on a medication for the long term.
  • Second, choose a pharmacy and have all your prescriptions filled there. This will create a single file listing all the prescription drugs you’re taking in one place, accessible by a specialist in pharmaceuticals.
  • Third, ask. When filling a new prescription, always ask the pharmacist (not the pharmacist’s assistant: the actual pharmacist, who has an advanced degree in the subject) how it will fit with your existing prescriptions and with any over-the-counter drugs you have around the house. Ask whether it is incompatible or redundant with any OTC drugs.
  • Fourth, keep your own list of all the drugs you’re taking (Rx and OTC) . Carry it in your wallet, so that if you’re ever in an accident or have an acute attack that sends you to the emergency room, medical personnel can find it easily.
  • Fifth, unless a condition is life-threatening, don’t be in such a hurry to swat it with a drug. Most ailments go away on their own. Most aches and pains resolve themselves in time or improve more effectively with physical therapy than with drugs. Tincture of time is often the best medicine.
  • Assume any new symptom or strange health manifestation that develops after you start taking a drug may be a side effect. Look it up.
  • Sixth, ease off as many drugs as you can. You may find you don’t actually need them, or other approaches with less malign side effects may work as well. Educate yourself about the issue in general and about ways to get off any unnecessary drugs.
  • Finally, take care of yourself. As a matter of fact, you are the only person who can take care of yourself. Eat healthy. Kick the nicotine habit. Drink in (extreme) moderation. Get regular exercise. None of this is hard…but it’s the best treatment you can apply.

This is the sixth of seven planned posts on
The Drugging of America

 

The Drugging of America: Overprescription

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The other day I said I would address the issue of overmedication, and in particular the amazing overuse of anti-hypertensive drugs. Turns out this is a major problem, especially among older Americans and women. In 2017, a quarter of Americans between 65 and 69 were taking at least five prescription drugs for chronic conditions. Between the ages of 70 and 79, that figure rises to nearly half the population. This phenomenon is called “polypharmacy”: the use of five or more drugs.

And it’s not restricted to the elderly. By 2013, the Mayo Clinic reported that 70 percent of Americans were taking one or more prescription drugs, and 20 percent were on five or more prescriptions.

This doesn’t include over-the-counter nostrums, many of which are real, active pharmaceuticals. If you count the pills you can buy off the shelf at your local Walgreen’s, no prescription asked, those figures are undoubtedly much higher.

Overall, women and the elderly are the most over-prescribed. Nearly 1 in 4 women between the ages of 50 and 64 are on antidepressants, according to the Mayo study. Researchers estimate that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. Doctors say it is not uncommon to encounter patients taking more than 20 drugs to treat acid reflux, heart disease, depression or insomnia, and other disorders.

The medicating of America has been increasing at a fast clip. The Mayo study reports, “The percentage of people who took at least one prescription drug in the past month increased from 44 percent in 1999-2000 to 48 percent in 2007-08.” By 2009, spending on prescription drugs had reached $250 billion: 12 percent of total personal health spending in this country.

And folks: that was eight years ago. This abuse has been growing exponentially for decades.

Many of these drugs are inappropriate or ineffective. So many, in fact, that there’s a name for such misuse: PIM, for “potentially inappropriate medication.”

Why should you care?

Because polypharmacy can harm your long-term physical and mental health. It ups the risk of drug duplication, drug interactions, and adverse drug reactions. Research has shown that medication use may be associated with poor functioning and impaired mental capacity among both younger and older people, and side effects of these drugs affect people of all ages.

“Polypharmacy may be problematic for a number of reasons,” says a report in the Journals of Gerontology. “For example it may increase the risk of using potentially inappropriate medications (PIMs) (,), which have been associated with negative effects on long-term physical and cognitive functioning (). Polypharmacy also results in medication nonadherence (,), increased risk of drug duplication, drug–drug interactions () and adverse drug reactions (ADRs) (,,), and higher health care costs (,,). Researchers have also found that medication use may be associated with poor functional status and decreased cognitive capacity among older adults.”

Often one pill leads to another pill leads to another pill. As The Washington Post describes the process:

At least 15 percent of seniors seeking care annually from doctors or hospitals have suffered a medication problem; in half of these cases, the problem is believed to be potentially preventable. Studies have linked polypharmacy to unnecessary death. Older patients, who have greater difficulty metabolizing medicines, are more likely to suffer dizziness, confusion and falls. And the side effects of drugs are frequently misinterpreted as a new problem, triggering more prescriptions, a process known as a prescribing cascade.

The glide path to overuse can be gradual: A patient taking a drug to lower blood pressure develops swollen ankles, so a doctor prescribes a diuretic. The diuretic causes a potassium deficiency, resulting in a medicine to treat low potassium. But that triggers nausea, which is treated with another drug, which causes confusion, which in turn is treated with more medication.

For many patients, problems arise when they are discharged from the hospital on a host of new medications, layered on top of old ones.

Why is this happening?

Almost certainly because of aggressive marketing by Big Pharma to the public (“Ask your doctor about…”) and directly to doctors. As you can imagine, the profit motive here is vast. With the Baby Boom evolving toward a Geezer Boom, we’re looking at potential profits of many billions of dollars. If we’re at $250 billion now, just imagine what these companies can make in the next few years if every Baby Boomer in the country is gulping down upwards of five meds — every day!

Doctors, being human, are as vulnerable to effective marketing and propaganda as the rest of us. Often they do not have time or energy to read journals that report these issues and that may clue them to PIMs — they rely on journal editors to sift the reliable from the unreliable (not necessarily a safe assumption). They often read only a study’s abstract, which may be inconsistent with the data reported in the article.

Pharmaceutical companies spend billions each year to promote their products, but little is said when drugs prove to be harmful or useless. Thus a doctor may not learn that a drug she or he has been prescribing has been found to be less than desirable for patients.

The Australasian Journal of Medicine observed:

It is telling that drug companies are spending billions every year promoting their products. It is also notable that many new drugs are withdrawn within a very short time of their launch. Worryingly, there is sometimes a relative lack of urgency when a drug is clearly shown to be harming patients. For example 19.8 million patients were prescribed five questionable drugs before action was taken to remove them from the market. This included painkillers, anti-histamines, drugs used to treat obesity and anti-hypertensive drugs. Not one of these were lifesaving nor, in many cases, were they the only drugs available for that indication. In another case physicians prescribed a new painkiller to 2.5 million patients with acute pain, even though many well-tested similar drugs were available and the drug was known to elevate liver enzymes. Similarly the rationale for not withdrawing an anti-histamine from the market as soon as researchers clearly identified it as causing deaths has not been explained. It is surprising that the drug was not removed from the market when the adverse effects were identified, but only after the manufacturer had developed a new product to substitute for it.

Medical and biosciences journals publish more than an article a minute. Even if a practicing physician could keep up with that torrent, much of what goes to print leaves a lot to be desired: “. . .only 5% of published papers reached minimum standards of scientific soundness and clinical relevance, and in most journals the figure was less than 1%.”

Much of this material, even though it appears in often-cited journals, is low in quality and ends up being retracted:

In the period from 2000–2010 a total of 788 papers have been retracted, i.e. expunged from the public record. Approximately three-quarters of these papers had been withdrawn because of a serious error; the rest of the retractions were attributed to fraud (data fabrication or falsification). The fakes were more likely to appear in leading publications with a high “impact factor”. The impact factor is a proxy measure of how often research is cited in other peer reviewed journals. More than half (53%) of the faked research papers had been written by a first author who was a “repeat offender”. This was the case in only one in five (18%) of the erroneous papers. At about the same time it was estimated that the number of articles published between 1950 and 2004 that ought to be retracted should have been as many as 100,000 and at least 10,000. The authors further conclude that although high impact journals tend to have fewer undetected flawed articles than their lower-impact peers, even the most vigilant journals potentially host papers that should be retracted.

And scientific publishing is itself a profit-making enterprise. At the least, any scholarly publication must find funding to support its existence, even if it doesn’t generate a profit for the institution that produces it. Hence, sponsorship by pharmaceutical companies and related interests.

Doctors themselves distrust both Big Pharma and many of the research journals that should provide the basis for an evidence-based practice. A discussion forum for medical doctors addressed this issue. Said one commenter, who writes as “Swank Dieter,”

Those who do not read the journals are uninformed. Those who do read them are misinformed. Personally, I do not trust any article that appears in a journal that takes drug company advertising.

An oncologist signing himself as “Dr. Dave” remarks,

Even when I have to come up with crap to feed the insatiable hunger of my residents or Fellowship students I still rarely read the journals cover to cover or worse even the abstracts.

Time is the issue PLUS the quality of the articles has decreased so drastically in 40 years it takes too much time to read the article THEN sit down with paper and pen to decide if the actual stats are valid or if they were slightly nudged to make the outcome fit the title or sponsor.

There used to be a time where if it was written in a prominent journal it was as good as factual but today that assumption is SO inaccurate it is pathetic.
I can remember rounding with my mentor and being grilled on some nonsensical topic and if I was lucky enough to recall a JNEM article or JAMA article I was off the hook since they were bulletproof.

Now if a kid gives me ANY article as support my standardized reply is did you review the details of the article and are you SURE the statistics are actually proper and not sheer modification?

This is not just an American problem. Polypharmacy is a global issue among developed countries. QJM, a respected international journal of internal medicine, reports that in the UK adults over 65 consume a mean of two drugs a day, increasing to 2.5 at age 75. In Northern Italy, over-75s take a mean of 3.5 drugs a day, and in Denmark, four drugs a day. In Europe as in America, more women than men are targeted to take prescribed drugs.

In the UK, QJM continues, 10 percent of over-65s living in the community (as opposed to an institution) take five or more drugs a day, rising to 15 percent among people 75 and older. Yet this is as nothing compared to rates in the United States: as many as 40 percent of Americans over 65 consume five or more drugs a day. This number rises to six to eight drugs a day among those locked up in nursing homes!

So there you have an overview. The problem extends way beyond the so-called “opioid epidemic,” which is a manifestation of this issue. It touches not just people who have become addicted to prescription and street drugs — in some cases as a result of medical treatment. Excessive medication with prescription and nonprescription drugs affects all of us, and the practice is growing.

As I said the other day, the issue is too  large to cover in one post. So, in coming days I’ll address a few other matters:

Watch this space!