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Thread: Too many prescription drugs and they could be causing us more problems than you know.

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    Distinguished Community Member Lazarus's Avatar
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    Default Too many prescription drugs and they could be causing us more problems than you know.

    This physician wants her patients to use fewer medications
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    (Jack Valley/Getty Images/iStockphoto)
    By Ranit Mishori
    January 28, 2017
    There was nothing unique about that patient encounter except that it was my first appointment of 2017 and everyone at the office was buzzing about their New Year’s resolutions.

    It went like this:
    R
    Me: “Are you taking all of your medications?”

    Patient: “Yes, of course.”

    Me: “Okay, let’s review them. Do you remember what they are?”

    Patient: “I am not sure, but they are all here.” (Patient hands me a plastic bag brimming with orange pill bottles, boxes and over-the-counter containers.)

    Me (in my head): Oh, brother!

    That’s when I made my resolution: In 2017, I will try to tip the balance: I will not only try to write fewer prescriptions, I will also try to get more of my patients off their drugs altogether.

    [My doctors prescribed pain meds but couldn’t help me get off them]

    The “why” was obvious to me: Too many patients are taking too many drugs, for too long, in too-high doses, suffering harmful effects.


    The “how”? That was less obvious. Starting in the second year of medical school (course name: Pharmacology) and continuing through residency training and beyond, doctors are taught how to prescribe drugs.

    Here’s some of what we learn: which drugs are best for different conditions (for high blood pressure, diabetes, depression, pain and so on); which antibiotic is best for which type of infection; what are the most beneficial dosages and how frequently should certain drugs be taken; what is the best route for certain drugs (oral, rectal, IV); what the common side effects of most drugs are; which drugs are better for children, which for adults. There is much to know, and doctors have to stay up-to-date constantly, on old and new medications, recalls, generics, brand names, warning labels.

    This is important, of course. Drugs have an important place. But rarely do we teach young doctors — that is one of the things I do now — how and when to deprescribe a drug. Doing so is not as simple as saying “stop.” Deprescribing is its own process, requiring extreme caution and a certain skill on the part of the physician. It is a skill, however, that is not being taught, and it is barely studied to develop best practices.


    [‘America’s other drug problem’: Giving the elderly too many prescriptions]

    And that hurts patients, because few drugs are meant to be used forever, and all have potential to cause harm. For some drugs, those harms include addiction — much in the news these days — especially in the case of opioids, some anti-anxiety medications and certain sleeping aids. Cutting down on some of these drugs needs to be done very gradually and carefully.

    Some people simply take medications for too long: Take certain heartburn medications (called proton pump inhibitors, or PPIs) for more than the recommended two weeks, and you risk pneumonia, intestinal infections, broken bones and vitamin B-12 deficiency.

    Some people outgrow their medication: They change their lifestyle, and their diabetes, cholesterol or high blood pressure medications may not be needed anymore. But they keep taking them, because no one told them to stop.


    But it’s my patient with the bag of medications who illustrates the situation most acutely: an older adult who is prescribed too many medications, by too many physicians, all at the same time, even if all are given for legitimate reasons.

    “Polypharmacy” is the name we give to prescribing patients five or more medications at the same time.

    [A window into one of the most baffling things about drug prices]

    Why is that problematic? First of all, drugs are chemicals that can interact with one another, potentially causing all kinds of complications that may not be apparent if you just take the one medication. Second, the aging process causes the kidneys and liver to be less efficient in processing medications. That often leads to more of the drugs sticking around in the body and magnifying their effects — and side effects. Polypharmacy has been shown to contribute to higher rates of hospitalizations and death and — of course — to higher costs.


    The problem is widespread: According to some studies, about 20 percent of adult patients are routinely on five or more drugs, and in people older than 65, between 30 and 70 percent are treated with polypharmacy. In nursing homes and other residential facilities, that rate goes up to 90 percent.

    Most patients — 89 percent, in one recent study of polypharmacy — have told researchers that they would be interested in stopping a medication if their physician agreed that was the right course of action.

    So what can we physicians do?

    First, we need to appreciate the scale of the problem and the potential harm of polypharmacy.

    We need to recognize that there are professional and cultural norms that push us to prescribe (rather than find other solutions) and to overprescribe.

    We doctors need to get out of our comfort zone. Yes, it is easier to keep somebody on a medication and just keep refilling it when the pharmacy calls, but is it better for the patient?


    [The horrifying way some drug addicts are now getting their fix]

    We need to get over our fear of causing harm by deprescribing. That’s not an irrational fear, of course. Indeed, many medications (for example, anti-depression medications, some high blood pressure drugs and steroids) need to be stopped gradually because stopping abruptly can be dangerous.

    We also need to make sure we are treating the patient, not the disease. That means considering whether and what to prescribe while taking into consideration the patient’s age, other health conditions and overall life expectancy. As doctors, we need to ask ourselves, for example: For an 87-year-old woman with metastatic cancer, should I prescribe a medication to lower her cholesterol level? The answer is probably no: It is highly unlikely that the patient would benefit from this drug and very likely that she would suffer from harms caused by the drug and its interactions with her other medications.


    Common classes of medications that are good candidates for deprescribing include:

    ● Anti-anxiety medications known as benzodiazepines, which can contribute to cognitive impairment, delirium, falls (and related injuries), breathing problems and motor-vehicle accidents.

    ● Atypical antipsychotics, which are often used to treat psychosis and, in the elderly, dementia.

    ● Anti-cholesterol statins, which can cause muscle problems, cognitive impairment and a higher risk of diabetes. Statins also have a high risk for interaction with other medications and certain foods. Given that the benefits of statins are long term, they are not needed for elderly patients.

    ● Tricyclic antidepressants, which are used for depression and dementia. These are not recommended in the elderly but are often used nonetheless, causing side effects or harms that can include low blood pressure (which contributes to falls and fractures), heart arrhythmias and other disturbances, delirium, difficulty urinating, dry mouth and constipation.


    ● Proton pump inhibitors, mentioned above.

    Knowing which classes of drugs require special attention is important, but it is not enough. How to do it effectively, efficiently and with the lowest chances of harm is still anybody’s guess. We need researchers to help us by discovering and evaluating the best discontinuation protocols.

    There is also a big-picture issue here: Deprescribing requires a lot of thought and planning. There are many more incentives for doctors to prescribe a medication than to stop one. Insurers and payers need to create incentives to allow primary-care physicians to spend adequate time with our patients to get them off drugs and carefully monitor their response when a medication is withdrawn in a supervised manner.

    For my part, I am going to try to do that in 2017.

    Mishori is a professor of family medicine and the director of the Health and Media Fellowship in the Department of Family Medicine at Georgetown University School of Medicine.
    Linda~~~~

    Be the kind of woman that when your feet hit the floor each morning the devil says:"Oh Crap, She's up!"


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    Distinguished Community Member Earth Mother 2 Angels's Avatar
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    ((((((Linda)))))) ~

    Great article, and thank you for sharing it!

    I've been griping about doctors overprescribing for years, realizing the damage it was causing my loved ones. Recently, one of our close friends revealed that she'd been taking Celexa for 20 years. No doctor had ever told her that she shouldn't take it that long. She had many serious side effects, so her physician finally slowly weaned her. She said that withdrawal was horrible. Now, completely off of Celexa, she feels like a new person.

    When Jim was first diagnosed with cancer, every doctor, nurse, tech, therapist asked him what drugs he was taking. His answer: None. Jim said that every time he answered with "None," the response was shock. "NONE? You mean you don't take any drugs at all?"

    The last time Jim was discharged from the hospital, the hospitalist prescribed a drug, which would have affected his blood pressure. He's very fortunate that he has a beautiful blood pressure, and, for that reason, this drug would have tanked him. He'd also prescribed Lasix, which combined with this drug, would have been disastrous for Jim. I questioned the pharmacist about the drugs, and her explanation prompted me to call Jim's oncologist. Jim's nurse also weighed in on the inappropriateness of the hospitalist's drug scripts.

    The author of the article is right, of course, and well meaning. However, in my experience, doctors are so overloaded with patients that taking the time with each one to review their meds and try to reduce them is unlikely. Doctors are also not experts in pharmacology. So many physicians think of drug interaction or side effects as the last culprit for a patient's symptoms. It should be the first consideration, and once that is ruled out, other options can be explored.

    In a perfect world, doctors would know everything about every drug they prescribe. Since they don't, it is up to us, as patients, to be on top of every medication we are prescribed and/or take. We need to research our drugs for side effects, interactions, and symptoms indicating a problem. We need to ask our doctors whether our symptoms could be drug related, then present our findings to the doctor.

    I also think that it would be beneficial for doctors to refer patients to a pharmacologist, who specializes in drugs, so that takes the pressure off of them to know everything about the thousands of different drugs their patients may be taking. A Pharmacologist could confer with our PCPs and specialists to guide the medication process and make sure that none of them prescribes anything without the rest of the team in agreement.

    This article struck a nerve in me, as you can tell. It's so very important that everyone is fully on top of their medications, because our physicians may not be. More often than not in my experience, they weren't.

    Love & Light,



    Rose
    Mom to Jon, 49, (seizure disorder; Gtube; trache; colostomy; osteoporosis; hypothyroid; enlarged prostate; lymphedema, assorted mysteries) and Michael, 32, (intractable seizures; Gtube), who were born with an undiagnosed progressive neuromuscular disease and courageous spirits. Our Angel Michael received his wings in 2003. Our Angel Jon received his wings April 2019. Now, they watch over Jim and me.

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    Distinguished Community Member Sunshine's Avatar
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    I have a serious list of meds I take and the side effects are potent.

    When I went to Mayo @ a year ago, I saw a pharmacologist. The consult was not able to come up with any med reduction. She could only rec the timing. Each med she saw as necessary, it seems.

    Since then I have added a few more meds, Flomax for the UTI, Macrodantin for the UTI, Linzess for the SEs of muscle relaxants.

    Hate the way the FLomax makes me feel: congested, and amplifies the SE of the muscle relaxant. But, When I tried to be off it, the Bladder issue re-emerged.
    Its gotten ridiculous and I will discuss it with PCP at my annual.

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    Linda, good article for many of us on here.
    Virginia

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    Distinguished Community Member Howie's Avatar
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    I take 6 meds, but most are for my high blood pressure. No one drug worked. I'm not sure how it is now, because they didn't even check my BP last visit.
    Evolution spans the Universe.

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    ((((((Hugs to All)))))) ~

    Sunshine ~

    I'm so sorry that you have to take so many meds. It's awful that you have to take drugs to combat the side effects of other drugs. It's just a vicious cycle. When is your next PCP visit? I'm concerned about the stress of all of this for you and the suffering you're enduring. Maybe it would be a good idea to call your PCP for a visit soon.

    Howie ~

    Taking a patient's blood pressure is the first thing every doctor I've ever met does, before s/he sees the patient. That is the case, regardless for the reason for the patient's visit. Blood pressure, temperature, heart rate are standard procedure for a doctor visit. And you take several meds for your blood pressure, so that is more reason to take yours, when you are at the doctor's office.

    On your next visit, you might want to insist that your BP is taken.

    Do you have your own BP monitor/machine to check your BP at home? If so, are you checking your BP regularly every day? I hope that you are.

    I know you will tell me that I'm clucking, which I guess I am. It's only because I care about you, and high BP can lead to some pretty awful things. Please take good care of yourself.

    Love & Light,



    Rose
    Mom to Jon, 49, (seizure disorder; Gtube; trache; colostomy; osteoporosis; hypothyroid; enlarged prostate; lymphedema, assorted mysteries) and Michael, 32, (intractable seizures; Gtube), who were born with an undiagnosed progressive neuromuscular disease and courageous spirits. Our Angel Michael received his wings in 2003. Our Angel Jon received his wings April 2019. Now, they watch over Jim and me.

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    A blood pressure reading should be taken at every visit regardless of the reason for that visit. It’s an opportunity to save a life. High blood pressure is a “silent killer.”
    There comes a time when silence is betrayal.- MLK

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    Distinguished Community Member Howie's Avatar
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    Rose, I have a BP cuff, but don't use it. Besides, it hurts! I'm not interested in a long life. I just want to outlive my cat Sam. MS ended my life as I knew it, but I did more in that short time, than most folks ever have.

    But I appreciate you concern. I'll be fine as long as Sam doesn't kill me!
    Evolution spans the Universe.

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    Distinguished Community Member agate's Avatar
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    It's possible your BP was taken and you weren't aware of it. There are ways of taking it that don't involve a cuff, and they are fast. I've had this happen a couple of times. I was amazed to find out they'd taken my BP.

    They aren't the most accurate way though, according to what I've heard. But some doctors' offices are using them.

    Why not give your doctor's office a call and assume that they did take your BP (since they were definitely supposed to)? You could say, "By the way, what was my BP reading when I was in here on [give the date]?"

    Then if they didn't take it, they'll realize it and apologize. It might persuade them to do better by you next time.

    About the hurtful BP cuff: You're probably pumping it up too high. It should be tight enough to hurt a little bit at first but it shouldn't be so very painful.

    Sorry about the hen activity but when a person comes in here and says something like "MS ended my life as I knew it" (etc.), it gets some hens all bothered.
    Last edited by agate; 07-30-2019 at 10:15 PM.
    i don't trip--I do random gravity checks.

    MS diagnosed 1980. Avonex 2002-2005. Copaxone 6/07 - 5/10.
    Member of this MS board since 2001.

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    Distinguished Community Member Lazarus's Avatar
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    So Howie, what was your before MS life? ( or does it make you sad to think about that time).
    Linda~~~~

    Be the kind of woman that when your feet hit the floor each morning the devil says:"Oh Crap, She's up!"

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