Lentis/Medication Overload

Introduction

‌Medication overloading is the use of multiple medications for which the harm to the patient outweighs the benefit. There is no strict cutoff for when the number of medications becomes harmful, but the greater the number of medications a person is taking, the greater their likelihood of experiencing harm, including serious adverse drug events. This term is very similar to polypharmacy, a scientific term describing the condition of taking multiple medications. Usually, the threshold for polypharmacy is five or more medications, although the cutoff varies because there is not a single agreed-upon definition.
‌Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. Over the last decade, older people sought medical treatment or visited the emergency room more than 35 million times for adverse drug events, and there were more than 2 million hospital admissions for serious adverse drug events ^[1]. Older adults are hospitalized for adverse drug events at a greater rate than the general population is hospitalized for opioids ^[2]. The problem of medication overload has remained hidden largely because the practice of excessive prescribing is deeply embedded in American health care.

The History of Commercial Drugs

Start of Regulated Medication (1820’s - 1940’s)

‌Over the past 200 years, therapeutics have grown and changed. In 1820, eleven doctors set up the U.S. Pharmacopeia and recorded the first list of standard drugs.^[3] In 1848, the Drug Importation Act was passed by Congress requiring U.S. customs service inspections to help stop entry of tainted or low-quality drugs from overseas. In 1905, the American Medical Association began a voluntary program of drug approval, drug companies must show the drug will treat what it is claimed to.^[4] On June 30th in 1906, with the passage of the Pure Food and Drugs Act, an early form of the Food and Drug Administration is created. Later in 1938, amendments were passed to the Pure Food and Drug Act that brought the abuse of non-narcotic medicines under the responsibility of the FDA.^[5]

Mid-Century Development (1950’s - 1970’s)

‌After WWII there was an amazing development of new medicines: tranquilizers, new amphetamines, barbiturates, and opioids. The national marketing of these medicines increased their use. This post-war era brings with it affluence, social change and mass use of medicines and drugs. The predecessors to the modern Drug Enforcement Administration and other government and private organizations begin setting up education programs to stem the tide of abuse and addiction. ^[6] Later, the Comprehensive Drug Abuse Prevention and Control Act of 1970 is enacted as a United States federal law requiring the pharmaceutical industry to maintain physical security and strict record-keeping for certain types of medicines. Controlled substances would be divided into five schedules (or classes) based on their potential for abuse, accepted medical use, and accepted safety under medical supervision. Then in 1972, the OTC Drug Review was conducted as a means to review the safety and efficacy of OTC ingredients, doses, formulations, and labeling used in medicines available to consumers without a prescription.^[7]

The Modern Day Pharmacy (1980’s - Present)

‌In the 1980s the problems posed by drugs continue to escalate. The Anti-Drug Abuse Act of 1988 is passed to help coordinate the U.S. Government’s efforts to control drug abuse and medicine diversion. A position is created in the White House – the Director of National Drug Control Policy often called the “Drug Czar”. In 1989, the FDA issued guidelines asking drug makers to determine if a drug is likely to have usefulness in elderly people and to include elderly people in studies when applicable. In 1999, an update to the previous law for Patient Package Inserts requires the drug companies to subscribe to a standard and easy to read format for all drug Facts Labels on OTC products. A year later in 2000, the rise of the Internet creates a growing problem as people are going to illegitimate websites to fill orders for medications without a prescription. The DEA sets up special units to monitor and shut down such illegal “pharmacies”.^[8] The Drug Safety Board is formed in 2005 to advise the FDA on drug safety issues and to work with the FDA to share safety information with health professionals and patients. Today, more than four in ten older adults take five or more prescription medications a day, an increase of 300 percent over the past two decades.^[9] Nearly 20 percent take ten drugs or more. When over-the-counter medications and supplements are included, the number of older people taking five or more drugs rises to 67 percent.^[10] More than ever the drug problem is rising.

Causes of Medication Overload

Comic illustrating medication overload

‌No single cause explains the dramatic rise in the number of medications older people are taking. Rather, a broad array of forces is at work, with four overarching aspects of our health care system contributing to this epidemic.

Culture

‌The culture of prescribing has convinced patients and clinicians that there is a “pill for every ill. Taking a lot of medications can be seen as the norm in today's society. Massive pharmaceutical companies directly market to consumers, the U.S. is among two countries, the other being New Zealand, that allows this to happen. The big pharma companies not only push consumers to buy their products but also put pressure on doctors to prescribe their drugs.

Lack of Ability

‌Clinicians and patients lacking critical information and skills needed to appraise the evidence and make informed decisions regarding medications. Doctors are being trained to treat symptoms and in doing so this can lead to a cascade of prescriptions and ultimately an overload. Each illness is treated separately, often tacking on another pill to the patient's daily intake.

Fragmented Systems

‌The fragmented health care system contributes to this problem, with its multiplicity of health care professionals in a variety of settings, leading to more — and more inappropriate — prescribing. It can be hard for doctors to coordinate with each other regarding the patient's history taking medicines. The information is not properly shared amongst all, and this can lead to incompatible drug mixing.

Lack of Regulation

‌The only regulation relevant to this issue is the FDA's drug labeling guidelines, requiring labels on consumer products to include product identify, business identity, and product contents. This was meant to serve as a means to increase awareness of drugs' uses and side effects. However, low health literacy rates, especially among the elderly, mean that the labels do little to enlighten users about their situations.^[11]
‌Current regulations do combat the over-use of drugs but as part of an addiction issue. Over-use of drugs due to addiction is fundamentally different than the over-use of drugs due to polypharmacy. A drug is craved, requested, prescribed, and obtained due to an individual's want to continue using. In polypharmacy, a doctor prescribes medication to combat specific symptoms resulting in the unintended consequence of a snowball of medication due to side-effects of the prescribed medication.

Current Means to Combat the Problem

‌The medication overload afflicting millions of older adults is a complex problem, with many causes and agents and no easy fix. A combination of a holistic, multi-pronged set of policies, regulations, and payment models, as well as changes in both the training and practice habits of health care professionals, have been seen to combat the trend of polypharmacy. A comprehensive set of solutions includes interventions to help prevent excessive prescribing as well as interventions to promote judicious discontinuation of medications that are inappropriate, potentially harmful, or no longer necessary. Interventions address the three main drivers described previously: the culture of prescribing, information and knowledge gaps, and our fragmented health care system.

Changing the Culture of Prescribing

‌Several campaigns have been launched to address the risks associated with the intake of multiple medications concurrently. The campaigns aim to bring awareness to patients about these risks and encourage conversations with their healthcare providers about reducing the number of medications taken. The EMPOWER campaign conducted by researchers of the University of Montreal mailed informational pamphlets to older patients in hopes to reduce inappropriate benzodiazepine prescription doses. After 6 months, the campaign reduced benzodiazepine use in patients aged 65 years older by 27 percent in comparison to a control group. ^[12] However patient education is only one part of medication overloading intervention. Shared decision making is the idea healthcare providers get to know patient goals and values, so both parties can decide on the best treatment plan. Good shared decision making is dependent on the patient's knowledge of their current condition, and treatment risks and options. Thus, patient-provider communication skills are vital in this process. Ming Tai-Seale, a professor from the University of California San Diego, asserts "patient-provider communication and shared decision making are essential for primary care delivery and are vital contributors to patient experience and health outcomes." ^[13]

Informing and Increasing Knowledge

‌ There is little regulation and guidelines for deprescribing and medication checkups. Deprescribing is defined as "the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit."^[14] There are disease guidelines that address how to add drugs to a prescription, but little mention when or how to stop them. Bruyère Research Institute has developed evidence-based deprescribing guidelines. Each of their guidelines contains an infographic, patient pamphlet, and a decision algorithm illustrating the best way to deprescribe a medication.
‌Along with guidelines and regulations, a few Universities and health accrediting bodies are attempting to address medication overloading in their curriculums. For example, "the University of British Columbia in Vancouver, Canada, includes prescription risks and deprescribing in the curriculum for first-year-medical students and second-year pharmacy doctoral students." ^[15]

Creating Centralized Care

‌ Health care delivery such as integrated health systems and team-based models of care are becoming more common and play an integral part in deprescribing. Integrated health systems can increase care coordination and communication among the different parts of a patient's healthcare. Kaiser Permanente (KP) health system "integrates hospitals, physicians, and health insurance under the same systemwide EMR and global budget." The integration of these 3 systems allows clinicians to access the same records and communicate better with patients. Coordination is also improved among clinicians to decide on the best treatment. Improved communication can reduce medication overload by ensuring excess medications are not prescribed.

Participants

‌It is the interaction between participants that keep up a negative cycle of repetition that sees the number of prescriptions grow. This web of interactions pushes each group to seek out medication for every symptom. It is important for people to realize the pressures behind decisions, and whether those decisions are ultimately beneficial.

Doctors

‌Doctors are the ones who prescribe medication. However, many doctors such as Dr. Caleb Alexander realize the issue: "A cardiologist puts someone on good, evidence-based medications for his heart... an endocrinologist does the same for his bones... pretty soon, you have an 82-year-old man who’s on 14 medications.” According to Dr. Dima Qato, even though doctors are ware of patients taking many drugs, they might still prescribe additional medication because they are "not paying attention to the interactions and safety of multiple medications," leading to "a major health concern."^[16] Once doctors do know of the issue, few oppose de-prescribing.
‌Many times, doctors are not aware of their patients taking drugs or supplements. A study by JAMA Internal Medicine noted that at least 42% of patients did not tell their doctors of their most commonly used supplements or other drugs. This usually happened because the patient didn't feel the doctor needed to know, and the doctor hadn't asked.^[17]
‌Doctors receive pressure from multiple fronts to continue prescribing. Some patients think that there is a medication for every illness and pressure doctors. Drug companies also give incentives to hospitals and clinics to prescribe.

Patients/Consumers

‌In 2000, half of adults in the U.S. were taking at least one prescription drug; by 2012, that number had grown to nearly 60 percent.^[18] Not only are more people taking prescription drugs, but they are also taking a greater number of drugs. The drastic rise in these prescriptions has negatively affected the health of those that consume them, cases of delirium, falls, and death have risen. For older adults, taking 6 to 9 medications is associated with a 59 percent greater chance of death compared to taking no medications. Taking 10 or more medications is associated with a 96 percent greater chance of death.^[19]
‌Patients can be divided into two categories. Some patients believe that doctors are withholding medication and seek out additional treatment. This group many times is influenced by pharmaceutical companies advertising their products as hugely beneficial.^[20] Many patients, however, are starting to become frustrated with polypharmacy. According to Carla Moore, “each time she returned with a new health complaint, including a side effect from a drug she was taking, she says her doctor wrote a new prescription.” ^[21] Many patients know that there is a problem, but they do not know who to talk to.

Drug Companies

‌Drug companies seek out profit. Though they are regulated by the government, being a big industry with billions of dollars means there is a high incentive to keep pushing products. "The pharmaceutical industry plays too large of a role in influencing care practitioners and policy guidelines, and thus an overemphasis on medications" exist.^[22] The United States is also one of the few countries where drug companies are allowed to market to consumers and patients directly. This directly affects the amount of medication prescribed because patients who ask for specific medications are much more likely to have something prescribed as those who simply wait for a doctor's diagnosis.^[23] Drug companies also apply the largest pressure on doctors to prescribe, by giving incentives to clinics and hospitals. There seems to be no end in sight.

Conclusion

‌If nothing is done to change current practices, medication overload can lead to the premature deaths of at least 150,000 older people in the U.S. over the next decade. Strong, coordinated, and immediate action between different sectors in the healthcare industry is needed to stem the tide of this epidemic. Unseen relationship of pressures have pushed the healthcare industry to cultivate a culture of overprescribing medications. As a result, a trend of increased number of different medications have been increasing. Cooperation among the pharmaceutical industry, healthcare providers, and patients, is needed to effectively deprescribe as "a pill for every ill" treatment model is not optimal - as Abraham Verghese said, "treat the patient not the CT scan." Further analysis of countries experiencing similar problems and how they are overcoming this issue is needed to examine better ways to battle overload medication.