Polypharmacy is the concurrent use of four or more medications by a patient; which is most common among the elderly, affecting about 40% of older adults living in their own homes. In the United Kingdom, and many other western healthcare systems, the central role of general-practice in the health services means that long-term prescribing is mainly carried out in the primary-care setting i.e. the first port-of-call for acute and chronic ill-health.
The Prescribing Cost Analysis in England (1) confirms a clear year-on-year increase in the number of medications dispensed in primary care. The total number of medications dispensed increased by 64% from 587 million in 2001, to 962 million in 2011; an average of 12 medications per patient per year in 2001, and 18 medications per patient per year in 2011.
And the figures continue to rise.
In 2015, the cost of prescriptions in the UK totaled £9.27-billion (a mere R150-billion), with a staggering 1.08 billion prescription items dispensed to the general public.
Concerns about polypharmacy include increased adverse drug reactions, unforeseen drug interactions, prescribing cascade (where side effects of drugs are misdiagnosed as symptoms of another problem resulting in further prescriptions and further side effects) and higher costs.
Polypharmacy is often associated with a decreased quality of life, including decreased mobility and cognition; in many instances it can be more harmful than helpful i.e. presenting too much potential risk for too little possible benefit.
Yet polypharmacy is not always bad, and can of course save lives.
Certain medications can interact with others in a positive way when prescribed together, to achieve a greater effect that any of the single agents alone. For example, a common treatment regimen in the first year after a myocardial infarction (heart attack) could include a statin (to lower cholesterol levels in the blood), an ACE inhibitor (to treat hypertension), a beta-blocker (to reduce blood pressure), aspirin (to treat pain, fever, and inflammation), paracetamol (a pain reliever) and an antidepressant.
Therefore, health professionals consider it a situation that requires careful monitoring and regular review to validate whether all of the medications are still necessary.
A 2013 report by The Kings Fund (an independent charity working to improve health and care in England) makes an important distinction; (2)
- Appropriate polypharmacy is prescribing for an individual, for complex conditions, or for multiple conditions in circumstances where medicines use has been optimised and the medicines are prescribed according to best evidence. The overall intent for the combination of medicines prescribed should be to maintain good quality of life, improve longevity and minimise harm from drugs.
- Problematic polypharmacy is where multiple medications are prescribed inappropriately, or where the intended benefits of the medication is not realised. The reasons why prescribing may be problematic may be that the treatments are not evidence-based, or the risk of harm from treatments is likely to outweigh benefits, or where one or more of the following apply:
- The drug combination is hazardous because of interactions.
- The overall demands of medicine-taking, or ‘pill burden’, are unacceptable to the patient.
- These demands make it difficult to achieve clinically useful medication adherence.
- Medicines are being prescribed to treat the side effects of other medicines, where alternative solutions are available to reduce the number of medicines prescribed.
In pharmacology (the study of drugs) it is well-known that research cannot accurately predict the side effects, or clinical effects, of a combination of drugs without studying that particular combination in test subjects. Knowledge of the individual drugs in question does not guarantee accurate predictions of the side effects of combinations of those drugs.
Also, the effects vary greatly among individuals; partly due to differing genetics, yet also the myriad other off-prescription and over-the-counter medications that a patent might take without their doctor’s knowledge. Even the foods we eat can have a dramatic effect on our medications; in some cases diminishing the strength of the drug, in others, increasing it to dangerous levels.
Dr Bernard Brom, founder and chairman of The South African Society of Integrative Medicine (3) warns that, despite the potential benefits of medication, they remain chemical drugs, all of which are toxic;
“All drugs are chemicals that work by interfering with chemical processes, much like any poison. The fact is that drugs are poisons and are being used for one of their poisonous effects. Taken in too high a dose they will kill. Doctors know this and must decide if the benefits are worth the risk.”
Worryingly, this information is not always made clear to the person receiving the drug. While the doctor may not be consciously trying to hide the facts, the enormous pressure to highlight certain predetermined points will often guide the way research is set up and what information the public receives.
We place a lot of trust in our doctors; yet might be better served to support this process by undertaking more research ourselves before passively agreeing to consume whatever we are instructed too by our medical practitioner, as well intended as they may be.
Dr Peter Gotzsche, co-founder of the Cochrane Collaboration (4), gives this stark warning;
“Prescription drugs are now the third leading cause of death after cardiovascular disease and cancer. Many people are dying by doing exactly what their doctors tell them. Any drug comes with between 20-40 warnings and contraindications; they interact with each other, and even with foods. No doctor can know all of this.”
(NB: Cochrane is a global independent network of researchers, professionals, patients, carers, and people interested in health. Cochrane consists of 37,000 independent contributors from more than 130 countries; working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Visit: www.cochrane.org for more information).
Yet this statistic does not present on official figures from the World Health Organization (5), who recorded the top-10 causes of death globally in 2015 as the following;
- Ischaemic heart disease.
- Lower respiratory infections.
- Chronic obstructive pulmonary disease.
- Trachea, bronchitis, lung cancers.
- Diabetes mellitus.
- Alzheimer’s disease.
- Diarrhoeal diseases.
- Road injury.
Alarmingly, the omission of the world’s third leading cause of death is due to a historic administrative technicality that still pervades today. The annual list compiled by the Centers for Disease Control and Prevention (6) is created using death certificates filled out by physicians, funeral directors, medical examiners, and coroners. However, it relies on assigning an International Classification of Disease code to the cause of death. As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured.
According to Martin Makary and Michael Daniel in a report for the British Medical Journal (7) this includes medical error, which has been defined as;
“An unintended act (either of omission or commission), or one that does not achieve its intended outcome; the failure of a planned action to be completed as intended (an error of execution); the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may harm to the patient.”
This is a serious concern.
Misdiagnosis by physicians is a serious and common occurrence in the health sector. The repercussions of a misdiagnosis can have a huge impact upon the life of the person involved and of their friends and family. Needless to say a misdiagnosis would result in an erroneous or unnecessary medical drug being prescribed.
Figures vary, and many cases go unreported; yet according to America’s National Centre for Policy Analysis (8), diagnostic errors are the leading cause of medical malpractice litigation. Also, audited figures from Britain’s National Health Service Litigation Authority (9) show that in the financial year 2014-15, insurance claims citing “wrong diagnosis” totaled an incredible £193,680,744.
We live in challenging times. Synthetic pollutants and environmental stressors seem to define the current age. People today struggle with health issues that previous generations could never have foreseen.
Healthcare exists to offset these challenges and lessen their effects upon quality of life. In many ways this has been achieved. Medical advances have eradicated numerous diseases and increased life expectancy across the world.
Yet as 19th and 20th century practice focused heavily on infectious agents such as bacteria, virus and parasites; the 21st century has brought in newer lifestyle-related conditions that medicine alone cannot effectively address.
Many of the illnesses that afflict society today are members of the chronic degenerative disease family, which result from a continuous process of deteriorating cell structure and accompanying loss of function. These include, but are not limited to, type-II diabetes, cardiovascular disease, arthritis and even cancer.
There is no single cause to these diseases, which are characterized by several stages e.g. initiation phase, subclinical stage and clinical diagnosis.
Therefore, deciding whether and how to reduce a list of medications isn’t simple and requires not just the clinical research, but also the experience and judgment of a healthcare professional, and the personal discernment and informed opinion of the patient; who must become an active member of their own health team, not merely a passive bystander awaiting instruction.
Anatomy teaches us that structure, function and form are mutually inter-related. As such, emotional disturbances can affect internal organs, spinal problems can affect the gut, nutrition can affect emotions and so on. Health, and disease, stem from a complex interaction of physical, emotional, genetic, environmental, dietary and lifestyle factors that can rarely, if ever, be allocated a drug comprehensive enough to bring about a curative resolution.
In the past, it was considered poor practice and frowned upon to prescribe several medications at the same time to a patient. Increasingly it is recognised that polypharmacy is a ‘necessary evil’ that for many patients is required to improve clinical outcome. However, it still remains the case that some people are unnecessarily prescribed multiple medications, when they are unlikely to benefit, or where drug interactions are likely to cause harm.
Polypharmacy is certainly a common and growing global issue, driven by our ageing population and by the increasing levels of multi-morbidity; two or more chronic medical conditions in an individual. Numerous evidence-based guidelines help drive the increase in polypharmacy, yet rarely advise on how to manage multi-morbidity.
Another important challenge is that of working alongside patients to empower them to make informed choices about treatments, and the burden of pills they are expected to consume. Increasingly, it is recognised that many people find their medication regimens an unpleasant chore, which alone can detract from their quality of life. If this is not managed well, medicines will not be taken as the prescriber intends, resulting in significant and costly waste, and of course a failure to realise the anticipated benefits of treatment.