Before our entire health conversation became centered around the COVID19 pandemic, there was the opioid epidemic. This opioid epidemic still rages on, and now that people have a harder time getting their narcotics from doctors, they are turning to the streets. The powerful and rapidly acting synthetic opioid fentanyl and its derivatives have now displaced heroin as the injection street drug of choice. Hundreds of thousands have died from narcotic overdose in the last 10 years in the United States alone. I predict that the death toll from narcotics will continue to greatly outnumber the death toll from COVID19. Sadly, many of these addictions started in medical clinics, and as such, are directly attributable to the healthcare system.
In the 1980s drug companies began shoving these very addictive narcotic medicines down our throats. They told us lies like, “Opiate medications prescribed are not addictive.” These companies came up with the clever marketing scheme, pain is the 5th vital sign. They were able to infiltrate hospitals and clinics and before anyone knew it, hospitals were mandating that providers ask about pain, and document levels 1-10 along with the other vital signs like heart rate and blood pressure. Along with this came the aggressive treatment of pain, to drive pain levels down to 0 or 1, often with narcotics.
The drug companies were right about pain being a vital sign. What I mean is that pain is a part of life. Anyone who does not experience any pain is either dead or fully sedated. What is most amazing to me about the whole opioid crisis is that healthcare providers actually went along with this. It is so obvious that these medications are very addictive to anyone treating patients with narcotics. Furthermore, tolerance builds up so quickly that patients continuously request increasing doses, which has so often led to patient’s cessation of breathing and dying in their sleep. Sadly, providers and not pharmaceutical companies are the ones who actually control the distribution of such medications. It is our job as providers to do what is best for our patients and not allow third parties seeking financial gain to compromise our care.
But, as the experts in charge of prescription medications, healthcare providers should have known better. We should have had the courage and strength to stand up to both the pharmaceutical companies as well as our addicted and desperate patients. We should have thrown out the pain scale paradigm immediately. Sadly, providers seem to do what third parties like pharmaceutical companies tell them, and it continues to hurt the patients we serve.
Unfortunately, the opioid crisis is part of a larger epidemic that is disproportionately and adversely affecting the elderly while bankrupting all of us. This epidemic is polypharmacy, and it is one of the most serious health issues we are currently facing. Since prescription medications come directly from the healthcare system, this means that the healthcare system is directly responsible for one of the most serious health problems. What a great way to ensure continued business, right?
When I hear doctors complain about healthcare being listed as the 3rd cause of death behind heart disease and cancer, I think about medications. The reality is that medications, when used appropriately and with good indication, can save lives and ameliorate (help) disease. However, outside of a narrow treatment window, our current prescription medications are nothing more than chemical toxins.
Polypharmacy occurs when a patient takes multiple medications. There are different exact definitions, but most people consider someone to have polypharmacy when they take at least 5 medications regularly, and certainly if they take more than 10. In 2020 the average Medicare recipients (people over 65) took more than 5 medications. Sometimes such medications are indicated, however often they are not. What I see these days are elderly people taking medications to treat side effects caused by other medications. This is a huge problem.
Try to think about polypharmacy like a doctor for a second. Your patient has type 2 diabetes, congestive heart failure, and high blood pressure. This may require 10 medications, all of which are supported by research to prolong life in these conditions. However, several of these medications were studied in isolation. As a result it is hard to say what the drug's effect might be when mixed with so many other medications. It literally becomes impossible to judge efficacy, side effects, and potential drug interactions, when mixing so many chemicals.
While I question the benefit of taking so many indicated medications together, the larger issue I encounter is compliance. Many of the elderly people on multiple medications also suffer from memory impairment. When I ask these individuals what medications they are on, it is normal for them not to know. Most individuals are unable to name 1 or 2 of the 20 medications they are on. At the same time, these people frequently handle their own medications, relying on things like pill boxes.
When I bring sick, elderly people into the hospital, they almost never remember what medications they have actually taken and when. This should terrify providers and loved ones alike. It should make us question the value of such complex medication regimens. If patients cannot engage, adhere, and observe medication effects, should we ever really be giving them medications in the first place?
According to the studies I’ve found, the average number of medications taken by those over 65 seems to have more than doubled from 2 to 5 prescriptions over the past 30 or so years in the United States. In my practice the numbers seem much higher than this and when people get over age 80, the number of drugs seems to skyrocket. Most elderly patients I take care of in the hospital take 10 to 25 medications and supplements. This is way too many. When I see more than 10 medications on a chart, I always list polypharmacy and recommend removing medications as able. n my practice, these elderly people do much better on less medication.
I have personally seen multiple elderly patients stop taking most of their medications, only to find that their thinking and functional abilities improve. Many medications are known to cause more side effects and harm to the elderly (Beer’s List, American Geriatric Society). Such medications should always be considered for removal, in the absence of strong benefit. At least 10% of the patients I admit to the hospital are due to medication side effects or complications. Possibly more. Bleeding from blood thinners, dizziness and falls from blood pressure medications, confusion from mind altering medications, kidney and electrolyte issues, accidental, and intentional overdoses represent the most common problems I see related to medications. Most all of these are completely preventable and in most cases patients would have probably been better off without the drug in the first place.
The reasons polypharmacy has become such an issue are multifactorial. The first problem is pharmaceutical companies that are effectively able to control the healthcare system to do their bidding. The next big problem is academic incentives, which encourages research supporting the use of additional medications. Far less studies recommend the removal of medications or encourage inexpensive interventions that are not profitable. Perhaps the biggest problem is our increasingly unhealthy population though. Far too many people are obese, sedentary, have unhealthy habits, and are all too happy to try a pill rather than to make the harder but more meaningful intervention of changing their behavior. We have become increasingly dependent on quick fixes. Furthermore, our population has become increasingly intolerant of anything unpleasant or uncomfortable. Instead of not eating unhealthy foods, drinking alcohol, and smoking tobacco to help with acid reflux, most people want a proton pump inhibitor pill. Even if that pill has numerous secondary-negative health effects like bone loss and nutrient deficiencies with continued use.
These days many patients seem to demand medications. Patients come into my office asking for a pill for pain, nausea, fatigue, or whatever else is bothering them. When I try and remove medications, I am often met with great apprehension. Patients often do not want their medications changed or removed. They have this idea that things are going to fall apart if they stop taking their medicines. Even healthcare providers seem unreasonably concerned about patients deteriorating if they come off of their medications. I see so many doctors worried to stop a medication that another doctor started. Both patients and providers seem to be heavily biased that medications are always helpful. The reality is that medications can be just as likely to cause harm as they are to cause good.
I have a few simple rules regarding medications:
If a patient does not know why they take something and I cannot find a good reason, that medication is removed.
If a medication is potentially harmful and it does not seem important, that medication gets removed.
If I suspect a medication is causing a side effect, that medication is removed.
If a medication leads to not only one, but two hospitalizations, that medication is removed, even when strongly indicated.
If a patient cannot safely take a medication, such as a blood thinner, that medication is removed.
If someone elderly wants to stop taking all of their medications, I remove all of them.
If I believe a medication regimen is too complex for an individual, I trim it down to just a few of the most indicated therapies.
These days, I believe the mark of a good geriatric provider is someone who removes more medications than they begin. The era of mindless pill-popping needs to end.
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Author
William Brandenburg, MD, owner of Wonder Medicine clinic and full time rural hospitalist.
Editor
Karlee Brandenburg, RN-BSN, owner of Wonder Medicine.
Conflict of Interest
This article promotes Wonder Medicine clinic, which the author and editor own.
Disclaimer
This article was written for educational purposes only. It is not intended to serve as formal medical advice. Please talk with your healthcare provider if you are having a medical problem.
References
Charlesworth et al. Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci. 2015.
Morin et al. The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clin Epidemiol. 2018.
Rawle et al. Assocations Between Polypharmacy and Cognitive and Physical Capabilities. J Am Geriatr Soc. 2018.
Fried et al. Health outcomes associated with polypharmcy in community-dwelling older aduls: a systematic reveiew.. J Am Geriatr Soc. 2014.
Wimmer et al. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2017.
Beers Criteria/List. American Geriatrical Society. 2019 addition