Be courageous: help stop the pill madness

Medicine people give it a sterile-sounding name. Polypharmacy means giving too many drugs, usually to an elderly person.

But this practice is worthy of clearer words: dumb, dreadful or doctoring at its worst.

The idea to mention the growing problem of giving too many pills in combination came to me after reading this Medscape coverage of a trial of statin removal in patients nearing end of life. The randomized clinical trial was presented at the 2014 Annual Meeting of the American Society of Clinical Oncology. One group of patients had their statin stopped and the other group continued the drug as is the normal practice. The researchers found no difference in mortality but they did note patients in the discontinuation arm reported an improved quality of life and a trend toward fewer symptoms. A cost analysis showed major savings, and if this practice took hold over large populations, savings to the health care system would be immense.

That we need a study to tell us it’s okay to stop non-evidence-based pills is telling. I’m not sure where commonsense got lost. These chemicals, such as statins, ACE-inhibitors, beta-blockers, were shown to be beneficial in the setting of clinical trials of patients who were not elderly, frail, encumbered by cancer, demented or close to death.

Take the statin trial from the cancer meeting. Of course there was no difference in mortality from stopping the drug. Depending on the risk of the patient (high-risk–more benefit, low-risk–less benefit), statin drugs confer protection from cardiac events of 1-3% over 5-10 years. If you have life-limiting disease, such as dementia, cancer or frailty, that 1-3% statin benefit over 5-10 years is not helpful to you. You get all the harm and none of the benefit. (In fact, for many of these patients, some in diapers and with delirium, a cardiac event might be considered a blessing.)

Another example is ACE-inhibitors. These blood-pressure reducing drugs have proven benefit in patients with congestive heart failure. But again, they were not studied in the frail, elderly and chronically ill. A common problem in the elderly is unsteadiness of gait. Low blood pressure contributes to this problem and stopping blood pressure medications (that may have once been helpful) often works wonders. “Are you dizzy when you stand-up” is a question I ask every old patient in the office. I see my yearly visit with patients as an opportunity to stop drugs that are not beneficial. This tree often bears low-hanging fruit.

One thing Staci has taught me about pill burden is that patients admitted to palliative care and hospice services often flourish when their “nonsense” medications are stopped. She teaches me that the chronically ill and elderly need most to eat food not pills. This is perhaps one of the reasons why some studies show patients started early in their course on palliative care live longer. Of course they do.

Many of the drugs we use now as if decried from gospel (statins, ACE-I and beta-blockers) were studied in the 1980s and 1990s, a time when many fewer drugs were on the market. Nowadays, it’s common for an elderly patient to be taking more than ten medications. Think about that. That’s ten chemicals that can interact with each other, sometimes increasing effect and other times decreasing effect. That’s ten pills to be cleared by the kidneys or liver, whose filtering functions diminish with aging.

Doctors (and patients) should not need a carefully designed trial to give us permission to practice minimally-disruptive commonsense medicine.

Please, let’s stop the madness with the pills. To do no harm does a lot.

JMM

Comments

  1. DoctorSH says

    DrJ:

    Nice post!!

    To understand polypharmacy we really need to get to the causes.

    1) Docs like their prescription pads. It is something they can do that no one else can.
    2) Docs find it easier to give a pill than to think thru triggers and accommodate for them.
    3) The advent of EBM guideline and third party guidelines almost force docs to use meds/polypharmacy.
    4) Third party healthcare and the time limits imposed on seeing patients makes it easier to prescribe a drug, rather than delving further into the health issues.
    5) Patients often demand drugs as they think a pill will solve their problems.. better living thru chemistry???
    6) Population based medicine instead of individualized.

    There are many others and I hope that other commenters can add on.

  2. says

    Such common sense advice here, Dr. John. I hope that other docs will follow your lead in stopping – or at least, slowing down – this pill madness.

    I’ve been learning more than I ever wanted to learn lately about polypharmacy after bunking out at the bedside of a close friend hospitalized for five agonizing weeks following a drug toxicity reaction called Stevens Johnson Syndrome.

    SJS causes an explosion of absolutely horrific symptoms as hour by hour, the skin erupts into cracked, open bloody lesions. The toxicity affects all mucous membranes of the body. Permanent blindness is often a tragic end result – despite, as in my friend’s case, several emergency ophthalmology procedures including Amniotic Membrane Transplant surgery.

    SJS is apparently very rare (most physicians will go through their entire careers and never see even one living example of this heart-breaking drug toxicity). So during my friend’s five weeks being treated in a teaching hospital, she entertained an ongoing parade of visiting med students, residents, fellows and even local physicians who had heard through the grapevine about a real live Stevens Johnson survivor in the flesh – lots and lots of open, bleeding flesh. My only hope is that any of them who saw the suffering that drug toxicity can cause will hesitate for even a moment before signing prescription pads in the future.

    Most of us who are prescribed meds with a pat on the head and instructions to take these drugs every day for the rest of our natural lives will never know the catastrophic results of drug toxicity like my friend has survived. But the quality-of-life pharmaceutical damage being inflicted upon the frail elderly you describe here is no less heartbreaking.

    regards,
    C.

  3. Deborah Shlian, MD, MBA says

    Couldn’t agree more. As a physician and also caretaker for my aged parents, I have always been suspect of poly-pharmacy in the frail and elderly. Both my parents did much better off the statins and anti-hypertensives.

  4. Joan says

    Bravo, Dr. John! You speak truth!

    I am a 64 year old female former long distance cyclist with “lone” AF and a gigantic left atrium. I take lots of supplements but no drugs except a daily adult aspirin.

    Every time I visit a doc–internist, cardio, electrophysiologist, I am offered pills. Statins. Flecainide. Metoprolo. Rhythmol. Usually off-handedly, as if they were totally innocuous substances and I, the generic old lady patient with hypertension, diabetes or metabolic syndrome; none of which I have.

    The practice of medicine (in my recent experience) has seemingly become a soulless, rote exercise. You get 5 minutes with the tech who takes your BP, etc., 5 minutes with a scribe who types frantically into a computer as you try to relate what you deem important, and 5 min. with the doc, who usually does not even touch you, but decides that you might need a life-altering regimen of statins, despite an HDL of 86, or a nice shot of flecainide to send you into wild atrial flutter during the wee hours of the morning, far away from any major hospital.

    I’m beginning to think that the profit motive has swallowed up most medical practices to the point that the patients have become merely revenue-generating units. And of course the only counter-balance to this revenue driven protocol is the obdurate & rote denial of services by the insurance companies. Meanwhile us patients are caught in the middle of a tug of war for profits. Not good.

    • says

      Your last two paragraphs are depressing. That’s because you are, in large part, spot on. One of the aims here is to give such sober observations of the deficits in US healthcare a platform. Thank you.

    • Nereida Savoy says

      Absolutely agree. Attempt to decrease meds at every visit and listen more at every visit.

  5. says

    As a fitness professional, and a 59 year old triathlete (USAT #2702), and a current member of the A-FIB club, I must say I depend on you for the latest updates on cardiac related incidents. I share your website with so many athletes that thought we were placing red-line heart hour deposits in our lifespan bank. We now know that it has consequences. Thank You for your Extreme Knowledge and complete Honesty. The heart pumps, but YOU ROCK!

  6. Hazel Nissen says

    Hi John, great site. Just thought it might be worth you reading this recently published paper suggesting reduced heart rate is not due to changes in autonomic control. Cheers

    Exercise training reduces resting heart rate via
    downregulation of the funny channel HCN4

    Nature Communications Journal

    • says

      @ Pradeep – Better than that – Physicians should read this and embrace it. As I stated in my earlier comment – PHYSICIAN GOAL should be to stop more medications in the elderly than they start at the VERY least.

  7. says

    In the 1980′s and 1990′s we were already being warned about the dangers of polypharmacy in older patients. One gerontologist at any time he could would say that once a patient reached over 7 medications in a day there was almost a 100% chance of a drug – drug interaction (which we don’t often talk about these days), or a simple adverse reaction to drugs. maybe one of the more bothersome conclusions from your post has to do with how long it takes us to incorporate good ideas into routine care. Over a quarter of a century is indeed a long time.
    Thanks for bringing this to the fore again.

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