“In the United States, we’ve been taught to expect that there’s a pill for everything, and modern medicine has often delivered on that expectation,” said Dr. Nick Schneeman, Lifespark Chief Medical Officer. “It’s also contributed to the rise of polypharmacy, a massive problem for frail and complex populations.”
Polypharmacy is defined as the simultaneous use of five or more prescription drugs, over-the-counter (OTC) medications, or dietary supplements. Polypharmacy can lead to a host of problems, including dangerous drug interactions, harmful side effects, increased ER visits and hospitalizations, higher healthcare costs, lower quality of life, and greater risk of mortality.
Polypharmacy isn’t new, but Dr. Schneeman pointed to several factors fueling its growth:
- People are living longer which increases their chances of developing multiple comorbidities.
- Direct-to-consumer advertising drives consumer demand and puts pressure on doctors.
- Primary care physicians often defer to subspecialists to prescribe medicines related to their areas of expertise.
- Our nation’s fee-for-service model rewards efficiency rather than improved outcomes.
- Physicians aren’t trained to review and deprescribe drugs.
Multiple comorbidities
An older adult’s medical profile may include several serious health conditions, such as congestive heart failure, type-2 diabetes, hypertension, kidney disease, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), osteoarthritis, and depression. Many of these conditions are managed by a specialist—cardiologist, endocrinologist, nephrologist, pulmonologist, rheumatologist, psychiatrist—who typically starts the client on one or more medications.
Hospitals are another source of new prescriptions. “People frequently get discharged with new medications related to their hospitalization, but then stay on them indefinitely, assuming they’re following doctor’s orders,” said Sarah Johnson, APRN, CNP, Lifespark Associate Medical Director. One example, Sarah said, are proton pump inhibitors (PPI) prescribed for short-term GERD (acid reflux) and to prevent stress ulcers. Unless a clinician intervenes, the client might continue taking the PPI for years, potentially accelerating bone loss—a serious side effect for older adults.
Consumer marketing
Thanks to persuasive direct-to-consumer (DTC) marketing, we’ve come to believe that drugs are a cure-all. According to the National Institutes of Health, consumers have been shown to place unwarranted trust in DTC ads, often understanding a drug’s benefits much better than they understand its risks. Equally disturbing is that more than half the doctors surveyed said they had prescribed a drug to accommodate a person’s request, a situation that can lead to unnecessary or even harmful prescribing. On a related note, only two countries in the world allow DTC advertising: the United States and New Zealand.
Lack of primary care physician control
Another issue is that the primary care physician is less likely to be in charge of risk-benefit discussions about individual medications. “Twenty-five years ago, the family practice doctor was like the quarterback, but that role has eroded significantly,” Dr. Schneeman said. “Today, subspecialists don’t act like consultants—they take charge and prescribe.” For example, a cardiologist might start a client on a blood thinner, a statin, and a beta blocker without consulting the primary care physicians to find out what other medications the client is taking, what risk factors they may have, or even what their life goals are. “Primary care physicians may not feel they have the authority—or the time—to challenge the subspecialists,” he said.
Fee-for-service model
On a related note, the current fee-for-service model rewards doctors and healthcare systems for seeing as many clients as possible. In contrast, a value-based care system rewards improved outcomes, reduced hospitalizations, and lower healthcare costs. “It takes a lot longer than a 15-minute office visit to go through a list of 12–18 drugs and pare it down to a few essential medications at the appropriate dosage,” said Dr. Schneeman. The same holds true for explaining the risks and benefits of a test, procedure, or medication. “Doing nothing might actually be the better choice, but it’s easier and faster to order a couple of tests and prescribe a drug, which is often what the consumer expects,” he said.
Inadequate training
“Providers who aren’t trained in geriatric medicine don’t realize how problematic overprescribing is,” said Sarah Johnson. Few medical schools offer courses in how to review a complex list of medications, examine it for possible drug interactions, identify non-FDA-approved off-label usage, and determine which drugs are necessary and at what dosage. “Deprescribing can radically improve a client’s health, but if it’s not done properly, the person could go into heart failure or develop angina,” Dr. Schneeman said. “The goal isn’t to eliminate every medication, but rather to be sure the combination of all medications is providing the most benefit for the least amount of risk.”
What’s next?
In an ideal world, value-based care would be the norm, physicians would be trained in deprescribing, specialists would consult with primary care physicians, and direct-to-consumer advertising would be limited like it is in most other countries. But given the current realities, are there other ways to combat polypharmacy? The short answer is “yes”—and we’ll explore them in Part 2: Strategies to Combat Polypharmacy.
To learn how Lifespark’s whole-person approach can help your clients age magnificently, schedule a free consultation.