Polypharmacy: When is enough, enough?

Print Friendly
June 13, 2014 | 17 Comments

Comments

  1. One the most readable and useful column to appear on this site. Congrats to Dr Mangin
    Pierre Biron, Montreal

  2. I can’t agree with you more. We refuse to examine the actual side effects of meds, especially multiple meds, maybe prescribed by more than more than one MD. It’s like opening a can of worms. My experience with 3 anticonvulsants, Haldol (claimed by my neurologist to be an anticonvulsant), and the vagal nerve stimulator proved to be almost deadly. The neurological side effects were very difficult to deal with and getting worse. I told my neurologist about them and he was very sympathetic, period. I remember thinking, “Things are really bad now; they’re not going to get better; and they are going to get worse. Then it suddenly occurred to me that I had the power to prevent that. That thought was dismissed immediately, but it kept recurring. Within 2-3 weeks I had a method & a time. I got on my moped one AM (no helmet), drove down a busy highway, & as a semi was passing me @ 50mph I rode under the trailer. It should have worked. I was almighty surprised, & more than a little angry to wake up a week later in the ICU. Our emergency & acute care system here is remarkable. That was a year ago this week. No one ever questioned suicide. It was a “freak accident ” because I was doing something stupid. I just agreed with that. It was 4-6 months before it even occurred to me that the med side effects could have caused some suicidal thoughts/attempts. I had thought I was just selfish & weak. What changed? Mainly, my neurologist . The Haldol was discontinued, the VNS was turned off, & the lamotrigine was decreased. Even she has never mentioned emotional side effects of these meds so I finally decided to talk with her about it. At the mention of these needs she became very tense & distant. “I’m just the neurologist & can’t possibly deal with all these these things!” She then did a quick neuro check & was out the door within less than a minute. I’m still sure she’s competent, but I overestimated her willingness to listen to her patients.

  3. Comment from Johanna Ryan

    I ran across a Fatality Report on the NIOSH website (Nat’l Institute of Occupational Safety & Health) that I had to share here. I wish it were unusual, but we see way too much of this in people with chronic back pain:

    A 28-year-old firefighter died in his sleep at a conference. Since suffering a back injury three years ago, he’d been on sedentary duty as the chief of his small rural fire service. Three back surgeries and numerous epidural blocks had provided only limited relief, and he was being treated for depression, anxiety and insomnia. Prior to the injury he was in excellent physical condition as required by his job.

    He had appeared jaundiced the previous day and had slept through the trip to the conference while his wife drove. She awoke the next morning to find him dead. The autopsy found cardiomegaly and moderate to marked pulmonary edema, but no evidence of clots in the coronary or pulmonary arteries. Mild atherosclerosis was also found. He had “intermittent” high blood pressure and smoked about two cigarettes a day. He had never complained of chest pain or other symptoms of cardiac distress.

    The cause of death was given as “accidental multiple drug intoxication.” However, it was emphasized that all meds found in his system were “well within therapeutic range.” He’d been relying on his wife to keep track of his meds, and she confirmed he had never taken more than directed; in fact, she hadn’t even given him all his prescribed meds the night before.

    Here was his medication list:

    Morphine (MS Contin) 60 mg twice a day
    Methocarbamol (Robaxin) 1500 – 2250 mg/day as needed
    Cyclobenzaprine (Flexeril) 5 mg as needed
    Diazepam (Valium) 20 mg, 3x a day
    Venlafaxine (Effexor) 75 mg twice a day
    Gabapentin (Neurontin) 300 mg 5x a day
    Zolpidem (Ambien) 20 mg at bedtime
    Paroxetine (Paxil) 40 mg at bedtime

    Just following doctor’s orders, and dead at twenty-eight.

    • Drug intoxication can be a convenient diagnosis for a pathologist and it must not become a dumping ground..most serious ADRs occur early in therapy not weeks or months later …other things can cause unexpected deaths in young people and the causes can remain obscure unless a smart pathologist can think laterally rather than vertically ..IMHO

  4. How do you even find a doctor willing to do a review of all your medications? My primary care doctor won’t touch it–he insists I get birth control from my OB/GYN, medications for my ulcerative colitis from my gastroenterologist, and medications for my depression from my psychiatrist–he’ll only prescribe medications for my asthma and arthritis. I’ve searched high and low for a primary care provider who can coordinate all of my care and medications, but I haven’t found anyone in the last 3 years. I live in a mostly-rural area with a shortage of doctors, and I’m at my wit’s end. Everyone is so specialized that they only pay attention to one part of me, and no one is willing to monitor my care overall.

  5. In the last 3 years have twice got the 92 y/o Mum totally off drugs, first by increasing supplements and then weaning her off the first 4 per website below.

    Second go round, was 5 drugs and that took longer as a resident doctor was involved and not very knowledgeable and somewhat rigid in following Ministry of Health dictates.

    Even though there has been little change physically there has been a noticeable but slow improvement in Brain function.
    Certainly her position has been aided by a highly nutrient dense smoothie on a daily basis.

    Bottom line – Family can do it better with time and effort.

  6. Further to Johanna Ryan – this below, i posted just the other day, on a forum i follow;

    “Pfizer “voluntarily” recalled over 104,000 bottles of its antidepressant Effexor XR (including a generic version), after a pharmacist discovered a dangerous heart drug capsule in one of the bottles.”

    From a Dr Mercola mail out.

  7. Good article Dee.
    The polypharmacy ‘enemy’ in New Zealand is not the industry and IMHO they never have been that significant a player (we are not naieve prescribers) but rather the hospitals and the clinical specialities – and now and more concerningly perhaps the public health lobby with their poly-pharmaceutical ‘requirements for good clinical practice’.
    I did a recent prescribing and compliance audit of my ‘failed triple therapies’ for CVD and there was a reason for all of them …yet we are rewarded for achieving these nebulous hypothetical goals which in the generously co-morbid patients probably have quite marginal benefits – and benefits (or lack thereof) for which they are surely entitled to negotiate with their main advocates – the primary care clinician.
    After all GP’s are the most significant medication “reviewers, rationers and stoppers” – on New Zealand at least. Canada may be different.

  8. A number of years ago,before there were geriatricians,I was asked to supervise a geriatric assessment unit,with the help of two very competent nurses.After two years,it was apparent that most of the patients were there because of side effects.We discontinued all of their meds except the few we felt were needed.Most of them were on anti hypertensives,antihyperglycemics and antacids. all tolerated discintinuation of these meds.In follow up six weeks to three months later,most of them were back on the previous meds.I wrote a letter to the editor about our experience.No comment! good for you people and good luck!

  9. At 96, mentally sharp, she lives in her own condo. She complains of fatigue, dizziness, and a loss of interest in life. She’s on a statin ‘just in case’, a bone density drug ‘just in case’, and a blood pressure drug. Her blood pressure is low – very low. She has been told that feeling ‘out of sorts’ is just part of getting old. Presumably her doctor will soon suggest an antidepressant.

    She’s 95. She asked me to look at a hole in her living room wall. “That’s where I hit my head when I fell.” Three of her drugs have dizziness as adverse effects.

    She was 98 when her legs were injured in a car crash. She continued to live on her own. Her legs hurt and she had muscle spasms. One day I noticed that one arm seemed a little droopy and she had difficulty getting up from a seated position. Her face was bloated. She told me she wanted to die. She had been given Quinine Sulphate, an antimalarial used off-label for leg cramps. Side effects: low blood glucose, swelling of face, muscle weakness, abnormal heart rhythms, stroke….etc. Her doctor hadn’t read the FDA warning.

    She was in her early 90’s. She took the first dose of Seroquel which was to help her sleep. The ambulance came a few hours later.

    She’s in her late 80’s. She was dizzy. She fell. A week later in ER she was told she’d had a concussion. How many seniors’ concussions don’t get diagnosed? And they get further medicated?

    He’s almost 90. A few years ago he developed neck pain. His doctor prescribed a pain killer and then another pain killer. The side effect was constipation. He was given a stool softener, then another one. Then an antidepressant for pain relief. Another antidepressant followed – most likely to deal with the adverse effects of the first one? Loss of balance was one of the side effects. He fell – lots. A vertebra cracked, then another one. The last drug given was Aricept. I didn’t tell him it was a drug for Alzheimer’s and he certainly does not have Alzheimer’s. He does have Iatrogenisis. He’s on at least seven drugs.

    Here’s what Pfizer has to say about Aricept (donepezil): Adverse events reported during clinical trials: nausea, diarrhea, insomnia, fatigue, vomiting, muscle cramps, anorexia.
    Other (frequent) adverse effects observed during clinical trials: hypotension, fecal incontinence, dehydration, bone fracture, irritability, aggression, eye irritation, urinary incontinence., gait abnormality His doctor refused to look at the print-outs from RxISK.

    He’s 70, recently bereaved. His doctor gave him a sleeping pill and an antidepressant. His body started vibrating. He was frightened. He didn’t know about drug adverse effects. His doctor refused to look at the print-outs from RxISK. He took himself off both drugs and is seeing a bereavement counsellor.

    Our local pharmacist says the doctors just keep prescribing and prescribing

  10. I’m currently working as an RN in an inpatient psychiatry setting, occasionally working in an acute/emergent psychiatric clinic and teaching about one semester a year of psych nursing clinicals. I’m also in a doctoral NP program with a psych/mental health focus. That being said, I am disturbed by the huge number of patients that have been “on this medication” for years; and they don’t know why. Too many times when I look through the chart – I find nothing. So when the patient asks to discuss his or her medication I have no answers and it’s frustrating and it’s poor patient care.

  11. thanks for this excellent article. I am a naturopath and acupuncturist in New Zealand. I have been in practice for over 25 years, and during this time have seen a very disturbing trend towards increasing rates of polypharmacy. I regularly see patients who present with complex pictures and unusual symptoms, which are the direct result of medications they are taking. When I point out that many of their symptoms are drug induced they are always shocked and incredulous that the meds designed to “make them well” are in fact, making them sicker.

  12. I have said this for long and weary – that when there is a number of drugs prescribed how can they work independently. When I queried my husband’s medication, that included seven drugs, I got no specific answer that made sense. I understood that if one was on long term medication that there should be a three monthly review. But surgeries are already very busy so that would be an added burden. Could a nurse practitioner do this?

  13. so good to read this. When my Father decided to refuse the drugs he was taking, his blood pressure rose slightly and stayed in a safe range. He was much more comfortable and we no longer worried if he was taking his medicine!

  14. Thank you for this article. I am a survivor at 66, after 20 years of being on 12 different prescriptions daily including statins, as many as three different BP medications at a time and of course the “go to drug” most prescribed anti-depressants, up to three different kinds at a time. All because no one bothered with diagnosing and treating auto-immune Hashimoto’s. For last year have been healthy on only thyroid hormone replacement of Nature Throid (brand name desiccated thyroid prescription) and some good supplements and vitamins. I am so thankful to be alive, no longer in care of so called professionals who don’t stay up to date on research and instead are in cohoots with Big Pharma.

    • I too
      Have switched from big pharma thyroid medication to natural thyroid hormone. Seeing a naturopath has changed my life . Feel great now. Hope you will too ! j

  15. Hello There. I found your blog using msn. This is an extremely well written article.
    I’ll make sure to bookmark it and return to read more of your useful information. Thanks for
    the post. I will definitely return.

Leave a Reply