by Dr. Derelie (Dee) Mangin
David Braley and Nancy Gordon Chair in Family Medicine, McMaster University
The scenario is familiar: you or your mother or father has multiple pills to take at multiple times of the day. A pillbox called a dosette may be used to try and reduce the confusion and keep things on track. Where’s the problem? Surely if you need the pills to stay healthy, then you need the pills?
The problem is the more pills you take the more likely you are to have a side effect and that your pills are going to interact with each other or with one of your conditions. So a pill that looks like a good idea on the face of it, when added to the cocktail of your other pills and illnesses can give you more problems than it solves.
If you’re taking more than five pills you’re twice as likely to have a side effect than if you’re taking fewer than two.
Prescribing cascades can be triggered too. This is when a drug causes symptoms that are a side effect that is not recognised as a side effect leading to treatment with another drug that causes its own side effect that is treated with another drug… and so the cascade continues, like a series of dominoes, until you fall over in the end – sometimes literally.
Your mother might be given an anti-inflammatory drug, develop high blood pressure, be given a diuretic to treat this, develop gout….. If she had her blood pressure measured after a trial of stopping the anti-inflammatory drug the cascade may never have got started.
When the number of pills leads to confusion, it’s often impossible to take them all – which could be protective but in the chaos the pills that get skipped might also be the ones that are really needed.
The average number of drugs most older adults are taking in developed countries is around 7.
When you consider that if you have one chronic illness you are likely to have multiple this is not surprising. The majority of people attending primary care now have multiple chronic conditions. About half of people over 65 have at least three coexisting chronic conditions. One in five has five or more. But while things get worse as we age, most people with multiple conditions are under 65.
Clinical trials exclude these very patients – they almost never include people with multiple illnesses of taking multiple drugs. So we are in the middle of an enormous global experiment with almost no data collection. It’s time we got to grips with this – looking beyond diagnoses and back to patients.
What do you do with an invisible elephant in the room?
More people die of adverse drug effects in Europe alone each year than die of colon cancer, or breast cancer, or prostate cancer. It’s the equivalent of more than a jumbo jet or two every day. If this was an airline, would you fly on it?
Yet this cause of death and illness is largely lost in the hype around the need to treat diabetes or hypertension or osteoporosis. There are no measures in place to prevent death from this far more common cause of death.
What causes this wave of dangerous caring?
Modern medicine treats diseases not patients. Quality of care has morphed into ‘following the guidelines’. But these guidelines are for diseases not people. If you’re a doctor and a guideline adherer, then quality of care measures will rate you highly.
But applying guidelines in a 75 year old with 5 chronic conditions, no matter what they are, results in risky polypharmacy. This is illustrated wonderfully in a study that showed that applying the guidelines for an average number of chronic conditions in an older patient resulted in 19 doses of 12 different medications taken at 5 different times of day with 10 possibilities for drug-drug or drug-disease interactions.
Extrapolating the data from partial statistical lives in clinical trials doesn’t work in the complex lives of real patients.
So valuing quality of care on the basis of treatment for diseases rather than care for patients makes harmful polypharmacy invisible.
The doctors who provide care that is measurably better in terms of guideline adherence provide care that is meaningfully worse for the patient.
But the patient centred doctor who listens to the patients priorities and tries to minimise the potential for the harms of polypharmacy would be rated as poorer doctor on measures of care that are tied to adherence to disease based guidelines and targets.
Doctors more and more feel the pressure not to discontinue medications in order to remain congruent with ‘best practice’. This is made worse when faced with health policy pronouncements that variation in practice is bad and standardization is the answer to improved health outcomes. It can drive doctors to initiate or continue prescription, where they otherwise wouldn’t. It has over-focused the medical system on efficacy and on initiating and continuing treatments.
There are some patients who do need many medications. But being realistic, most people taking long term medicines are not benefiting from them.
For half of people taking a medicine to be benefit, the ‘Number Needed To Treat’ would be 2 – that is for every 2 people that take a medicine, 1 benefits. The Number Needed to Treat for most drugs used for chronic disease is well into double digits. This means that most are exposed to the risks without hope of benefits.
Even these estimates of benefit are optimistically skewed by commercial and publication bias towards positive results. Until we have access to patient level data for independent analysis, the work of the Cochrane Tamiflu group and Peter Gøtzsche’s Nordic Cochrane Group show we can’t really know how great these benefits are likely to be, nor the extent of the potential harmful effects.
Drugs are frequently being taken by patients on the basis of data on surrogate outcome measures, which are just numbers and rating scales, rather than things that really matter to patients. When things that matter to patients are finally measured, on average the treatment effect estimate was nearly twice as high in the trials using surrogate outcomes than in the trials using final patient relevant outcomes.
Using preventive treatments in older age can simply shift the causes of illness and death without making life longer or better. We are like cars – if the clutch, the alternator and the piston are all failing, putting in a shiny new clutch won’t make the car go better or last longer.
Doses in the older age group is often higher than needed because of reduced body mass, and because starting doses from trials are often too high even for younger adults.
Things that are risk factors at a younger age don’t play out the same way in older age, and sometimes the relationship even reverses. For example blood pressure – older people need a slightly higher blood pressure, and applying the guidelines for younger people can be dangerous.
But maybe because we are sensitive about ageism, we think it a good thing to start medicines for the elderly also and we are nervous about stopping, when, given the data, the reverse should be true.
As medicine becomes increasingly specialized and subspecialized fragmented prescribing means fragmented responsibility – the more prescribers you have the more likely you are to have an adverse effect from your medicines.
Most people on more than five drugs have never had a review of their medication. Why is this?
The whole framework of medical care is centred around the therapeutic imperative to ‘do things’. There is really no less-is-more framework to not doing things or stopping things.
We desperately need a new kind of preventative medicine – Quaternary Prevention, which is the process of preventing the harms of excess medical care. Without a review and trial of discontinuation there is often no way to know whether a drug is still needed – if blood pressure is normal the assumption is that it’s the pills that are keeping it that way – but blood pressure medications can often be withdrawn in older patients without the need for restarting.
This is not just a matter of taking a pill for nothing. Pills for blood pressure lead to a higher rate of falls resulting in serious injury such as hip fracture and head injury.
When prescribing gets fragmented, you are the Patient may be the person best placed to help start the conversation about deprescribing. You can set the doctors mind at rest about ageism. You are the person best placed to ensure you get what-matters-to-you medical care rather than treatment for diseases.
Trials of multiple medication discontinuation ‘deprescribing’ show that this can be done successfully and that it leads to lower death rates and less hospital admissions.
Deprescribing is the process of working out whether you would be better off on less medicines, or a lower dose of some of your medicines. It needs an ongoing conversation with your doctor pharmacist of nurse practitioner around what matters most to you and what the risk benefit balance looks like for you or each of your drugs.
Deprescribing might mean having a controlled ‘pause’ in one or more of your medications, carefully monitoring what happens and then using this information to decide whether ‘less is more’ in this case. Think of it as a drug holiday. It might mean lowering a dose and observing what happens rather than stopping.
Teamwork is important because there are some drugs you shouldn’t stop suddenly and there are others where successful discontinuation is more likely if you taper the drug slowly – this includes diuretics, blood pressure medications, antipsychotics, proton pump inhibitors and others.
At RxISK we are interested in trying to find solutions – helping support the teamwork between doctor and patient around polypharmacy, and helping you work out whether you might be on too many drugs or could benefit from a lower dose of some of your drugs. We’ve used a parrot as the logo – parrots are chatty birds, they hang around where cocktails are served and they’re also intelligent. We’ve tried to create something that will help start the conversation and in doing so overcome some of the barriers to addressing polypharmacy.
Calculate your RxISK Polypharmacy Index by checking on some of the things that increase the risk of you taking a drug cocktail that’s of more harm than benefit to you. The higher the number, the more you need to start the conversation with your doctor and / or pharmacist. You can print out the responses to the questions and your score to take with you and form the basis for intelligent conversation with your doctor, pharmacist or nurse practitioner.
Use our Interaction Checker on this site to see if there are any possible interactions between your drugs and illnesses. You’ll have to log in the first time to use this as we have to pay a small fee on your behalf any time someone uses the service.
(If you find it useful and want to make a donation to help support this that would be great too!)
Dr. Derelie (Dee) Mangin
David Braley and Nancy Gordon Chair in Family Medicine
Dr. Mangin’s research focuses on contributing significantly to the body of scholarship on family medicine; developing, implementing and evaluating curricular innovations; undertaking quality research dedicated to evaluating the critical role of the family physician; and developing improved models of family medicine and primary care service.
The chair is being supported by a donation from David Braley, president of Hamilton-based Orlick Industries Limited, and his wife Nancy Gordon, a registered nurse who trained and practiced in Hamilton hospitals.
One the most readable and useful column to appear on this site. Congrats to Dr Mangin
Pierre Biron, Montreal
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.
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
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.
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.
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.
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.
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!
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
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.
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.
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?
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!
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.
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