Friday, September 22, 2023

Too many people take too many pills

As a pharmacist in a big hospital in Adelaide, Emily Reeve would often see patients overwhelmed by the number of drugs they took each day. “They’d say ‘I take so many medicines that I rattle when I walk’,” she recalls. And she worried that some of the medications these patients were on seemed useless, or even harmful.

Dr Reeve’s patients are not unusual, at least in the rich world. About 15% of people in England take five or more prescription drugs every day. So do 20% of Americans and Canadians aged 40-79. Since the old tend to be sicker, the number of pills a person pops tends to rise over time. Of Americans who are 65 or older, two-thirds take at least five medications each day. In Canada, a quarter of over-65s take ten or more.

Not all those prescriptions are beneficial. Half of older Canadians take at least one that is, in some way, inappropriate. A review of overprescribing in England in 2021 concluded that at least 10% of prescriptions handed out by family doctors, pharmacists and the like should probably not have been issued. And even properly prescribed drugs have side effects. The more medicines someone takes, the more they will experience...

Getting people off drugs is unfamiliar terrain for modern health systems, which are mostly set up to put patients on them. But that is beginning to change. Doctors, pharmacists and nurses are setting up “deprescribing networks” to try to spread the word. (Dr Reeve, now at Monash University, in Melbourne, runs one in Australia.) England’s National Health Service published a plan to reduce overprescribing in 2021. The first international conference on it took place last year, in Denmark...

Other problems are more straightforwardly medical. Some patients end up taking several drugs that affect the same biological pathway. One example is anticholinergics, which suppress the activity of acetylcholine, a neurotransmitter. Several drugs, including some anti-allergy pills, anti-incontinence drugs and tricyclic antidepressants, work this way. But doctors are not always aware of that, says Dr Reeve.

That can cause overdosing. Loading up on anticholinergics can suppress acetylcholine so strongly that it can leave patients stupefied or confused. Often such effects are wrongly ascribed to old age, or to disease. By cutting away problematic drugs, “we’ve had incidents where we have been able to reverse the [incorrect] diagnosis of dementia,” says Barbara Farrell, an academic and pharmacist at the Bruyere Research Institute in Canada.

Overprescribing can become self-reinforcing, says Dr Steinman. Several common drugs block reabsorption of serotonin, another neurotransmitter. Taking too many can cause tremors, insomnia and jerky movements of the arms and legs. Those symptoms are often mistaken for Parkinson’s disease. So drugs for Parkinson’s are added, in what is known as a “prescribing cascade”. These, in turn, can cause low blood pressure and delirium–which are, of course, treated with yet more drugs...

Perhaps the most common reason is that patients are not told when to stop taking a drug, or forget. In America one in five patients who are given gabapentin, a potent painkiller, after surgery are still taking it 90 days later (the recommended maximum is four weeks). Often prescriptions are renewed automatically by other doctors, who see them on a patient’s notes and assume they have to be continued...

Evidence about how to proceed is nevertheless starting to build up. Brochures have been developed in Canada to help patients wean themselves off a number of common drugs. They explain, among other things, what alternatives are available—such as cognitive behavioural therapy rather than sleeping pills for insomnia. Trials suggest they work.

Automated de-prescribing tools and guidelines for some medicines have also been developed in recent years. Medsafer, one such electronic tool, increased the share of hospital patients for whom drugs were de-prescribed from 30% to 55%, according to a study published earlier this year in jama Internal Medicine. The Drug Burden Index, another tool, tallies the cumulative doses of drugs with anticholinergic or sedative effects.

A medical movement, in other words, is beginning. Its potential impact could be considerable. Keith Ridge, England’s chief pharmaceutical officer, drew an ironic but telling comparison in 2021: “With well over a billion items dispensed each year”, he wrote, “there is a huge prize to be gained in improving the health of millions of people—comparable to a new ‘blockbuster’ medicine—if we can only get this right.”

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