A veteran finishes his meal of medications and can no longer stomach the food in front of him. An octogenarian fractures his hip from a fall shortly after taking Xanax. A healthy young woman dies suddenly from the interaction between a new nausea medication and her long-standing anti-depressant.
What do these stories have in common? Harm from medications used beyond their need.
Many factors contribute to a patient’s accumulation of medicines, including acute and chronic illnesses, multiple health care providers, and targeted marketing by drugmakers. But as our population ages — and our medication lists lengthen — it becomes ever more important to scrutinize each prescription. Within the VA Connecticut Healthcare System, we are making efforts to “deprescribe” medications that are no longer needed, and we believe this should become more widespread.
Americans are taking more medications now than ever before. The total number of prescriptions filled each year has increased by 85 percent over the past two decades, according to data cited by Consumer Reports. One study found that one in 10 Americans takes five or more prescription medications, and 30 percent of the overmedicated are over age 65, an age group that carries an increased risk of complications. These numbers do not take into account over-the-counter medications and supplements, which roughly half of older Americans take regularly.
Why do people keep taking medications that are no longer needed? Why do health care providers keep prescribing them? For clinicians, the challenges include limited time during office visits and lack of knowledge about removing medications from a patient’s list.
While some medications, like antibiotics, are prescribed with a clear end date, many others are not. Providers may worry a patient will view them as neglectful — or worse, incompetent — if they take a longstanding medication away. It can also be difficult for clinicians to discontinue medications started by other prescribers, especially if the original reason is unclear.
One thing is very clear: accumulating medications comes at a significant cost, one that goes well beyond our wallets. It can result in adverse drug events, which account for approximately 1.3 million emergency department visits each year. Nearly 35 percent of these visits lead to hospitalizations and sometimes death. And patients who take many pills may become reluctant to take every single medication each day, which can result in missed doses of important drugs.
Although patients can be reluctant to stop taking a longstanding prescription, they too are concerned about the number of medications they use. In a recent study of middle-aged Canadians, two-thirds were aware that medications can cause harm, and three-quarters were willing to stop taking a medication if their physician recommended it.
To be sure, many medications are critical in treating acute and chronic diseases. There are countless situations in which patients should remain on multiple medications, and discontinuing some prescriptions can be detrimental. To address this, researchers in the United Kingdom developed the START and STOPP criteria to identify risky medications in older adults and situations in which the same medications may be appropriate and even necessary. A study of the use of START and STOPP during hospital stays found it can improve the appropriateness of prescriptions for at least six months after discharge.
At the VA, several recent initiatives have focused on deprescribing, with good results. These include electronic alerts for patients on more than 10 medications and an expectation that clinicians review medication lists during each visit. VA Connecticut also offers a special clinic where pharmacists, geriatricians and primary care providers work together with patients to trim their medication lists.
The benefits go beyond a simple decrease in pills: one study showed participants were able to think more clearly after removing medications and had a better understanding of why they were on each medication.
It is critical for clinicians and patients to make some simple but crucial questions a part of every visit. Patients should feel empowered to ask: “Why am I still taking this medication?” and “How long will I need to be taking it?” Providers should ask the question: “Does this patient still need this medication?”
Taking too many medications that are no longer necessary is an insidious problem: It hurts both the patient and society. But, if we work together with our patients, it's a problem we can fix.
The authors work on the staff at the VA West Haven COE Clinic.