We hear a lot about how the opioid crisis is destroying families and communities. But the scope and impact of medication overload is much bigger: in the last two decades the number of older adults taking five or more medications has increased 300 percent. There’s also been a spike in the number of serious adverse drug events (ADEs). These alarming facts and others are outlined in a new report from the Lown Institute titled, “Medication Overload: America’s Other Drug Problem.” Jana talks with the report’s co-authors: Judith Garber, a Health Policy and Communications Fellow at the Lown Institute; and Shannon Brownlee, Senior VP at the Institute and author of the book, “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.” Judith and Shannon talk about the dangers of medication overload, what’s driving the practice, solutions that have been effective in tackling the problem and what you can do to prevent adverse drug events.
TIPS FROM JUDITH AND SHANNON…
Before adding another medication, ask your doctor these questions to avoid unnecessary medications and set a “stop date” for medications that aren’t meant to be taken long-term:
- What is this medication for? What disease is it treating?
- Is there evidence that this drug is effective for patients of my age and with my medical conditions?
- Out of 100 patients like me, how many are helped and how many are harmed by this medication?
- How will we know when the medication is working or not working?
- Can I start on a lower dose and see if that works?
- How long should I take this medication? When should I stop taking it?
- Do you know how this medication might interact with other drugs I’m already taking?
- Are there side effects I should watch out for if I take this medication?
INTRO CLIP AND MUSIC
JANA: My 90 year-old mother is currently taking Lisinopril, Atorvastatin, Levothyroxine, Omneprezol and Wellbutrin. It sounds like a lot of prescription medications, but compared with other older folks I’ve spoken with, Mom’s pill rack isn’t that full. In fact, in the last two decades, the number of older adults taking five or more medications has increased 300%. There’s also been a spike in the number of serious adverse drug events or ADEs. These alarming facts and others are documented in a new report titled, “Medication Overload: America’s Other Drug Problem.” The report was just released by the Lown institute, a nonpartisan think tank calling for a national plan of action to tackle overprescribing in America. Here with me to talk about the report are its co-authors, Judith Garber, a Health Policy and Communications Fellow at the institute, and Shannon Brownlee, Senior VP of the Institute and author of “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.” Judith and Shannon, welcome to the Agewyz Podcast.
JUDITH: Hi! Thank you.
SHANNON: Happy to be with you.
JANA: Great. So as I mentioned, the report’s titled, “Medication Overload.” Could one of you define medication overload, for folks who just aren’t familiar with that term?
SHANNON: Sure. This is Shannon, and thanks again. So some people may have heard the term polypharmacy. That’s a scientific term that’s used to say that someone is taking five or more drugs. And polypharmacy doesn’t necessarily mean something’s bad. There are certainly plenty of people who can take five or more drugs and need to take them, and those drugs are being very well managed. They’re the right dose for that patient and everything’s doing pretty well. Medication overload is a term that indicates that there may be a problem, that there may be unrecognized side effects from one or more drugs, that there are drugs that may be treating side effects of other drugs and that there’s a need to really examine what drugs the patient is on and whether or not they’re the right dose for that patient. So medication overload is sort of the negative term and polypharmacy is a fairly neutral way to simply described taking a lot of drugs.
JANA: Uh Huh. Polypharmacy is a term I can only guess at because of the five years of modern Greek my parents forced on me. Um, I know that “poly” means “many” in Greek, and “pharmakeia” means “medicine”. So that’s one good thing I got out of that. So lots of people take more than five drugs for multiple chronic conditions, but not all are at risk. So what factors might put them at greater risk of a serious, potentially life threatening side effect?
SHANNON: Yeah… I’m going to let Judith get in here, but just very briefly, you can think of polypharmacy, the neutral, sort of semi-neutral term as kind of a risk factor. Just like having high cholesterol doesn’t mean you have heart disease. It just means you have a risk factor for having heart disease. And the same way you know, taking five or more drugs is a risk factor for something going wrong. So Judith, do you want to address her question?
JUDITH: I would say another… well, just as taking five or more can be a risk factor, but there’s a big difference between taking 6 medications and taking 16 medications or 26 medications, which is also not unheard of. And the more medications that you’re taking, the greater your risk for an adverse drug event. Also, certain medications have different effects and different effects with each other. You probably are aware that taking benzodiazepines along with opioids can have a pretty bad effect together, and other drugs together can have bad effects. Also, transitioning between the hospital and a skilled nursing facility or home and hospital– those transitions are when sometimes drugs can be added without knowing the patient’s full medication list, or continued in the community when they’re not meant to be. And that can put people at risk of an adverse drug event.
JANA: Right. You used a really great story with a patient named Joseph who lives with his wife in Akron. There are some great graphics in this that as someone like me who has no real scientific background, it’s really helpful to understand the journey that this person went on who began at age 65 with a series of diagnoses that led to his being put on medications that was complicated along the way by the fact that his opioid prescribed by the hospital for a broken leg, was followed by his primary care physician prescribing a medication for sleep, unaware that the hospital had previously given him an opioid script. So could you talk a little bit about how Joseph’s story as an example, and how his story ends without interventions versus with interventions? That’s just a really great story.
JUDITH: Sure. So in our final report we actually changed the name of the patient to not be confused with an actual person that we tell the story of whose name was Joseph, but in this hypothetical patient story we actually talked to a few clinicians to make sure that the story made sense, uh, and was something that could be believed. But as you sort of go through the patient’s story– this is in the Lown report– a big theme running through the report is that none of the different clinicians in the different care settings are talking to each other. So the primary care doctor doesn’t know that his cardiologist put him on another blood pressure medication. Neither of them know that he got an opioid in the hospital, and also none of them are necessarily taking into account his other medications when they’re prescribing more. And eventually what ends up leading to a really bad effect is that he has the flu and gets dehydrated, which is something that often happens for older people, but then if you’re not eating or drinking, then medications have even a larger effect on your body.
SHANNON: So there’s sort of two problems here, and it’s important to recognize that both can be going on at the same time. One of them is that there are particular drugs that should be worried about for really anybody, but particularly for older adults. The opioids for sure can really pack a wallop for older adultsm, but so can benzodiazepines. These are drugs that are often prescribed for anxiety or for sleep. Valium is one example. Those are particularly problematic drugs. Believe it or not, high blood pressure medication can be really problematic, especially if a patient is on more than one of them and the patient can get dizzy and fall, which is a really, really catastrophic event for a lot of older people. So there are certain drugs to watch out for. But the problem is exacerbated by the fact that doctors in different settings in the hospital, in the nursing home, in the primary care clinic and the cardiologist’s office, they don’t communicate. And so they may be prescribing at cross purposes, or they may prescribe a drug to treat a symptom of another drug that they don’t necessarily know the patient is even on. Or they may prescribe duplicate versions of the same class of drugs. This is a real problem with the high blood pressure medication. So if you’re on one high blood pressure medication and then somebody else sees that your blood pressure isn’t quite as low as they might like and puts you on another one, one effect can be dizziness and falls. So those two things are going on. There are particular drugs to be worried about, and then there’s the lack of communication in the healthcare system.
JANA: To put this in context, I think it’s important to note how this compares with the opioid crisis. And I was really shocked to read some of your findings with regard to the scope of this problem versus the opioid crisis, which we’ve heard a lot about and we are finally addressing. I wonder if one of you can put this into context, comparing it to the opiod crisis.
JUDITH: Sure. So we really did want to make that comparison because we know how big of a reaction the opioid crisis has gotten in terms of media attention and policy. So over the last 10 years or so, there have been 3.2 million opioid-related hospitalization in adults of all ages. So that’s all adults, that’s 3.2 million. That’s a lot of hospitalizations. And in the same amount of time, there’ve been about, a little more than 2 million hospital admissions for adverse drug events, but just for older adults. And older adults are only about 15% of the population. So, you know, about two thirds the amount, that’s opioid-related hospitalization. And that’s just for that small population. So that really, I think, shows how big an issue that is.
JANA: And you define older adults as people who are age 65 and older, correct?
JANA: So in the report you essentially note that in our culture of prescribing there’s plenty of blame to go around, and that healthcare providers, patients and industry all play a role. And Shannon, you sort of touched on this problem of communication earlier, which I have certainly experienced. I bet you guys have experienced as well. You see this as a systemic problem driven by complex social and cultural factors. What are some of the social factors that make this a difficult problem to solve?
SHANNON: Yeah, yeah, it’s a very difficult problem. So one of them is that doctors want to help their patients. Most doctors go into it for all the right reasons and what they want more than anything is to relieve suffering, to cure whenever they can, to prevent illness down the road, to prevent disability. And one of the easiest tools, and sometimes best tools that they have to do that, are drugs. So the patient comes in with a problem– and let’s use a really simple one– the patient comes in with an upper respiratory infection, and the patient thinks that antibiotics are the thing that is going to fix that respiratory infection because they’ve taken it in the past. And the physician has a choice at that point, when the patient says, Gee, can you just give me a Z-pack? The doctor can say, you know, you’re almost certainly not suffering from a bacterial infection. You’ve almost certainly got a virus and the Z-pack isn’t gonna do anything for a virus. And all it’s going to do is upset your gut and lead to increased antibiotic resistance. The doctor can do that. The doctor doesn’t have very much time, or the doctor can write a prescription and send the patient out. The patient feels good, the patient feels cared for. My doctor wrote me a prescription. The doctor feels like I made my patient happy. So that’s one of the cultural pieces of it.
SHANNON: Now, interestingly, doctors also often believe– and studies have shown– that they think that older patients in particular are very reluctant to stop taking drugs. They have this idea that if they suggest taking the patient off a drug, that the majority of patients are going to say, no, my cardiologist prescribed that and I know I need it because I’ll die if I don’t have, if I don’t use it. Or the patient may say, well, Gosh, why do you want to take me off any drugs? Are you giving up on me? Am I so old that you don’t care if I die? And in fact, patients may be more willing to get off at least some drugs than physicians think. But there’s this real set of assumptions. Patients go in expecting something to be done. The doctor’s easiest path is often to just write a prescription, and the communication doesn’t happen. There isn’t a real conversation that happens. So that’s one of the culture pieces. The other piece of it is, we think there’s a pill for everything. We think that, you know, that anything can be fixed with a pill. You can eat anything you want, you can never exercise, you could take that statin and you’re never going to have heart disease. We have this magical idea about pills. And that’s been driven partly by the pharmaceutical industry for sure. So that’s a piece of it as well, is that patients and families think that drugs are probably a lot more effective than they are.
JANA: You have to be super vigilant. I mean I know when I was living with my mom– I live with her for three years after my father died, and during that time she was on a variety of medications that could easily have produced an adverse side effect had I not been there. In fact, she was on, I think it was Gabapentin or Lyrica, and we were going to an event in Washington DC where I grew up, and we were outside and she was pitching forward really sharply. And she said, I don’t know why I feel like I’m about to fall over. And I racked my brain to think, did we start a new medication? What’s she on? And I think it was the Lyrica that was causing the adverse effect and we took her off it. But had I not been there to sort of be really vigilant, you know, she would have continued to take it because she was at that point 80 years old and grief-stricken because of my father’s death. So I wondered if you found the rate of adverse side events more common in older adults who don’t have a caregiver? Or if that’s something you even looked at.
SHANNON: We didn’t look at that. And that’s a very interesting question. On the other hand, some families drive some of the prescribing. So they may be the ones that say, you know, isn’t there– can’t you put the patient on this drug or that drug? So, if it’s a savvy caregiver, a really well-informed caregiver, which, boy, was your mother lucky she had you, the likelihood of an adverse drug event because of an unnecessary medication or a medication that patient just can’t take, having that kind of a caregiver who’s really vigilant is a benefit. So I can tell you a little story about my mother. So my mother is 89 and she had a little episode that landed her in the hospital and they thought it might be a heart attack and it wasn’t. But the cardiologist saw that her cholesterol was a bit high and that her blood pressure was a bit high. So he prescribed an opioid because she’d come in with a headache, a statin and a couple of blood pressure medications. She was already on one blood pressure medication. And I instructed my brother to ask the cardiologist if maybe that wasn’t a lot of new drugs for a woman who was taking only one drug. And the cardiologist said, no, there’s nothing wrong with taking all these drugs. Then when my brother took her to the primary care doctor that week, they said, no, don’t even fill any of those prescriptions. This is not appropriate for this patient. And it’s not that the cardiologist was wrong. It was that the cardiologist was prescribing to guidelines. And we can talk a little bit about that if you’d like, as one of the big drivers, but without me knowing a fair amount about polypharmacy and medication overload, and my brother being vigilant and willing to question these prescriptions, my mom would have been on a bunch of new drugs. And she’s already a little dizzy as it is.
JANA: Right. Judith, have you had any experience of this in your own family?
JUDITH: Well, my parents are a bit younger. They’re just turning 65, so they’re actually both retiring this year. And I actually haven’t asked them about their medications, but doing this research has sort of made me think I should.
JANA: I think it’s time.
JUDITH: It’s a little bit touchy, though, now that I think about it. How am I going to start that conversation? It seems a little intrusive, even though I am their daughter. Something I remember though with my grandmother, when we used to visit her back, I guess when I was a kid in the ’90s, I remember seeing her pill organizer– the box of like, take it Monday, Tuesday, Wednesday, Thursday, Friday, all the days, and all the pills in the box, and I think that really influenced me in how I thought about what it means to be older. You know, you see this when you’re younger and you think, okay, when I’m older I’ll be taking that many pills too. And we know that now, you know, 20 years later, it’s gotten much worse. Now there are a lot of patients who need two pill organizers to even fit all their pills in. But I think that has something to do with why we think it’s normal for older people to be taking many medications. Because we see it when we’re younger and it seems normal.
JANA: Yeah. I was really surprised to read that learning about the dangers of excessive prescribing is not a mandated, formal part of the curriculum for either physicians or nurses, physician assistants and other health professionals. It’s not required at any level of the learning process for medical professionals. I wonder if one of you can elaborate on the information and knowledge gaps that exist among both clinicians and patients.
SHANNON: Yeah, I’ll start. There are two, sort of parts to this. One of them is what clinicians, doctors, nurses, physicians assistants… what did they learn in school during their training? And then what kind of information do they rely on when they’re taking care of patients at the point of care? So at the point of care, one of the things that they rely on very heavily are things called clinical guidelines. And these are guidelines that are written by the various specialty societies. So there’s the Academy of Cardiology, there’s the surgeons, there are the rheumatologists, the kidney specialists… each of the societies writes guidelines for their particular conditions. And often it’s kind of organ-based. So the kidney specialists focus on diseases of the kidney and they focus on treatments for diseases of the kidney. Cardiologists focus on diseases of the heart. And these guidelines are written, one hopes– they aren’t always– uh, but one hopes they’re written on the basis of the best available evidence. Now some guidelines are better than others, but very few guidelines give really clear instructions to doctors, to nurses, to physicians assistants, about how they need to treat older patients differently and how they need to treat older patients with multiple illnesses differently. So what happens is, doctors do something that’s called treating to the guidelines. So the guidelines for blood pressure for cardiologists, or for primary care, say you should keep the patient’s blood pressure under 130 over 70. I’m making those numbers up. And so the patient comes in, and the patient’s got blood pressure, that’s, you know, 140. So they say, okay, I can give you blood pressure medication. And that may not be the right thing for an older patient who has multiple illnesses, who has maybe already a little bit frail.
SHANNON: So the information that they’re getting at the point of care is not always helping them make a decision that’s right for that patient. If they’re treating to the guidelines. In addition, they get paid based on how well they adhere to guidelines. And that’s a real problem. That’s a real problem. Especially for primary care. Primary care doctors get dinged by the insurance companies if they have a bunch of patients whose blood glucose level isn’t hitting the mark, and that may not be the right way to treat that patient, especially an older patient with multiple illnesses. But before that point of care happens, there’s a training process. And we have been going through a period of healthcare and medical thinking over the last 50 years that has not thought about what it means to do too much. What overtreatment is. And I’m particularly interested in this because I wrote a book about overtreatment about 11 years ago, but it was a largely unrecognized problem. And so training programs haven’t thought that they needed to get people to really be careful about not prescribing too much. So doctors and nurses and physicians assistants just aren’t trained to be aware of medication overload, much less know how to do anything about it.
JANA: Wow. This is kind of a conspiracy theorist question, but do you think the insurance and pharmaceutical companies have a hand in discouraging this educational piece? You know, you hear about these surprise hospital bills, and you go into a hospital that you think is covered by your insurance plan only to find out the physician doing the procedure is not in the plan and then you get this huge bill. I just feel like the insurance companies might have a hand, or the pharmaceutical companies, may have a hand in the training piece of this. But again, this is a conspiracy theory.
SHANNON: Well, they do. They play a very, very important role. So the pharmaceutical industry plays an outsize role in what we know and what we don’t know about how the human body works and how to treat disease. The pharmaceutical industry pays for more than three quarters of clinical trials in this country. So a clinical trial is a study that involves human subjects. And the pharmaceutical industry, not the federal government, which should be paying for most of these trials, but the pharmaceutical industry is paying for the trials. And that means that the kinds of trials that get run are really all about drugs. And the way those trials are run is not always really, really sound science. There’s bias in the science. But there’s even more bias in the way the results are reported in the journals. And there can be bias in the way the guidelines are written. So the pharmaceutical industry has this outsized effect on what we know and what we don’t know. But the other way the pharmaceutical industry drives what clinicians know and don’t know is that they pay for a great deal of continuing education. So all nurses and doctors, to keep their credentials, need to do continuing education I think every year, and the pharmaceutical industry figured out that it could sell more product if it could influence that training. And they influence it very, very heavily. So yes, indirectly and directly, Pharma has had a hand in what your doctor actually knows about the drugs that he or she is prescribing.
JANA: And that sort of dovetails with the financial piece of this in terms of the impact of costs. You wrote that high costs can lead to non-adherence and anxiety. And again, this is because of the pharmaceutical industry driving costs. I wonder if you can elaborate on the impact of costs.
SHANNON: So when you think about sort of the cost of pharmaceuticals– we’ve been focusing on the price, and prices are egregiously high for so many important drugs. But the other part of it is how much we consume. And so the more drugs you’re on, obviously, the more costly it is to pay for those pharmaceuticals. So the drug industry has had a really kind of pernicious effect on this problem of medication overload. And in some ways we want to demonize the industry, but in fact the industry is playing by the rules that we set up. We basically said this is a capitalist system and these are publicly traded companies and their fiduciary duty is not to patients, it’s to shareholders. And so their goal is to sell as much product as possible given the regulations around them. So the problem is that we, the people have not insisted on regulations that benefit us. We’ve let the regulatory regime permit a lot of drugs onto the market that aren’t necessarily as beneficial as they are claimed to be, and may be more harmful. And we have not been willing to insist that physicians and other prescribers really understand what the benefits and harms are. And I know I’ve just made a whole lot of doctors really upset by saying, I don’t necessarily know about this drug that they’re prescribing. But the fact is, how can they? Because so much of it is hidden.
JANA: Yeah. Well, I mean, and it gets back to your earlier point that doctors want to do well by their patients. Their primary goal is to take care of people. That’s– I assume that’s why most of them go into the profession to begin with. Judith, did you want to add anything to that?
JUDITH: Yeah, sure. So we know that there’s a significant number of older people who don’t take all the medications that they’re prescribed because they can’t afford them. And as much as we want doctors and patients together to be able to de-prescribe unnecessary medications, it shouldn’t be that people just stop taking their medications because they can’t afford them. That’s not a healthy thing to do. So being on too many medications increases your cost, and then you might not be able to refill the prescription that you really, really need because you’re on so many drugs that you shouldn’t be on.
SHANNON: So, the sheer number of drugs, the sheer number of drugs that people have to take, ends up being a burden by itself. It’s confusing. It’s exhausting. And patients don’t necessarily stop taking the ones that they should be stopping, and they don’t always take the ones that they really need. This is a real problem.
JUDITH: I was reminded of something– one of our doctors in our working group, Dr. James McCormick, was telling a story about an older patient that’s, I think, 92, who was on about 20 medications and she just didn’t have any time to eat. There was no room for food in her day because she was trying to take all the medications.
JANA: Oh my God. And then you have to throw in the fact that many of the folks who have to take these medications have dementia and they can’t remember when to take things. So how is the US doing compared with other countries? I’m almost afraid to ask, but… compared with other high income countries, in addressing medication overload?
SHANNON: Well, I’m sorry to be laughing because it’s a pretty serious problem, but the reality is is that um, most other high income countries are suffering from the same problem. They may not have it to quite the same degree, but they certainly are suffering from medication overload. The difference is that a number of countries– the UK, Canada, Australia, Sweden– have a little bit of a headstart in terms of addressing the problem. So when we created this report, we relied heavily on a group of advisors and a working group of experts, a number of whom are Canadian. Because they’ve had experience with trying some remedies to the problem, and because they’ve got a headstart on trying to publicize the problem in Canada and get patients and families and clinicians and pharmacists aware of the severity of the problem.
JANA: And so what are some of the remedies that they’re taking?
SHANNON: So we recommend in the report, the Lown Institute created this report in part to kind of highlight the problem. But we also didn’t want to stop there. We think it’s very important that there be real efforts to come up with a strategic plan for addressing medication overload, and so this report includes a few of the solutions that are being worked on right now and that have been found to be effective. One of the things that’s really important is to engage patients and families. And one of the most successful trials of an intervention is called the Empower Study. And it’s pretty simple in concept, but quite powerful in terms of outcomes. The study mailed a brochure to patients who are on a particular kind of drug, on benzodiazepine, and just very simply laid out a few of the reasons they might want to consider not taking this drug. And Judith, if you’ll fill in some of the details on that– Judith is more familiar with this study than I am– but there’s some really interesting results to take away from that study.
JUDITH: Yeah, that campaign ended up leading to about a 22% greater reduction in benzodiazepine use among these older adults who got the brochure compared to the control group. So that was an interesting thing. It wasn’t just the campaign, it was a campaign compared to a similar group of patients that did not have the intervention of the brochure. They also found when they were talking to patients who didn’t taper, they said that they had asked, but they had sort of been discouraged by either their doctor or a pharmacist, which led them to think that they should also, not to keep mailing stuff to patients, but at the same time try and get the clinicians and their primary care doctors, or their pharmacists, to understand that it was important to open up a conversation about medications and be open to de-prescribing.
SHANNON: There was another study that followed on, that basically sent a brochure or a little notice to the physician and pharmacist at the same time. And so there was an even greater de-prescribing or getting rid of that prescription in that population of patients where the physician was involved in the process as well. So that’s just one small example. But there are other examples of interventions that are a little bit more systemic, and we think that the strategic plan, action plan to really address this problem, has to look at the various, kind of categories of drivers. The ways that the system and attitudes, culture, the pharmaceutical industry et cetera, all kind of push towards medication overload, and find a way to put a brake on inappropriate prescribing, which you can kind of think of as the upstream problem. Then increase the communication and conversation around the possibility of de-prescribing or getting rid of some of the drugs at the downstream end.
SHANNON: Once the patient already is overloaded, what can we do to reduce the number of medications, or maybe just reduce the dose of some of their medications? So at the upstream end, if you think of the pharmaceutical industry as having this very powerful effect on what patients know, what physicians know, what pharmacists know… one of the ways to address that is through regulating direct-to-consumer advertising. Right now direct-to- consumer ads are regulated. That incredibly long list of side effects that’s rattled off at lightening speed, is part of the regulation of those ads by the Food and Drug Administration. One of the things that the ads don’t do, is they don’t make clear what the benefit is and what the potential harms are and what the likelihood is. So if you listen to a statin advertisement, it’ll tell you it cuts the rate of heart attacks in half.
SHANNON: Well, what it does is maybe cuts the rate of heart attacks from 2% down to 1%. So that’s half, but it’s not very big in absolute terms. So we could require that these ads be much more explicit in what the potential benefits and what the potential harms are, and what the chances are. Another area that’s more inside healthcare is those guidelines, and we think that the guideline producers, which are the specialty societies, can adopt this problem as theirs and say, we’re going to start writing guidelines from now on, that really take into account the potential for harming patients who have multiple chronic illnesses, and we’re going to alert prescribers to that possibility, and maybe give them some advice about when to think about stopping a drug. I mean, should a terminally ill patient be on a statin, which is a drug to prevent a future event? You know, should a extremely demented patient be on Warfarin, which is a blood thinner that’s supposed to prevent stroke, when the chances that they will fall and have a catastrophic bleed go up?
SHANNON: So there are ways for the guideline writers to change what they do, and there are also training issues that can be addressed. But one of the most important and difficult things that has to be done is to increase awareness among patients and families. And this program is great. This is one of the ways that you can increase that. In our wildest dreams we imagine a public service campaign on TV, that to some degree can counter the barrage of advertising by Pharma, and say, Hey, did you know there’s such a thing as too many drugs? Patients can be equipped. We think patients and families can be equipped with a few tools that will help them avoid overprescribing, and help them have conversations with their doctors about getting off a few of the drugs that they’re on. And you know, therer’s fairly simple instructions about what patients and families can do.
JANA: What can everyday listeners do to advance the goals of your report? A lot of your recommendations are for policymakers and legislators, so for folks who are listening to this, what can they do?
SHANNON: Judith, take it away.
JUDITH: Well, I actually wanted to go back to something you said earlier when you asked about whether patients with caregivers are less likely to have an adverse drug event. And I don’t actually know the statistics on that. I think that’s a really interesting question that we should study. But I do think there is a role for caregivers or family members that can really help in preventing adverse drug events. And one of those things is just having a list of all the medications that your family member is on, because often the doctors don’t know all of the medications you’re on. And having that list, and then at some point, you know if that list gets really long and you just show it to the doctor or primary care provider, they might go, Whoa! Just seeing all those meds in a list in front of you can be a pretty powerful tool for them to say, you may need to get off of some of them. Also, you know as you were telling the story about your mother, with the Lyrica or the Gabapentin… you knew that something was wrong because you were aware of how she normally is and normal acts, and obviously so is she. But in a care transition to a skilled nursing facility or a hospital, the clinician might not be able to know that this is a new symptom, because they’re not aware of what the baseline kind of mood is. So being aware of rapid changes in cognitive ability and memory and mood are very important for identifying a possible drug side effect.
SHANNON: I just want to jump in here just for a sec, but one of our working group members has a kind of rule of thumb, which is: if there’s a new symptom, think drug. If there’s any kind of a new symptom, it’s worth thinking and asking if it could possibly be caused by a drug. So that symptom could be dizziness. That symptom could be confusion. That symptom could be tiredness, lack of energy. There are many, many possible symptoms that they might indicate a new disease, but they actually might well be a symptom of a side effect.
JANA: Yeah. I think there’s just such a huge, huge role for carers, as they say, internationally, caregivers and you know, sons, daughters, friends, for us to play in this because we need to really be vigilant with our loved ones. And we’re the ones who are going to say, no, I don’t want my parent on this. And I can tell you, the shock that I’ve seen on physician faces when I’ve gone to medical appointments with my mother with an actual list in hand of what she’s taking, so I can say, this is what she’s on, blah, blah, blah. The shock in their faces– oh, you know that? Well, of course I do. She’s my mother. She’s just lost her husband. I want to keep her on this earth. So, you know, I just think it’s such a huge role for us as patients and daughters and sons to play in this, and that we can’t rely on policymakers to push for changes that are going to help us. That’s my personal feeling.
SHANNON: I think you’re right, but you know, the other thing is doctors– doctors are very responsive to patients and families.
JANA: Yes, yes. Yes, I think you’re right.
SHANNON: When you show your willingness– whether it’s you the patient or you the family member– show willingness to really work with the clinician to find ways to reduce the load of medications, many doctors will welcome you with open arms. But why doesn’t this happen more often? Why doesn’t this process of what we’re calling a prescription checkup happen more often? For primary care, time is a huge factor. So if you’re a patient on 20 different drugs and you’re a very complex patient, unraveling all the various symptoms and side effects and what’s the right dose, is incredibly complex and time-consuming. And that’s a little scary for primary care because they got 10 other people in the waiting room, and those people want their appointments. So if you as a patient or a caregiver get real resistance from a clinician, to engaging in this process, you might need to find a different doctor. Or you might need to say, can we break this down into multiple visits? Because it’s important that we find a way to get to the bottom of what part of mom’s symptoms are real symptoms, and what part of mom’s symptoms are side effects, and whether or not we can get rid of some of these drugs. And that’s kind of hard for patients and families a lot of the time. You know, opening that conversation could be difficult.
JANA: Yeah, sure. Because obviously the sons, daughters, et cetera, have busy days and busy lives and they have to factor in their own needs too. So, it’s tough. During the process of pulling this report together, were there any surprises along the way for you? Did you discover anything that surprised you?
SHANNON: Oh… I was shocked by the numbers. I was really shocked by how significant a problem this is. 40% of people over 65 in this country are on five or more drugs. 20% are on 10 or more. That alone is a shocking statistic. But then when we started doing the estimates for hospitalizations and premature deaths? In the next decade, 150,000 people over 65 will die prematurely because of an adverse drug event. This is a massively devastating problem, and it is increasing suffering for too many people. And it’s so big that it’s going to take a truly coordinated effort to address it. We can’t do this piecemeal. And we can’t expect individual patients or individual families or individual doctors to do it on their own. So that’s what really shocked me. Judith, maybe you had some other pieces.
JUDITH: I had a similar reaction as you did, Shannon, more so the rise in prevalence of polypharmacy really shocked me. Because when I was younger I thought, wow, that’s a lot of medications my grandma is on. And she can’t remember to take them. She has a live-in aide. And to think that now there’s so many more people taking even more medications. I always think, you know, how much worse can it get? But it might get worse and it likely will if we don’t do anything about it. And I guess something that didn’t necessarily surprise me, but I guess I– it made me think a lot was, in pretty much every category of cause and driver of medication overload, Pharma is involved somehow. That’s something that really struck me is, there’s pretty much no area, nothing that drives polypharmacy doesn’t have some connection with Pharma, which was interesting to me.
JANA: Huh. Well, I want to let you guys go. Is there anything else that you want to talk about that we didn’t get to?
SHANNON: You know, one thing we didn’t talk about is the role that electronic medical records play. Electronic medical records have been sold as the panacea to the fragmentation of the healthcare system. And in fact what they’ve done is increased the fragmentation. And these are tools that could help so much with reducing medication overload by increasing doctors’ ability to know all the drugs that patients are on, to give them up-to-date information, et cetera. And they’re not doing it. And it’s an incredible waste. Billions and billions of dollars have been poured into electronic health records. And I’m not saying anything new that others have not already said, and that’s beginning to be recognized at the federal level. But if we don’t do something about electronic medical records at the same time that there are other solutions to this problem, the records are going to continue to work against good doctoring and that’s a waste. Electronic records on their own are a real issue that is not restricted to older patients.
JANA: Absolutely. Judith, anything that you’d like to add before we close?
JUDITH: Sure. Just one thing which is, Shannon talked a little bit before about the guidelines, and how often clinical guidelines don’t tell doctors when a drug should be stopped. And so something that, you know, if you are at the doctor’s office with either a family member or you’re the patient and you have a medical problem, and the doctor’s prescribing something for you, and you’re already on many medications, something that’s important to ask is, When will we know when the drug is working? And when will we know when it’s time to stop the medication? That’s something that the clinician might not be thinking about in the moment.
JANA: That is such a good point. We’ve been speaking with Judith Garber and Shannon Brownlee, co-authors of a new report from the Lown Institute titled, “Medication Overload: America’s Other Drug Problem.” We’ll have links on the Agewyz website to the report so you can read it for yourselves– and act. Judith and Shannon, thank you so much for this fascinating report and the work that you’re doing. I wish you all the best on advancing the goals of the report.
JUDITH: Thank you so much. It’s been great.
SHANNON: Thank you.