A “He-Said, He-Said” Exchange Between Len Kaye and Cliff Singer
The Question of the Day:
Has the overprescribing of medications reached epidemic proportions?
Len: That sounds about right to me. The facts speak for themselves – The average American between the ages of 19 and 64 takes 12 prescription drugs every year compared to seven 20 years ago. Spending on prescription drugs has increased by $200 billion in the last 20 years. I can’t remember the last time I left a doctor’s office without at least one script in hand.
Cliff: You know, nothing is more gratifying to geriatricians than stopping unnecessary medications. It’s called “pharmacologic debridement”…..trimming “dead tissue” from an overly long list of medications. Older adults take a lot of medications, and in many cases, way too many. But before we call this “overprescribing” Lenard (which is what I call you when you are at your preacher’s pulpit), we need to look at some facts. Evidence suggests that there are some conditions for which we “underprescribe”.
Len: Well, I’m afraid you and your partners in crime certainly don’t “underprescribe” when it comes to benzodiazepines (the wildly popular class of drugs with generic names ending in “pam” and lam”). I have to say that sometimes it looks like you are dispensing this class of sedatives for poor sleepers and anxious people like they are tic-tacs. I have heard from all too many older adults who have been on benzos for years, have become dependent on them, and have a heck of a time discontinuing their use even if they wanted to because of the severe physical and psychological consequences. I guess prescribers should practice what they preach and read the labels – benzos are only meant for patients under severe, disabling, or extreme distress and were never meant to be prescribed beyond a four to six week period of time. And, don’t get me started on the well documented overuse of this class of medications in long-term care institutions to control the “challenging” behaviors of residents.
Cliff: From the tone of your comments you apparently want me to say, “What’s wrong with benzodiazepines in old people? They are in fact safer than tic-tacs (people can choke on tic-tacs). Doctors know best, so butt out!” But I’ll refrain from taking the bait and falling into your trap. Benzodiazepines are high risk medications, especially for older adults, and prescribers (physicians, nurse practitioners, physician assistants, etc.) realize this. Benzodiazepines increase risk for injurious falls, memory lapses, nighttime breathing disorders and even auto accidents. They can be particularly dangerous when combined with alcohol or opioid pain medications. And you’re right about the fact they can induce dependency; both physical and emotional. They are also frequently used when alternative medical, social and psychological approaches would be safer and more effective. Given this, why then are almost 1 in 10 seniors on these medications, one third of them on them for the long term? The answer is that they work so well, at least initially, for a large number of common conditions, such as anxiety, insomnia, seizure disorders and muscle spasms. People want a quick fix for these distressing conditions and benzodiazepines often provide that. The medication may be started for short term relief, but getting off can be a challenge and they have to be tapered slowly over time while other treatments are employed if the underlying condition (insomnia, depression, anxiety, etc.) is still present. Finally, you’ve asked me not to get you “started” on the issue of benzodiazepines for agitation in nursing home residents with dementia, but you’ve gotten me started. Increased use of benzodiazepines in nursing home patients may be a result of well-meaning efforts to reduce antipsychotic medication in people with dementia. Yet, benzodiazepines pose even higher risks. We clearly need to use alternate approaches, but this requires culture change and investment in highly trained caregivers.
Len: I have to say Cliff that reading between the lines of your response to my assertions sounds to me like you agree more with my position than take issue with it. Since I appear to be on a roll and ahead in the delegate (oops, I mean “point”) count, what about this? I believe that prescribers need to start making more of an effort to help their patients understand the importance of taking their medications as prescribed and determining whether they can afford to purchase their medications in the first place. Are you aware that it has been estimated that as many as 50% of older patients do no adhere to their physicians’ prescribing guidelines. Older adults have the highest noncompliance rate of any patient group. As a result, they commonly under or overdose themselves, don’t take their meds for the prescribed period of time, share their medications with others, or fail to purchase full prescriptions and/or engage in pill splitting because of their prohibitive costs. The polypharmacy epidemic (the simultaneously taking of four or more drugs) has led to a slew of dangerous consequences including nonadherence to drug schedules, negative drug-drug reactions, medication prescribing errors, and increased costs for who else but the vulnerable consumer. The growing difficulties surrounding the proper management of prescriptions drugs has created nightmares for older adults, their relatives, and community providers, and remains one of the leading factors resulting in the institutionalization of loved ones.
Cliff: So this problem has “created nightmares for older adults”? Are you having troubled nights because of overprescribing in seniors, my friend? Well, don’t you worry, old Doc Singer has just the right pill for you. No kidding, I actually agree with everything you’ve just said, although I think most seniors do try to follow their medication regimen. Younger people are more likely to be in denial of their illness and are often even less likely to be able to afford their medications. The burden of prescription medication costs in this country is a national disgrace and although older adults are more likely to have prescription medication coverage, the high number of prescribed medications they take certainly creates a high level of financial stress. And, from both the prescribers’ and patients’ perspective, the amount of time trying to figure out what medications are covered and which ones aren’t is a major hassle. Expensive for the provider in terms of paid staff time trying to get medications “approved” and a significant inconvenience (and potential health risk) for patients as they may not be able to get their medication on the first or even second visit to the pharmacy. But yes, the high number of prescribed medications contributes to this problem. In my clinic, where perhaps the majority of patients have some degree of memory or cognitive impairment, trying to set up a monitored system for medication management may be the most important factor in keeping them safe at home. The fact that we have so many medications to treat so many conditions is a blessing, but is also a challenge for all elements of the health care system. Maybe we can discuss the underlying reasons for all of this prescribing? It’s not all the prescribers’ fault although the buck does stop there.
Len: As much as I am enjoying this back and forth banter with you, I think we need to draw our exchange to a close. I will do so by pointing to a major press release by the White House Office of National Drug Control Policy on March 15th which announced comprehensive guidelines for prescribing opioids for chronic pain have been released by the Center for Disease Control and Prevention (CDC). Why were those guidelines issued? Well, because primary care clinicians have been overprescribing painkillers for too long, and creating an all too frequent gateway to prescription opioid use disorder, abuse and addiction. Enough said.