This physician wants her patients to use fewer medications
Written by Dr. Sean Medlin and Dr. Krystal Czegus / Updated on January 30, 2017 / 0 comments
There is a right time and place for drugs and surgery and there is a right time and place for self-care. These two do not usually over-lap and this physician made an amazing New Years resolution that will surprise you!
She said “In 2017, I will try to tip the balance: I will not only try to prescribe fewer medications, I will also try to get more of my patients off their drugs altogether.”
The “why” was obvious: Too many patients are taking too many drugs, for too long, in too-high doses, suffering harmful effects.
Drugs have an important place. But rarely do we teach young doctors — that is one of the things I do now — how and when to deprescribe a drug. Doing so is not as simple as saying “stop.” Deprescribing is its own process, requiring extreme caution and a certain skill on the part of the physician. It is a skill, however, that is not being taught, and it is barely studied to develop best practices.
Not learning to deprescribe hurts patients, because few drugs are meant to be used forever, and all have potential to cause harm. For some drugs, those harms include addiction — much in the news these days — especially in the case of opioids, some anti-anxiety medications and certain sleeping aids.
Some people simply take medications for too long: Take certain heartburn medications (called proton pump inhibitors, or PPIs) for more than the recommended two weeks, and you risk pneumonia, intestinal infections, broken bones and vitamin B-12 deficiency.
Some people outgrow their medication: They change their lifestyle, and their diabetes, cholesterol or high blood pressure medications may not be needed anymore. But they keep taking them, because no one told them to stop.
But it’s the patient with the bag of medications who illustrates the situation most acutely: an older adult who is prescribed too many medications, by too many physicians, all at the same time, even if all are given for legitimate reasons.
“Polypharmacy” is the name we give to prescribing patients five or more medications at the same time.
Why is that problematic? First of all, drugs are chemicals that can interact with one another, potentially causing all kinds of complications that may not be apparent if you just take the one medication. Second, the aging process causes the kidneys and liver to be less efficient in processing medications. That often leads to more of the drugs sticking around in the body and magnifying their effects — and side effects. Polypharmacy has been shown to contribute to higher rates of hospitalizations and death and — of course — to higher costs.
The problem is widespread: According to some studies, about 20 percent of adult patients are routinely on five or more drugs, and in people older than 65, between 30 and 70 percent are treated with polypharmacy. In nursing homes and other residential facilities, that rate goes up to 90 percent.
We need to recognize that there are professional and cultural norms that push us to prescribe (rather than find other solutions) and to overprescribe.
Common classes of medications that are good candidates for deprescribing include:
● Anti-anxiety medications known as benzodiazepines, which can contribute to cognitive impairment, delirium, falls (and related injuries), breathing problems and motor-vehicle accidents.
● Atypical antipsychotics, which are often used to treat psychosis and, in the elderly, dementia.
● Anti-cholesterol statins, which can cause muscle problems, cognitive impairment and a higher risk of diabetes. Statins also have a high risk for interaction with other medications and certain foods. Given that the benefits of statins are long term, they are not needed for elderly patients.
● Tricyclic antidepressants, which are used for depression and dementia. These are not recommended in the elderly but are often used nonetheless, causing side effects or harms that can include low blood pressure (which contributes to falls and fractures), heart arrythmias and other disturbances, delirium, difficulty urinating, dry mouth and constipation.
● Proton pump inhibitors, mentioned above.
Knowing which classes of drugs require special attention is important, but it is not enough. How to do it effectively, efficiently and with the lowest chances of harm is still anybody’s guess. We need researchers to help us by discovering and evaluating the best discontinuation protocols.
There is also a big-picture issue here: Deprescribing requires a lot of thought and planning. There are many more incentives for doctors to prescribe a medication than to stop one. Insurers and payers need to create incentives to allow primary-care physicians to spend adequate time with our patients to get them off drugs and carefully monitor their response when a medication is withdrawn in a supervised manner. For my part, I am going to try to do that in 2017.
Mishori is a professor of family medicine and the director of the Health and Media Fellowship in the Department of Family Medicine at Georgetown University School of Medicine.
Advice for patients
Before you throw all those pill bottles into a plastic bag and bring them to your doctor’s office, consider posing these questions to your physician:
● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?
There are no post.