By Judith Garber and Shannon Brownlee
In 1995, Michael Russo (not his real name) was in his mid-50s and in remarkable health, effortlessly running half-marathons and playing competitive racquetball. But when Russo sought treatment for his moderate Crohn’s disease, he soon became the victim of a prescribing cascade. As each new medication brought on a new, often serious side effect, another medication was prescribed.
He was 59 when one medication prescribed for his Crohn’s disease activated latent tuberculosis, which led to him spending 31 days in the hospital, 17 of them in Intensive Care, including 11 on a respirator.
From 2001 until his death in 2014, Russo was in and out of the hospital, taking many medications and suffering multiple side effects. At the end of his life, he was taking more than 31 pills a day, but not one of his 15 physicians saw this as a problem worth addressing. Ultimately, it wasn’t the Crohn’s disease that killed him—it was the drugs and their devastating side effects.
Polypharmacy—a Too Common, Often Tragic Trend
Unfortunately, Russo’s story of harm caused by too many medications is not unusual. Over the past two decades, the number of older Americans taking five or more prescription medications—a red flag for potential harm—has tripled, rising to more than 42 percent, according to the Centers for Disease Control and Prevention.
Taking many medications has become the new normal, a trend most striking in older adults, but growing across all age groups. As this trend progresses, so has polypharmacy-related harm, an epidemic that experts call “medication overload.” In light of this growing crisis, the Lown Institute reviewed what is known about polypharmacy and the harm it can cause. This past April, the Institute released Medication Overload: America’s Other Drug Problem.
The report found the following: Harm from multiple medication use is frequent and increasing. While many patients benefit from taking multiple medications, polypharmacy also increases a person’s risk of suffering serious, sometimes life-threatening side effects. At the same time that medication use among older adults has increased, the rate at which side effects send older adults to the hospital or to the emergency room has risen dramatically. Last year, an estimated 5 million older people in the United States—about one in ten—sought medical care for an adverse drug event.
There is no single driver of medication overload. Many aspects of our healthcare system make it easy to prescribe medications, but it is far more difficult to review or stop them, even if a medication is likely to be causing harm to a patient.
One powerful push factor is our culture of prescribing—the belief that there is a “pill for every ill.” Doctors want to show their patients that they care, and often the easiest way to do that is by pull-ing out the prescription pad. Meanwhile, drug company marketing—to doctors and directly to consumers—often presents medications as quick fixes, while downplaying the risks. In Russo’s case, no one on his medical team thought to question whether his medications might be the cause of his worsening symptoms.
Another factor contributing to medication overload is our highly fragmented healthcare system, which leaves clinicians with incomplete information about their patients. Older adults with chronic conditions like Russo’s often see multiple specialists, who may prescribe drugs with little or no knowledge of the patient’s overall medical picture, or of what has already been prescribed. Even more prescriptions pile up when patients transfer in and out of hospitals, skilled nursing facilities and other institutions.
While primary care providers might seem like the best gatekeepers, they rarely have time to review long lists of drugs or make decisions with their patients about reducing or stopping medications. And electronic medical records often fail to help primary care providers oversee all the drugs their patients are taking. Big box stores do a better job of keeping track of inventory than the American healthcare system does on tracking patients’ prescriptions.
We need a national action plan. No magical solution will cure medication overload, but there are ways we can reduce it. We can change our culture of over-prescribing by helping patients and their families understand the risks of medication overload and countering the common belief that “more medications are better.”
We also must make more comprehensive, coordinated care a priority. Primary care providers should be at the hub of the wheel, ensuring that specialists’ recommendations work together and don’t send patients’ medications spiraling out of control. To do this, primary care clinicians need ready access to consultations with pharmacists and better training in geriatric care. All of a patient’s clinicians need clinical guidelines that help them avoid excess prescribing, and medical records that list all of the drugs their patients are taking.
We need a stopgap measure to slow the ever-increasing cascade of medication. We join other advocates in the call for regular “prescription checkups” for older adults, an opportunity for clinicians and patients to specifically address medication issues and remove those that are unnecessary or potentially harmful. Primary care clinicians, especially, need the time to conduct prescription checkups, as well as ongoing training to recognize drug side effects and feel confident in their ability to safely “de-prescribe.”
Doctors often are reluctant to de-prescribe medications because they are afraid their patients will reject the idea. If people initiate conversations about medications with their doctors, this can show doctors that patients are open to de-prescribing. Patients can also help avoid medication overload by asking questions that are rarely addressed prior to prescribing, such as, “When will we know the drug works?” “How will we know when to stop it?” and “What side effects should I be watching out for with this drug?”
With the U.S. population aging and medication use increasing, the problem of medication overload is only going to get worse. Across the next decade, medication overload will lead to an estimated 4.6 million hospitalizations of older Americans, at a cost of $60 billion. But that isn’t the only scenario. We can reduce preventable deaths like Russo’s if clinicians, patients, healthcare institutions and policymakers work together to address medication overload.
Judith Garber, M.A., is the health policy and communications Fellow at the Lown Institute in Brookline, Mass. Shannon Brownlee, M.Sc., is senior vice president of the Lown Institute. Before joining the Lown Institute, Brownlee was acting director of the health policy program at the New America Foundation, and authored Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (New York: Bloomsbury, 2008).