Medical Practice

No Quick Fix for the Culture of Prescribing that Drives Medication Overload

By THERESA BROWN, RN

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.

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chieftbWilliam Palmer MD Recent comment authors
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chieftb
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chieftb

This is why every patient, and especially older patients, need a primary care physician. We look at that long list of medications and make sure each and every one is needed. Care is so fragmented and each specialist adds a favorite drug, not to mention the OTC medications that patients think they need. It’s too much! Every time a drug is prescribed the following questions should be answered by the prescriber: 1. What is it for 2. How is it taken 3. How long should it be taken 4. What are the side effects or things to watch for 5.… Read more »

William Palmer MD
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William Palmer MD

Very good, Theresa, and needed. Don’t forget also that stopping certain drugs can be tricky too. Eg xanax…quitting suddenly can cause seizures months later. When you look at our unbelievably complex biochemistry, taking any chemical is like sticking a needle into a fine watch and hoping nothing critical is damaged.