The perils of polypharmacy–and what patients and clinicians can do to avoid them

Last week, the Massachusetts Medical Society approved policy to help address the risks of polypharmacy.

This is fortunate. The medical system needs to be more invested in preventing injury due to the excessive prescription of medications. MMS members’ advocacy adds to a chorus of concern about this growing problem.

Polypharmacy, defined as the regular use of five or more medications at the same time, is associated with poor health outcomes that can result from any or all of the following:

• Toxicity of the medications themselves
• Negative interactions between medications
• Patient confusion about how the medications are to be administered, resulting in over- or underdosing, or poor adherence.

The US spends more per person on medications than any other country in the world–and more on treating preventable medication side effects, like falls and hip fractures. The adverse clinical events associated with polypharmacy are diverse and serious for the individual patient and a financial burden for society. A study by the Lown Institute estimated that in the US between 2020 and 2030, the drug-related adverse events associated with polypharmacy will result in:

• 4.5 million hospital admissions
• 150,000 premature deaths – particularly in older patients
• 528 billions dollars in additional health care costs.

Responsibility for the painful human and financial costs of this problem is shared — unequally – among the following parties:

Clinicians. Across the US healthcare system, clinicians face multiple pressures. The financialization of medicine has resulted in almost all health providers working for larger organizations that have to deal with rising costs and falling revenues. The most immediate result is pressure on clinicians to be “efficient” – which translates into seeing as many patients per working day as possible. Prescribing a medication is both the quickest response to a patient’s symptoms and concerns and one that is typically considered meaningful by patients themselves.

These time pressures also limit the physician’s ability to review carefully the patient’s entire medication profile and be sure the new agents do not have negative interactions with medications the patient is currently taking.  Providing reassurance that the specific issues do not require additional treatment – even if correct – can take more time than writing a prescription and such advice is often poorly received.

Patients no doubt also bear some of the responsibility. Popular media is filled with reports of the wonders of modern medicine and advancements on all fronts. Adding to the lure of “technosalvation” are ubiquitous drug advertisements that amplify the false expectation that any physical ill can be cured with a pill.

Big pharma. But the lion’s share of the blame goes to the pharmaceutical industry. The drive for greater profits has resulted in ever higher charges, especially for new drugs, and more aggressive promotion of their use. A particularly insidious consequence of the corporatization of medicine is that pharmaceutical companies now often have direct access to physician prescribing data and will contact clinicians directly to encourage them to prescribe the medications they produce.

Lack of monitoring. One approach to counter the problems of polypharmacy would be independent monitoring of the medications being prescribed to patients. Medication monitoring has been shown to improve health outcomes for a variety of medical conditions by decreasing adverse events, emergency room visits and improving patient adherence. The Centers for Medicare does in fact require this, but compliance is haphazard: one review found that only half of Medicare patients are eligible for monitoring and less than 10% of eligible patients receive a comprehensive medication review.

Currently, the work required falls largely to pharmacies. Pharmacies are in the business of filling prescriptions and selling medications and have little, if any, incentive to perform such monitoring, which requires additional employee time, already at a premium.

To remedy this dearth of monitoring, the American Medical Association and MMS are advocating that clinicians encourage patients to bring all medications and supplements they are taking (or accurate, updated lists including current dosages) to each appointment, so they can be reviewed by the patient’s medical team. The need for such reviews is beautifully illustrated by the following case.

Appropriate vs. inappropriate drug prescribing: the importance of context

Patients with complex medical conditions or multiple ones, like asthma, diabetes, and heart disease, may require five or more concurrent prescription medications. With careful drug selection and monitoring, a safe and successful treatment regimen can be implemented.

However, when a patient reports additional symptoms or concerns, each of those does not necessarily require an additional medication. Effective solutions may involve changes in eating patterns, activities, or sleep habits. In such contexts, simply prescribing an additional medication as the initial response is inappropriate. Further, the risk of adverse outcomes increases sharply if prior assessment of the drug combinations is incomplete and ongoing monitoring for adverse effects is inadequate.

The problems can be further compounded if either direct effects or negative interactions of the recently added drug lead to a “prescribing cascade.” This refers to the situation in which the further new symptoms are not recognized as a side effect of the expanded regimen and are addressed by prescribing yet another medication.

Polypharmacy can result in poor adherence

Overprescription has also been shown in clinical studies to result in poor adherence: adherence refers to the ability to take medications as prescribed. Adherence decreases as the number of medications a patient takes increases, but there is a steep increase in nonadherence when the number of medications taken at the same time exceeds five.

A physician colleague, Dr. William Burman, used to inquire of the young doctors he trained, “Which medications does this patient of yours really need to be on?” He would caution them to do their best to keep that number to five or fewer: “Drug-drug interactions increase precipitously above five medications–and adherence falls precipitously too.”

Poor adherence to medications is a major reason for patient hospitalizations, poor outcomes, and increased medical costs. Dr. Burman noted in a recent email, “The impact of polypharmacy on adherence is terribly under-estimated.”

The trend away from short-term courses of medication to ongoing  courses 

Another important factor contributing to polypharmacy is the change in the way potentially short-term problems are managed. According to community pharmacy consultant David Morgan, “A lot of people are started on medications that at one time were just given for a couple months–like the medications for acid reflux–but then are never taken off of them.”

Previously, someone with a new complaint of indigestion or acid reflux would be given a short-term prescription for a medication to decrease gastric acid production and advised to avoid certain foods, spices, and excess alcohol at mealtimes. They would be seen again in a few weeks, and if the problem had resolved, the medication would be stopped and the dietary advice emphasized.

Increasingly, many such medications simply end up being continued indefinitely. The same prescribing pattern can be seen with medications given for other common, typically short-term, problems, such as muscle aches and difficulty sleeping.

Even more unfortunate, adding a pill is often done without counseling patients how they can address their symptoms by changing their behavior. While this saves the clinician time, it contributes significantly to the incidence of polypharmacy and all the resulting problems noted above.

The Solution: what the patient can do

The reality is that at present it largely falls to the patient to be both informed and vigilant about the medications they are prescribed. This is challenging and the effort increases with the number of medications. Frankly, to be adequately informed when taking five or more drugs (the definition of polypharmacy), almost everyone needs help, whether from a knowledgeable family member, friend, personal caregiver, or a patient advocate. Their involvement can mitigate the risks of overprescription–and medications in general–by helping you prepare a medication list and get answers to the important questions you need to ask when starting a new drug.

Preparing a complete medication list is a critical, and challenging, first step. Don’t hesitate to get help. The list should include the following details for each medication:

• The name of the doctor who prescribed the drug
• The name of the drug as written on the prescription
• Why you were given the prescription
  – the diagnosis, symptom, or lab abnormality being treated
• The date you started to take the medication
• The medication “regimen” – meaning how you are taking it
  • For pills or tablets: The dose of each individual tablet or pill;
    the number to be taken at one time
  • For liquid preparations: The concentration of drug per volume;
    the volume to be taken at one time
  • For both: the frequency (interval) that amount should be taken

• Don’t forget to include over the counter medications and vitamin supplements on this list

Have the list with you – at all times.

• You need it at home in case a caregiver needs to see it and to assure that you can accurately answer questions raised on a call.
• You need to bring it with you to appointments and provide it to every clinician you see – whether at a routine follow-up visit, a first meeting with a new physician, or in an emergency room or urgent care center. You can’t assume in any clinical encounter that the doctor has access to all your current prescriptions.
• And the persons you rely on for support in your healthcare encounters should have their own copy of the current list.

The list needs to be up to date.

• New medications must be added promptly.
• Any changes in dose regimen should be noted.
• Any medications discontinued must have the date and reason stopped indicated
• If a medication was stopped due to a significant adverse event, this side effect should be noted and the reason for discontinuation should remain in the record indefinitely

Ask questions – you deserve and need useful and reliable answers

This can present a most difficult challenge for many people – and a wonderful reason to have someone to support and assist at your healthcare sessions. You should ask the prescribing clinician:

• Why am I being prescribed this medication?

This is a critical question. Your clinician will surely have an answer.

• • There’s been a change in one of your medical conditions. 

This would be the clearest reason – an improvement might allow use of a less intense medication, and an incomplete response might require an alternative stronger medication, or an additional one.

• • It is to treat the new symptom you reported or a new lab finding. 

This raises the question of what is the cause of the new issue – is it a new diagnosis, an adverse effect of the new drug, or a new interaction among the drugs? Sometimes the doctor can’t be sure at first, and the question just needs to be raised again at the next visit.

• Are there alternative ways to manage the issue other than adding another medication?

The intent here is to learn if there are behavioral changes you might make that would provide benefit – dietary changes, different sleep habits, specific exercises or activities.

• What are the risks associated with this medication? Please tell me about:

• Common side effects

• Uncommon, but serious, effects – i.e., is there a “Black box” warning?

• Possible interactions with my other medications

• What is the risk of not starting the new medication now?

• Can you provide – or direct me to – a reliable source of information about the medication  

This is a surprisingly difficult question for any clinician. The ideal source would have the following characteristics:

• Be a few pages presenting the key findings detailed in the regulatory label approved for use by physicians and pharmacists, but using language suitable for patients.
• Be issued recently by the pharmaceutical company that produced the medication you have been prescribed, so that they are fully responsible for the content.

Such summaries should be readily available for every approved prescription medication.

Unfortunately, that is simply not the case. The current regulatory label itself is remarkably difficult for lay persons to find, especially for older (generic) drugs. If you are given the label, please get help reading it. Please do not attempt to search the internet yourself for drug safety information. Entering the drug name will return hundreds of links, but the content is all too often out of date, incomplete, or simply not intended to address patients taking the drug. 

If your healthcare provider tells you the information is on the web, ask them for a specific link. Go back to your clinician and ask again if the information proves incomplete.

The takeaway

The medicines available today can improve and even extend life in ways that were unimaginable just decades ago.

But the best way to “solve” a new symptom is often NOT more medications. Why? Because a new symptom is not always due to a new disease in the patient. It may be caused by one of their current medications or an interaction among the medications.

The bottom line is that polypharmacy – the use of five or more medications at the same time – is associated with poorer health outcomes, including increased hospitalizations due to medication toxicities and increased mortality–not to mention increased medical costs. It is the inappropriate prescription of medication for which there is no indication that defines polypharmacy; and it is the lack of monitoring for negative interactions from taking more than five medications that is among its greatest risks.

All of us – patients, their healthcare providers, and their family and friends – need to be more aware of this problem. The Massachusetts Medical Society’s new policy calls on clinicians not just to review medication lists at appointments, but to use the minimal number of medications required to optimize a patient’s health.

The medical systems we depend on need to be more proactive in providing greater access to reliable information regarding the often multiple medications patients are prescribed and effective means of monitoring them. To this end, the MMS also is advocating to ensure that electronic medical records  (EMRs) reflect the actual medications a patient is taking–including over the counter supplements–and that EMRs screen for interactions among all of a patients’ medications, whether prescribed or not.

These long term solutions involve addressing complex and at times seemingly intransigent factors embedded in our healthcare systems. For now, it is the patient who can best take the most effective actions to address this problem. Patients can:

• Get help – from family, friends, a caregiver, a patient advocate.
• Make a list of your medications – keep it up-to-date – and always have it with you.
• Ask your clinician questions about your current regimen and every new drug, so that you are aware of the risks of each medication and potential interactions among them.

One patient shared with me, “There is a sign in my doctor’s office that reads: “If you have questions, talk to your care team.” But there is no “team,” he said. There is no coordination at all.”

That is exactly where friends, family, caregivers and patient advocates can help: they can be your very own “team” and help you work with your clinicians to take the actions that will enable you to stay safe, healthy, and derive the full benefit that you should from your medications.

Acknowledgement: I am grateful to Dr. Robert Arbeit for his very helpful editorial input.

Photo credit: Ksenia Lakovleva, from Unsplash.com

Medical disclaimer:

All patient names in this article have been changed to protect confidentiality.

The suggestions given here are not intended as a substitute for the medical advice of your physician. The reader should regularly consult a physician in matters relating to his/her health and particularly with respect to any symptoms that may require diagnosis or medical attention. For additional questions, please call your healthcare provider for reliable, up-to-date information on testing and symptom management of all medical concerns.