Coffee heat rising

The Drugging of America: Deprescribing

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, 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:

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