The Irish Medical Times - Polypharmacy: panic, press and pop
I have come to terms with my compounded companions by researching the medications I am prescribed and asking my doctors questions. I understand how they assist my body and keep me going, I appreciate that without them my natural existence might be short-lived. Ironically, I find myself in this codependent bind due to toxic medication, the most powerful lifesaver we’ve got - chemotherapy. The cancer vs chemo battle reminds me of the movie The Untouchables, “They pull a knife, you pull a gun. He sends one of yours to the hospital, you send one of his to the morgue. That’s the Chicago way!” (replace ‘Chicago’ with ‘Chemo’). While battling cancer 20 years ago I asked one of the weary nurses how they work out the dose, expecting an explanation around height and weight, but instead she sighed and said “We work out how much will kill you, then we dial it back a little”. I found her fresh response most amusing and chuckled to myself as the venomous antidote flowed through my veins. I must note, a lot has changed in 20 years, chemo and its administration are likely now kinder on body and soul (for all involved).
Life saving medication aside, I wonder if we have created a culture where the solution comes in a white tablet. Polypharmacy, or multi drug regimens (regular use of concurrent medications), are often seen in the elderly with a number of comorbidities, or those with chronic illness.
GP, Dr Brendan O’Shea tweeted about reducing polypharmacy in Chronic Disease Management, “GP Nurses are in a key position to systematically engage in de-prescribing. Countless opportunities in CDM consultations. Prompt review of obesogenic psychotropic medications.”
Polypharmacy, especially in the elderly, can lead to an increased risk of adverse drug side effects such as falling, cognitive impairment, harmful drug interactions, drug dependency, financial hardships, hospitalisation and new conditions - which presumably will require more drugs. Like all the good American medication commercials I should conclude on a high note with the comforting tagline 'May cause death'. Patients are vulnerable by definition, most of us will keep taking pills if we are told to until they Pez dispense out of our belly buttons.
Perhaps over-prescribing could be replaced with social-prescribing - group activities can help reduce depression, anxiety and dementia, while physical activities can stem the risk of type 2 diabetes, heart disease and cancer (not to mention there is a high chance you could become a social media influencer/expert). Multidisciplinary team interventions can also help manage medications. In a study of a US Veterans Clinic there was a reduction in adverse drug reactions for those receiving medical management by pharmacists providing written drug recommendations to physicians.
If Covid plus social media has taught us anything it's that everyone is an expert, but it has also highlighted that there are 500 ways to skin a cat (please don’t Google that). If a patient's pill box is weighing them down then consult a medic and see if the full complement of medications is still appropriate. There may be room to reduce the quantity of medications while continuing to slow the disease progression and reduce the symptoms. It’s a challenge as the elderly and those with multimorbidities are generally not included in drug trials so guidance when prescribing to this group is thin on the ground. Nonetheless, a discussion about prevention or non-pharmacological therapy is worth some consideration. I’m not advocating for people to go rogue and stop medications, your body will not thank you for that, but certain non-essential meds may have pharma free alternatives.
Unless you have the constitution of Pac-man, taking lots of pills a day can be a source of stress. Some of my elderly relatives have alarms on their phones, that sound like air raid sirens, indicating that it's time to take a tablet. An afternoon spent in their company is frequently followed by severe PTSD - a child prangs the bell on their bike and I suddenly drop everything and start scurrying around shouting ‘quick, quick, quick’ to no one in particular. If there is a change in routine and a tablet missed, people can turn into Formula 1 drivers screeching across the city to throw into their desperate mouths what can amount to a calcium chew. On the flip side, adherence can wane as the number of medications mount, why skip one when you can skip all ten.
I am slightly dramatising and perhaps I am comparing apples and opioids here but if I can speak a language we all agree on - de-prescribing will save everyone money. The overall annual cost of medicines for the over 50’s population in Ireland in 2010 was estimated at €600 million. Given the rise in price of medications over the last 10 years, an increase in the aged population, more reported health conditions, and an uptick in chronic pain, I shudder to think where that cost number is now. That doesn’t even take into account the patients who are paying out of pocket!
Patients are an unusual consumer group because we don’t decide on our treatments (our physician does) and at times we don’t pay (the government does), yet we are the end user who somehow has to manage all the consequences. We are in the nose of the rocket yet we have no say in the direction we’re going.
Perhaps we need to tackle polypharmacy by thinking outside of the pill box, as Patient Advocate Pauline O’Shea commented “We need to develop access channels for patients to pharmaceutical companies and medical device producers to discuss products and services for patients, not at ‘testing stage’ but at concept stage, where the patient’s input can help develop appropriate products and services.”
If patients, physicians, pharmas and politicians could work together, I think we could find an approach that works for all.
Oh, look at the time! <sound of laptop crashing across the room, through the din of an air raid siren…panic, press and pop… phew!>
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