Medicine For People!

December 2015

Four Colors of Pills
"Four colors of pills" by Ragesoss - Own work. Licensed under CC BY-SA 3.0 via Commons.

Overmedication

Contents

  • Are You Taking Too Many Medicines?
  • Here are the questions
  • Here are examples of how these questions might work
  • The Man Who Came Back To Life
  • Four of Five Medications Were Not Needed
  • Fewer Drugs, Longer Life
  • Drugs That Don’t Age Well
  • Penny Wise, Pound Foolish
  • Any Stage of Life
  • Annual Medication Review
  • Facebook
  • Prior Authorization

Are You Taking Too Many Medicines?

Have you noticed that over time, you seem to be taking more and more medicines? Have you started to wonder if you really need all of them?"

You might be interested to know that one doctor has drawn up a set of questions that allow you and your physician to figure that out.This set of questions was drawn up with older people in mind, but it works for people of all ages.

Here are the questions

  1. Is the medication appropriate for someone with your level of health and ability?
  2. Is the medication appropriate for someone in your age group?
  3. Do the possible side effects outweigh the benefit?
  4. Are you experiencing a symptom which could be a side effect of a medication you are taking?
  5. Might there be another drug that is safer or more effective for you?
  6. Is it possible that the medication might be just as effective at a lower dose?

Here are examples of how these questions might work

1. Is the medication appropriate for someone with your level of health and activity?

We give nitrates to reduce angina, which is pain from the heart brought on by activity. If the person subsequently is confined to a wheelchair, they no longer need the nitrates.

If a person develops cancer, the statin they take to prevent heart disease becomes much less important. There is some evidence that higher cholesterol protects against cancer, and trying to prevent a condition that might occur in 10 years makes much less sense when life expectancy is less than 10 years.

2. Is the medication appropriate for someone in your age group?

Certain medications are much more likely to cause adverse effects in older people than they are in younger people.The American Geriatrics Society maintains a list of such medications, called the Beers List.The antihistamine which worked well at age 20 can make it difficult to urinate at age 80.   The blood pressure medication which helped the 50-year-old might make the 80-year-old faint and fall.

3. Do the possible side effects outweigh the benefit?

Many pain medications can become addictive while also losing their effectiveness as time goes on.   Older people seem to last longer if we reduce the number of anti-hypertensive medications they take and we let their blood pressure rise a bit. Similarly, for diabetic people of all ages, we’ve learned that allowing blood sugar levels to be slightly above normal is safer than forcing them to a completely normal level.

4. Are you experiencing a symptom which could be a side effect of a medication you are taking?

Most people are wise to this. One piece of advice: when you read the side effect list that comes from the pharmacy, try not to assume that you’re going to get any of those side effects. You probably won’t. At the same time, keep in mind you could be part of that small percentage that does get the side effect. If you think that’s happening, talk things over with your doctor.

5. Might there be another drug that is safer or more effective for you?

Some of the older and still widely used diuretics for high blood pressure and edema can cause people to lose potassium and magnesium (not good) and to run higher levels of blood sugar and uric acid (also not good). Ramipril and lisinopril are equally effective at lowering blood pressure. We don’t know why, but people seem to live longer when they take ramipril. Similarly, with many other medications we are better off paying attention to overall survival and less to numbers on the page (such as blood pressure) or on the lab report (such as cholesterol).

6. It possible that the medication might be just as effective at a lower dose?

For many medications, raising the dose beyond a certain level brings no further benefit. Some people are particularly sensitive to certain medications and do very well with a smaller dose.

The Man Who Came Back To Life

You may recall our story of the unconscious and dying ninety-year-old man whose family begged me to have the nursing home stop forcing his medications down, wishing to allow him to die comfortably.In that situation, I did not ask the questions listed above. It seemed best to have the nurses just flat stop giving him anything, and they did.

Surprisingly, that uncomplicated approach worked very well for the gentleman in question, as you can read in the April 2012 newsletter.

Four of Five Medications Were Not Needed

Most situations require a more thoughtful approach, such as using the questions listed above.

Now of course you might expect that cutting down on the number of medicines you take would save health care costs, but will you pay a price in terms of longevity?

Doctor Doron Garfinkel, the Israeli geriatric specialist who developed the questions above, studied this question.[1] He collected information on 119 patients in assisted living and tried discontinuing all medications (about 332 meds among these 119 people) that met any one of the above criteria. About four times out of five, it turned out the patient did not need the medication.

Fewer Drugs, Longer Life

Then, Doctor Garfinkel and his team waited 1 year. The patients in this assisted living unit were fairly sick individuals, and of the patients whose medications had thus been carefully reduced, about 20% died over the following 12 months. You may think, "Not good." But how do you think the other people in this facility, similar people with similar medications and similar illnesses, people who took about three more prescriptions each than those in Doctor Garfinkel’s study, did with those extra prescriptions? About 30% of them needed a hospital visit, compared with about 10% of those in the study group. And over twice as many (about 45%) of them died.

By the way, Doctor Garfinkel’s study was repeated in people living independently with similar results.[2] Again, about 80% of the medications were not needed, and longevity improved when the medications were discontinued.

Drugs That Don’t Age Well

In elderly folks, these are the medications most often not needed:

  • Opioids
  • Beta blockers
  • Clonidine
  • Gabapentin
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Tricyclic antidepressants

These are not bad medications; they can be life-saving for many people. If you are taking one or more of these, don’t stop them without asking your physician first. Beta blockers, for example, must be discontinued gradually to prevent complications. But if you are responsible for an older person who takes one of these, you should bring this issue up with their physician.

Penny Wise, Pound Foolish

Health economists tell us that for every dollar we spend on pharmaceutical medication, we spend about $1.33 taking care of the side effects.[3]When health planners and insurance companies put primary care on a starvation diet, they prevent physicians from taking time to undertake the careful medication review outlined above. Driven by special interests, these planners and companies condemn all of us to a super-expensive and harmful health care system.

Any Stage of Life

And while the examples given in this newsletter concerned older people, this is because older people are more likely to be on many drugs. But at any time of life, when a person is on medication for an ongoing condition, you and your doctor need to get together periodically and review whether that medication is still working for you.

Annual Medication Review

State law and good medical practice both accept 1 year as the maximum period for which a medication can be prescribed and refilled. Medications for diabetes, high blood pressure, and other conditions might require more frequent monitoring, but 1 year is the maximum for any medication.

Being a doctor, someone who writes prescriptions, I like to think that the prescriptions I write help people feel better and live longer. It is clear, though, that an equally if not more important task is to make sure people stop taking those medications when they are no longer needed. This is why we require that you come in at least once a year to make sure that any medication you are taking is still the best choice for you.

Facebook

Even if you don’t like most social media, please try our clinic page on Facebook. Regular followers will have seen our link to http://www.nytimes.com/2015/11/22/opinion/sunday/are-good-doctors-bad-for-your-health.html, which enlarges greatly on the topic of overmedication.

Prior Authorization

Some insurance companies require prior authorizations for prescriptions. Initially, we undertook this task from initial phone call to completion of the form. After spending way too much staff time on telephone hold, we asked you to make any required initial phone call, so as to limit our work to completion of the actual form. Now, the number of forms we are being asked to complete is exploding and the staff time required has greatly increased. With regret, we now must ask $30 for completion of these forms.

Endnotes

[1] IMAJ. 2007;9:430–434

[2] Arch Intern Med. 2010 Oct 11;170(18):1648-54.

[3] Bootman JL, Harrison DL, Cox E. The healthcare cost of drug related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157:2089–96.

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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.