Overprescribing pharmaceuticals has reached a critical stage wherein even the adverse effects of some drugs are mistakenly identified as new medical conditions.
Are you one of the over-age 65 Americans taking five or more medications daily? The ever-rising use of prescription drugs—particularly in older Americans—has led to a phenomenon called polypharmacy, a term used to describe the use of multiple drugs to treat one or more medical conditions. Author Hedva Barenholtz Levy, who holds a doctor of pharmacy degree, admits that polypharmacy is a common practice in the aging population, with dangerous consequences. Ms. Levy hopes that in her new book, “Maybe It’s Your Medications: How to Avoid Unnecessary Drug Therapy and Adverse Drug Reactions,” readers can gain new insight into the effects of overmedication and become empowered to act as advocates on behalf of their own health.
The Causes of Polypharmacy
How did we get to this state of widespread polypharmacy? It will be no surprise to learn that multiple contributing factors have been influencing medication use in the United States for years. Understanding the nature of these influences allows you to appreciate the breadth of the problem and be more prepared to stand up to these forces when feasible.
To begin with, as our population ages, there are more and more persons with multiple chronic conditions. Chronic health conditions go hand-in-hand with medication use. According to the Centers for Medicare and Medicaid Services (CMS), 69 percent of older adults are diagnosed with two or more chronic health conditions and 18 percent have six or more. In contrast, just 27 percent of adults age 18 and older report having more than one chronic health problem. Health conditions common among older adults include high blood pressure, high cholesterol, arthritis, diabetes, and heart disease. The majority of these require drug therapy, and often more than one medication, as described earlier.
Another contributing factor is advances in medicine. As a result of improved medical knowledge, technology, and medications, we are able to survive health events that would have been devastating in the past, such as heart attacks, strokes, and cancer. Subsequently, we are living longer and have the opportunity to acquire other health conditions or ailments that call for drug therapy.
Polypharmacy also is driven by pharmaceutical advancements. Pharmaceutical science has allowed for an increasing number of drug discoveries. We now can treat medical conditions for which we had no drug therapy options in the past. Over the past three decades, the FDA approved an average of thirty-three novel new drugs per year. That amounts to over a thousand new drugs during my career so far as a pharmacist. We also have seen a growth in the number of dietary supplements and over-the-counter (OTC) products on the market. These are multibillion-dollar industries that heavily advertise to consumers.
Advertisements for prescription drugs contribute to polypharmacy trends as well. Since 1997, regulations in the United States have allowed pharmaceutical manufacturers to advertise prescription-only medications directly to consumers, a practice known as direct-to-consumer advertising (DTCA). New Zealand is the only other country where this is legal. The impact of DTCA is complex and not without controversy. One of its benefits is increased awareness of certain health conditions that might be embarrassing for patients to talk about (such as overactive bladder or erectile dysfunction), which promotes physician-patient communication. On the other hand, DTCA is a lucrative opportunity, and drug companies spend about $6 billion annually in advertising to reach consumers. In a 2021 analysis, drugs with the highest DTCA spending were also noted to have the highest Medicare expenditures.
Increased access to health information on the internet also has influenced widespread polypharmacy. As patients seek information about a health condition and its treatment options, they are more apt to self-treat with nonprescription medications or request a prescription from their physicians.
With the wide availability of prescription and nonprescription medications, coupled with high exposure through marketing and the internet, consumers are immersed in the message that pharmaceuticals will treat just about every ailment or symptom. This has contributed to a pill-popping culture, in which individuals tend to prefer a “pill for every ill.” It is far easier to swallow a medication than to invest time and effort in lifestyle changes and other nondrug treatments. Unfortunately, patients often expect a prescription from their physicians when they describe a symptom, and many times physicians will oblige because they are trained to be healers and want to address their patients’ needs.
Safe and appropriate medication use ideally should include plans to stop a medication when it no longer is needed or effective, or if it is causing side effects. Most medications are not meant to be taken forever. Unfortunately, in current clinical practice, we do not routinely seek out ways to reduce drug therapy. And thus, medication lists continue to grow. When patients bring up a new symptom, physicians are trained to help by “doing something,” and the quickest and easiest thing often is to write a new prescription.
Stopping drug therapy is not as easy as it sounds. There are numerous barriers to overcome. Research consistently shows that three out of four individuals want to reduce the number of medications they take, and more than 90 percent indicate they are willing to stop medicines if their physician says it is possible. However, actual deprescribing occurs infrequently.Patients can become hesitant for various reasons. They might be fearful that symptoms will return or their health condition will worsen. They do not want to upset their doctors by bringing up the question of stopping medications. Many individuals grow accustomed to taking their medications and are reluctant to let go of a comfortable routine. Finally, if their doctor brings up stopping a medicine, patients might think the doctor is giving up or abandoning them and thus view deprescribing as a bad thing.
Physicians experience barriers to deprescribing, too. Physicians widely agree that they lack sufficient knowledge and guidance. How to stop drugs is not included in basic medical school curriculum. Clinical practice guidelines provide information on when to add medications, but fail to address when they might be stopped. As a result, clinicians are left without guidance on how to reduce or remove medications once prescribed. Another barrier is that physicians do not want to change a medication prescribed by one of their colleagues. Additionally, information often is lacking in a patient’s health record about why a drug was started years ago, making it difficult for someone to determine if deprescribing is appropriate. Finally, efforts to discontinue a medication require extra time and follow-up that often is just not available in the current structure and payment model of our health care system.Unless there is an overt problem, it is easiest to renew prescriptions and continue the same medication list. We call this prescribing inertia.
Deprescribing is possible but it requires a very person-centered approach, as everyone’s situation is unique. Success is achieved when clinicians work with one patient at a time to reduce unnecessary or harmful medications and address other drug therapy problems. Ultimately, greater patient engagement is a key component to being able to reduce or stop medications. However, many individuals are not even aware that deprescribing is an option. Clearly, greater awareness is needed.
Consequences of Polypharmacy
Adverse Drug Reactions
One of the most common consequences of polypharmacy is an increased risk of adverse drug reactions (ADRs). ADRs are the unintended or unwanted effects of drugs. A more commonly used term is drug side effects, which is roughly interchangeable. Most of us are familiar with stories about a bad experience with a medication. Statistically, the chance of experiencing an ADR increases with the number of medications the person takes.Of particular concern, older adults are three times more likely to have to go to an emergency department because of an adverse reaction compared to adults younger than 65, and seven times more likely to be hospitalized.
A word of wisdom in geriatric care is to first assume a new symptom is a drug side effect, rather than jumping to the conclusion that it is a new ailment. For example, the dementia medication donepezil can increase urinary incontinence (decreased ability to hold urine), leading to more frequent urination. In turn, the physician might prescribe a drug to treat an overactive bladder, rather than recognize a possible side effect of donepezil. Instead of adding another drug, it might be more helpful to reassess the benefits and risks of donepezil in light of the new adverse reaction.
Drug interactions are a second important consequence of polypharmacy. The more medications a person takes, the greater the likelihood of having a clinically significant interaction. Medications can interact with another medication or with a health condition, food, alcohol, or marijuana. Nonprescription drugs like over-the-counter medications and dietary supplements also can interact with prescription drugs.
Polypharmacy is associated with reduced medication adherence. This term (formerly called medication compliance) is defined as the extent to which a person correctly follows medication instructions. Adherence is an important topic that is more fully addressed in its own chapter. Poor medication adherence is common in older adults for a number of varied reasons. Longer medication lists typically involve more complex schedules for taking one’s medications. Individuals can feel overwhelmed when they have to remember to take multiple pills every day and at different times, with some pills having special instructions to be taken with or without food, for example. A complex medication schedule is just one example of how polypharmacy can negatively impact adherence. The downstream impact of poor adherence (not taking medications properly) is that a person’s health conditions will go untreated or be poorly managed, leading to worsening health and progression of the condition.
Cognitive and Physical Function
Polypharmacy has been associated with impaired cognition, delirium (fluctuating changes in mental status), and dementia.Physical function also can be negatively impacted. Studies have found an association between polypharmacy and increased falls, slower walking speed, decreased balance, and decreased grip strength. Indeed, polypharmacy contributes to increased fall risk as a result of additive side effects such as dizziness, low blood pressure, and effects on balance.
Non-Drug Treatment Strategies to Manage Health Conditions
Medications have a valuable and necessary role in keeping us healthy and extending lives. However, for many health conditions, medications are only part of the solution. Nondrug treatments refer to health-care interventions that do not involve medications or pharmaceuticals. Another term is nonpharmacologic treatments, but I will stick with the simpler word “nondrug.”
What Are Non-Drug Treatment Strategies?
Nondrug treatments include a broad array of interventions. Lifestyle modifications include healthy behaviors, such as eating a healthy diet, getting regular physical activity, and quitting smoking. They also include health condition-specific recommendations; for example, to manage reflux symptoms, individuals can adjust the timing and size of meals and elevate the head of their bed, along with other recommendations. These types of disease-specific modifications sometimes are referred to as “therapeutic lifestyle changes.” Other nondrug options simply offer alternatives to drug therapy; for example, applying heat or cold to manage pain or getting physical therapy.
Long-term healthy behaviors make up the core of disease prevention and healthy aging and can be adopted at any age, although earlier always is better. Robust data show that healthy lifestyle behaviors can slow, prevent, and, in some cases, even reverse disease progression.
Complementary and alternative medicine (CAM) refers to interventions that are not part of conventional medical practice. CAM includes mind-body therapies like meditation, relaxation, and Tai Chi. Dietary supplements often are considered as CAM.
Physical therapy is somewhat of an outlier among nondrug strategies in that it is accessed within conventional medical practice and typically is covered by insurance. Along with other nondrug approaches, it can reduce or avoid the need for long-term drug therapy.
Role of Non-Drug Strategies
Nondrug treatments have a role in managing many health conditions. They can be used alone or in addition to drug therapy and other medical approaches, depending on the particular health condition. Indeed, it is not unreasonable to start a nondrug treatment strategy before moving to drug therapy, in hopes of improving the signs or symptoms of the health condition without need for a medication. For example, diet modification, physical activity, and achieving a healthy weight are essential first steps in the management of diabetes, high blood pressure, high cholesterol, and other cardiovascular conditions.
There is specific terminology for CAM therapies, depending on how they are applied to one’s health care. CAM treatments that are used instead of conventional medicine are defined as alternative therapies. When they are used in conjunction with conventional medicine, they are defined as complementary or integrative therapies. Many CAM therapies are used in either capacity, and thus referring to them as “CAM” is most simple. For example, when treating mild depression in older adults, cognitive behavioral therapy (CBT) is recommended as initial therapy, but it can be combined with antidepressant drug therapy, as well.Treatments that center on lifestyle modifications like diet and exercise frequently are integrated as part of the standard of care for a number of diagnoses. Importantly, positive lifestyle changes should always be continued, even once drug therapy is initiated. Making these changes part of your way of life can yield long-term benefits by slowing disease progression and the need for additional drug therapy.
Dr. Hedva Barenholtz Levy, PharmD, is the founder of a community-based senior care pharmacy practice. A geriatric pharmacy specialist and educator, Dr. Levy has published numerous peer-reviewed journal articles and book chapters focusing on optimizing drug therapy in older adults. She is a graduate of the University of Michigan and resides in St. Louis.
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