Daniel Esgardo Rangel Barón: No Quick Fix for the Culture of Prescribing that Drives Medication Overload – The Health Care Blog


In my mid-twenties, I was twice prescribed the common antihistamine
Benadryl for allergies. However, my body’s reaction to the drug was anything
but common. Instead of my hives fading, they erupted all over my body and my
arms filled with extra fluid until they were almost twice normal size. I subsequently
described my experience to a new allergist, who dismissed it as “coincidence.”

When I later became a nurse, I learned that seemingly “harmless” medications often cause harm, and older adults are particularly vulnerable. Every year, Americans over age 65 have preventable “adverse drug events” (ADEs) that lead to 280,000 hospital stays and nearly 5 million outpatient visits. The Lown Institute in Boston draws attention to this underrecognized problem in their recent report, Medication Overload: America’s Other Drug Problem. Policymakers, patients, and health professionals must act, because over the next decade, medication overload is predicted to cause 4.6 million hospitalizations of older Americans and 150,000 premature deaths.

Nearly half of all older adults take at least five
prescription drugs, a 300 percent increase from 25 years ago. The
more drugs we take, the likelier it is that one of them, or some combination,
will cause serious harm. When you add in non-prescription medications,
including over-the-counter drugs like ibuprofen and Tylenol, as well as
vitamins and herbal supplements, the potential for harm only goes up.

I’ve seen this in my
work. It is not unusual for elderly, very ill patients on hospice to have
prescriptions for 20 to 30 drugs. Several of their medications may treat the
same problem, amplifying any serious side effects. Blood pressure medications provide
a good example. As older patients become more debilitated, lose weight, and are
taxed by other health issues, the effect of these medications can intensify,
severely lowering blood pressure, and causing the patients to fall. Indeed, if
I am following up with a hospice patient who has fallen, the first thing I
check is their prescription medications for hypertension.

Given the prevalence of ADEs,
why are medications still prescribed so readily? We are all, patients and
prescribers, deeply embedded in a culture of prescribing, wedded to the idea
that all health problems can be solved by taking a pill, or a lot of pills. Clinicians also feel increasingly
pressured to hurry through appointments, and offering pills makes visits go
faster. For patients, receiving a prescription often gives them a sense of being
well-cared for. 

Even clinicians who try to prescribe thoughtfully may feel pressure from patients who, having been enticed by drug advertisements to “ask their doctor” about a host of different medications, view a prescription as the key to better health. Direct-to-consumer drug advertising accelerated in 1997 when requirements for listing side effects were loosened by the FDA. That increase has coincided with a rapid rise in the rate of prescription drug use—and ADEs.

Most clinicians do not know how overloaded by medications their
patients are. Patients with multiple health problems likely receive
prescriptions from multiple specialists; no one doctor, nurse practitioner, or physician’s
assistant tracks and manages every drug a patient takes. Additionally, clinicians
are reluctant to discontinue medications because they worry that stopping a
prescription will cause harm.

Finally, physicians and other prescribers receive little to
no practical training in preventing medication overload or in deprescribing.
They may have learned that taking multiple medications can be a problem,
especially for older adults, but figuring out how best to avoid that problem
for individual patients is not easy. Consider warfarin, an anticoagulant and
one of the medications that often lands patients in the emergency department.
This drug is used routinely to prevent strokes from blood clots. It also
carries a risk of spontaneous bleeding and requires careful management to be
effective without being dangerous. For some older patients, aspirin will work
as well as warfarin, and would be much safer, but for other patients, the
reverse is true.

Medication overload is a tricky, multifaceted problem
without a simple solution. Over the past six months, the Lown Institute has
brought together a group of doctors, academics, pharmacists, nurses (including
myself), and patients to discuss what can be done.

Through our discussions, it has become clear that the best
way to reduce medication overload is for patients and prescribers to work
together. Patients need to understand that every drug has side effects, and
dangerous drug-to-drug interactions are always possible. Prescribers need more training
to help them recognize medication overload, and they need to be reimbursed for
the time it takes to talk over medications with patients. Clinicians and
patients need to discuss treatment options and the potential benefits and harms
of their medications, and that can’t all be done in a 10-minute visit.

Systemic changes are also needed to prevent medication
overload. Care coordination needs to include pharmacists and nurses as active
participants in medication review and deprescribing. Older
patients need a yearly “prescription check-up” to go over all their medications, and consider lowering the doses of, or even discontinuing,
some drugs.

Stopping dangerous prescribing, or overprescribing, will not be easy. A sense of need leads patients to request medications, and good intentions, usually, cause physicians to reach for the prescription pad. But the problem must be addressed to keep our patients as safe as possible. It begins by understanding that every pill has the potential to cause harm. Then we work together—patients, clinicians, and policymakers—to kick our overprescribing habit.

Theresa Brown, RN, is a clinical nurse, author of the New York Times bestseller The Shift: One Nurse, Twelve Hours, Four Patients’ Lives and is a frequent contributor to the New York Times.

Daniel Esgardo Rangel Barón: No Quick Fix for the Culture of Prescribing that Drives Medication Overload – The Health Care Blog

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