Doctors Prescribe Too Many Medications

This blog post originally appeared on Zaggocare.org

Medications save lives and make life more bearable for millions of people. No doubt about it. But medications can also cause harm. Logically, the more medications a patient takes, the higher the risk of side effects and dangerous interactions between medications. Did you know many patients take inappropriate or unnecessary medications? Unfortunately, over-prescribing is a widespread, dangerous problem in the US, especially for older patients (categorized as those 65+ years old). Why do doctors prescribe too many medications? What harm does it cause? And what can patients do?

An extensive report by the Lown Institute examines the impact of over-prescribing in older patients. Their report states that the US “is in the grips of an unseen epidemic of harm from the excessive prescribing of medications.” This important, often overlooked issue may impact your health, or the health of a loved one.

 

What are the dangers associated with medications?

Although medications are designed to help patients, they can also cause health issues. All medications have side effects. Some are potentially serious, while others are minor. But it’s important to understand that all medications carry some degree of risk. There are two major issues of concern – side effects and adverse drug reactions.

Adverse drug reactions (ADR) involve an unexpected or dangerous reaction to a medication. You can develop an ADR after one dose of medication, from prolonged use of a drug, or from a negative interaction between 2 or more medications.

The more medications you take, the higher your risk of problems, an issue called medication overload.

 

What is Medication Overload?

According to the Lown Institute report, medication overload is “the use of multiple medications for which the harm to the patient outweighs the benefit. There is no strict cutoff for when the number of medications becomes harmful, but the greater number of medications a person is taking, the greater their likelihood of experiencing harm, including serious adverse drug events.”

 

It’s as serious as the opioid crisis!

The Lown Institute reports that “medication overload is causing widespread yet unseen harm to our parents and our grandparents. It is every bit as serious as the opioid crisis, yet its scope remains invisible to many patients and health care professionals.”

 

How many medications are older Americans taking?

Older Americans, as a group, are taking a lot of medication:

  • More than 40% of older adults take 5 or more prescription medications a day, an increase of 300% over the past two decades!
  • Almost 20% of older adults take at least ten medications.

 

What is the impact of medication overload?

Health issues from medication overload can range from mild to life threatening. And the economic ramifications are staggering.

 

The Lown Institute report found that in 2018, in the US:

  • Medication issues led older adults to seek medical care nearly 5 million times.
  • Every day approximately 750 older people end up hospitalized due to medications, for a total of over 250,000 hospitalized patients/year.
  • These hospitalizations cost an estimated $3.8 billion.

 

Over the last decade:

  • There were over 35 million cases of older people seeking medical treatment for adverse drug events.
  • Medication issues led to 2 million hospital admissions.

 

The Lown Institute estimates that if changes are not made, in the next 10 years medication overload will lead to premature deaths for 150,000 older Americans and reduce the quality of life for millions more. Furthermore, the report estimates that reducing inappropriate or unnecessary medications could save as much as $62 billion over the next 10 years. And that’s only for money saved by avoiding unnecessary hospitalization for older adults. Certainly, there could be huge additional savings by keeping all patients, of all ages, healthier by reducing medication overload across the board.

 

What factors lead to medication overload?

Although many factors influence medication overload, the Lown Institute report identifies 3 overarching issues:

Culture of Prescribing

The culture of prescribing is shifting. Doctors and patients feel the need to “do something” to improve patient health. Ads for prescription medications encourage patients to seek medications for improved happiness and health. The practice of medicine is fast paced, with doctors often seeing patients in time-limited slots. Additionally, we have adopted a medical approach to normal aging. All these factors have led to a shared expectation among doctors and patients that there is a “pill for every ill.”

Information & Knowledge Gaps

Doctors and other clinicians, as well as patients, don’t always have the critical information and skills they need to evaluate the circumstances and make informed decisions regarding medications.

Fragmented Care

There is a widespread lack of communication among a patient’s various doctors and other healthcare providers. As a result, patients can suffer. One common scenario: one doctor writes prescriptions for what seems like a new health condition but is actually a side effect from another medication prescribed by another doctor. This practice, referred to as “prescribing cascade”, can lead to a cycle of debilitating health and even death.

 

A story of a devastating prescription cascade.

The story below illustrates how medication overload, due to a prescription cascade, killed Joe Esposito.

 

Joe Esposito was remarkably healthy, running half-marathons in his 50s. Unfortunately, a slew of medications left him on the brink of death in just a few years. Joe suffered from mild to moderate Crohn’s disease, an annoying, but rarely fatal condition. Through the process of seeking treatment, his list of medications cascaded from 1 to 6 to 20. Unfortunately, each new medication led to new side effects.

The cascade started with steroids for Crohn’s leading to bone loss and anal fistulas. Doctors prescribed antibiotics for the fistulas, which led to peripheral neuropathy in his feet. Since the pain made it difficult to sleep, doctors gave him benzodiazepines and Ambien for sleep, along with Lyrica for the nerve damage and Tramadol for the pain. And then he developed severe diarrhea from several of the medications. Doctors gave him medications for the diarrhea, including opium drops. Furthermore, drugs weakened his kidneys, which in turn raised his blood pressure, so doctors prescribed 4 blood pressure medications. And, doctors gave him an experimental anti-inflammatory drug which led to pericardial tuberculosis, which almost killed him.

At the end of his life, Joe took over 20 different medications each day, but not one of his doctors considered this a problem worth addressing. Moreover, no one stopped to consider that all of these medications caused his symptoms, not the Crohn’s disease.

 

What are doctors, hospitals and the government doing about this?

Not as much as we would hope and deserve! Although some doctors strive to minimize medication overload among their patients, there is no professional group, public organization, or government agency to date has formally taken responsibility for addressing this problem. The Lown Institute “calls for the development of a national strategy to address medication overload and help older people avoid its devastating effects on the quality and length of their lives.” Hopefully government agencies, non-profit organizations, hospitals and doctors will unite to address this serious issue.

 

What can you do?

While we wait for a national strategy to reduce medication overload, there are some steps you can take to reduce your own risk of medication issues. I suggest the following:

  1. Carry a list of all medications with you – on your phone, or in your wallet – and keep this list updated as you add and remove medications. Be sure to include over-the-counter medications.
  2. Make sure all your doctors have an accurate list of all your medications, including over-the-counter. At every appointment, your doctor (or a staff member) should ask you to confirm your medications. Listen carefully, check the doctor’s list against your own list, and make any corrections needed. Do NOT assume that each one of your doctors has access to your medication list via your Electronic Health Records (EHR). Many EHRs do not connect to each other.
  3. When a doctor recommends a new medication, ask these questions:
    • Is the medication absolutely necessary?
    • What will happen if you don’t take it?
    • Is there a chance your doctor is giving you this new medication to treat side effects from other medications you are taking? If so, what other options do you have?
    • Are there lifestyle changes you can try first?
    • Is the doctor giving you the smallest dose possible for your condition?
    • Will this new medication interact negatively with other medications you’re already taking?
    • Exactly how and when should you take it?
  4. Ask each doctor on your medical team if you can eliminate, or reduce, any of the medications you take.
  5. Don’t push your doctor to prescribe medication. Push aside the temptation to get “a pill for every ill”. And just because you saw an ad for a medication on TV, or a friend told you how much it helps her, it doesn’t mean it’s right for you.

 

About Zaggo:

Roberta Carson started Zaggo, a non-profit organization to help patients and family caregivers manage illnesses and injuries, after her experience as caregiver for her teenage son Zachary during his 27-month battle with terminal brain cancer. Roberta realized patients and families urgently need practical, easy-to-use information and tools. Zaggo’s mission is to provide patients and families with the educational information, tools, and resources they need to become empowered, engaged, effective members of their medical teams for the best possible care. With an easy-to-use guide book and organizational tools, the ZaggoCare System is the only product to offer the comprehensive advice and tools needed to help patients and caregivers manage illness or injury. As a charitable organization, 100% of the profits from the sale of ZaggoCare are donated to innovative brain tumor research in memory of Zachary.

National Women’s Health Week 2019

This past Mother’s Day launched the 20th annual National Women’s Health Week. Led by the U.S. Department of Health and Human Services Office on Women’s Health, the goal is to empower women to make their health a priority and raise awareness of the steps one can take to improve their health.

The Centers for Disease Control and Prevention (CDC) recommends many common measures, such as proper health screenings, staying physically active, eating healthy, and promoting other healthy behaviors. Healthy behaviors include getting enough sleep, being tobacco-free, washing your hands, not texting while driving, and wearing a seatbelt, a bicycle helmet, and sunscreen when appropriate. The Office on Women’s Health website has specific suggestions for women through their 20s to their 90s.

The Affordable Care Act (ACA; aka Obamacare) established Essential Health Benefits that insurers are required to cover, including maternity care. Following the Trump administration’s failed attempts to repeal the ACA in 2017, the Department of Health and Human Services (HHS) announced a year later that insurers will be allowed to omit these Essential Health Benefits from their insurance offerings, leaving the state of health insurance to pre-ACA standards when women were often charged inordinate fees for “extra” maternity coverage. This is compounded by the Trump-approved short-term insurance plans, that are held to much lighter standards than Obama-era insurance offerings. “Trumpcare” plans have low premiums but high out-of-pocket costs and poor benefit coverage — they’re not required to cover pre-existing conditions or healthcare situations such as pregnancy — and lack provider networks which leads to large unexpected hospital bills.

In 2018, The HHS-operated Office for Women’s Health (OWH) website had removed the “lesbian and bisexual health” page and other related links; then later, the OWH Breast Cancer websites were removed before being replaced days later with a single page featuring less comprehensive information. Earlier last year, the HHS announced it would form the new Conscience and Religious Freedom Division that would allow doctors to refuse treatment for those that go against their religious beliefs. The rule has recently been finalized — limiting access to care and undermining the civil rights, health, and well-being of women seeking reproductive health services, LGBT people, their children, and others.

 

A bill was signed into law last week criminalizing abortion in the state of Georgia. The law, which is set to go into effect in 2020, prohibits doctors from terminating any pregnancy after they are able to detect a heartbeat, which typically occurs at six weeks’ gestation. At this stage of pregnancy, the embryo is the size of a sweet-pea or the head of a nail and is more than 30 weeks away from being able to survive without intensive neonatal care; 20 weeks from having even a 50% chance of survival. Many women may not experience symptoms or know they are pregnant this early.

Women who seek an abortion in Georgia would be a party to murder, punishable by up to life in prison. Women who miscarry could be deemed guilty of second-degree murder and sentenced to 10 to 30 years imprisonment. Even residents who travel out-of-state to procure legal abortions would be punished by the Georgia law, as would anyone who helped or supported them in planning transport to a family planning clinic — charged with conspiracy to commit murder.

Similar laws are being pushed in Alabama and Texas, where murder charges stemming from abortions could carry the death penalty. These laws are dangerously detrimental to women’s health, not only in restricting access to important healthcare services but by doing immense harm to the mental health of women. Even women who do not live under these state laws can experience profound emotional trauma from knowing their bodily autonomy is not guaranteed or respected throughout the country.

 

Despite the harm being done to women’s access to healthcare and over the past two years, there are still resources for women in need. In a previous blog post, we detailed the National Breast Cancer and Cervical Cancer Early Detection Program; a program that has provided low-income, uninsured, and underserved women access to timely breast and cervical cancer screening and diagnostic services for over 25 years. Information for the local offerings from the program can be found in the NeedyMeds State Sponsored Programs database. There are other government programs for women’s health to be found on our site, including WISEWOMAN, a program that provides low-income, uninsured/under-insured women with blood pressure, cholesterol, and diabetes screenings.

NeedyMeds has a database of over 17,000 free, low cost, or sliding scale clinics, more than 6000 of which offer women’s health services including nearly 500 Planned Parenthood locations. Search your ZIP code for clinics in your area, and find Women’s Health in Services under the Details heading to find free or low-cost medical attention. Assistance for women’s health can also be found in our Diagnosis-Based Assistance database by searching for conditions that affect the women in our lives, including many that offer various forms of assistance for women seeking an abortion. For more resources, check our website at Needymeds.org or call our toll-free helpline at 1-800-503-6897 9am to 5pm Eastern Time Monday through Friday.

Mental Health Month 2019

May has been observed as Mental Health Month since 1949. One in five Americans are affected by a mental health condition in their lifetime — as many as 43.8 million — and everyone is impacted through family or loved ones. A main objective of mental health awareness is to fight the stigma surrounding those living with sometimes serious conditions through education and support and to improve the chance of recovery for those in need.

 

Everyone has stress and difficult emotions on occasion, and this is completely normal. Mental illness, however, is any condition that makes it difficult to function in daily life. It can affect relationships or job performance, and is caused by any number of complex interactions within the human brain. Mental illness can range from anxiety or mood disorders like depression, psychotic disorders like schizophrenia, eating disorders, or addictive behaviors.

 

Mental illness is prevalent in homeless populations, with 25% living with serious mental health conditions and an estimated 46% with any mental illness. Sixty-four percent of jail inmates, 54% of state prisoners, and 45% of federal prisoners report mental health concerns. LGBT individuals often deal with body dysmorphia, physical or emotional abuse, or feeling unsafe at school or work which can deeply affect their mental health. Adopted children are almost twice as likely as children brought up with their biological parents to suffer from some form of mental illness. Thousands of immigrant children have been separated from their parents/families under the Trump administration’s “zero tolerance” policy, and now face an increased risk of profound physical and mental health problems. Psychologists who have visited detention centers worry that the living conditions in these facilities will add to the trauma families have already endured, though the impact is difficult to predict as no research has been done on children who have been forcibly separated from their families due to the inherent ethical concerns.

 

The United States is facing a growing shortage of mental health professionals trained to work with youth — at a time when depression and anxiety are on the rise. Suicide was the second greatest cause of death for children from age 10-24 in 2017, after accidents. Mood disorders such as depression or bipolar disorder are the third most common cause of hospitalizations in the U.S. across ages 18-44. Serious mental illness costs America $193.2 billion in lost earnings per year.  

A new study shows the economic costs of untreated mood and anxiety disorders among moms exceeds $14 billion dollars through the first five years of a child’s life alone. Fewer adults experiencing psychological distress are being treated by a mental health professional. Of those reporting foregoing mental health care, 13% said they could not afford the cost of care, 12% reported that their insurance would not cover it, 10% indicated that fear or embarrassment kept them from seeking care, and 8% reported that they did not know where to get care.

 

Last year we wrote about Medicaid work requirements waivers promoted by the Trump administration being implemented around the country and the impact work requirements may have on Medicaid recipients. Seven states have since approved work requirements for those receiving Medicaid benefits, and six more are pending. Two states have had their work requirements overturned by the courts.

The growing concern is that people who work could potentially lose Medicaid coverage by not meeting the specific requirements set differently in each state or by getting lost in administrative obstacles to verifying work status or documenting exemption. Work requirement exemptions are based on “medical frailty,” which is defined differently state-to-state and does not always include mental illness in their consideration of frailty. Many mental illnesses can be accompanied by cognitive difficulties affecting executive function, processing speed, and ability to collaborate and communicate which can impact a person’s ability to navigate the complex bureaucratic systems necessary to verify their work status or exemption. Over 18,000 people have lost Medicaid coverage in Arkansas alone due to the work requirement.

 

NeedyMeds has Diagnosis Information Pages for various mental illnesses including depression, obsessive-compulsive disorder, and schizophrenia. We also have information for over 5,000 free, low-cost, or sliding-scale clinics throughout the country that offer counseling or mental health services. Search your ZIP Code for mental health clinics near you, or call our toll-free helpline for information at 1-800-503-6897 (open Monday through Friday, 9am to 5pm ET).

 

We encourage everyone to educate themselves, strive to understand the difficulties people around us live with, and to replace stigma with hope and support. If you or someone you know is suffering from a mental health condition, it is important to know that no one is alone in their struggle. Call for assistance, whether help is needed immediately or long-term.

Samaritans 24/7 Crisis Services via call or text: (877) 870-HOPE (4673)

The Trevor Project (LGBTQ+ crisis support): 1-866-488-7386 or Text “Trevor” to 1-202-304-1200

Trans Lifeline: (877) 565-8860

Does your physician know what you pay for health care?

by Mark A. Kelley, M.D.

This blog previously appeared on HealthWeb Navigator.

All of us should understand our own health care costs. However, the issues can be complicated: e.g. insurance premiums, deductibles, co-pays etc.

Physicians have a different perspective. Like any professional, they focus on how they are paid. Insurance companies require doctors to submit many details with their bills. Physicians rely on sophisticated billing systems to furnish that information, because without it, they are not paid. In a nutshell, patients worry about paying the bills and doctors worry about sending out the bills.

This raises a key question. How much do doctors know about your insurance and what you must pay?

Of course, the doctor can explain his/her own bills to you. Your doctor’s office has checked your insurance and knows what how they should bill your insurance company. Surprisingly, the doctor may not know much your hospital insurance coverage, or your deductible. Most physicians and their staffs have not been trained to gather this information because it does not affect physician payment. .

But things have changed. With high deductible insurance plans, patients have more risk for out-of-pocket costs. A blood test, x-ray or medication can come with a large bill if it drops into your deductible.

The prices may astound you.  A friend recently enrolled in a high deductible insurance plan. She refilled prescription, which previously cost her a $40 co-pay. With her new insurance, she had to pay $250 for the same refill because it was part of her deductible. The price was so high because the insurance company passed all the drug cost on to her.

Why is this important? It is wise to know what you are paying for — and health care is no exception.  Health care bills can mount quickly and squeeze the family budget. Sometimes, families face the tough choice of either paying the rent or seeing the doctor.

Physicians are seeing more of their patients struggling with health care bills. This pressure may discourage them from seeking medical care. Tight finances are becoming a health care risk, even for families with decent incomes.

How can patients and doctors work together to control the “costs of care”?

Here are a few suggestions:

  1. Know the details of your own insurance policy, especially “out-of-pocket costs”such as co-pays, coinsurance and deductibles. If you have any questions or concerns, contact your insurance company.
  2. When your doctor recommends a test, procedure, or treatment, make sure you know what it involves, why you need it, how effective it will be and how soon it must happen. These are questions that any good doctor would be glad to answer. The timing of the test or procedure may be important if you have already paid out your deductible before the end of the year. In that case, you may not have to pay anything for the service.
  3. Cost may (or may not) influence your decision to get a test or procedure.  For example, for an urgent life-saving procedure, cost may not even enter your mind. However, some tests or procedures may not be so convincing. In those cases, cost might influence your decision. If so, discuss the cost issue with your doctor who may suggest less expensive alternatives. The timing, location and type of service may all influence the cost: most often for planned (elective) procedures, x-rays or some medications.
  4. If health costs worry you, talk to your doctor. Don’t be afraid to bring up the issue. You are not alone. Many more patients are asking about costs these days. Physicians welcome solving these challenges with you. They can be very helpful if they understand your concerns.

 

Learn how physicians are addressing this problem on the website Costs of Care.

 

Sexual Assault Awareness & Prevention Month

CONTENT WARNING: This blog discusses rape and other forms of sexual violence.

 

Since 2001, April is recognized as Sexual Assault Awareness and Prevention Month. Over the past year and half, the #MeToo movement has grown to bring sexual violence, abuse, and toxic behavior into the forefront of American culture, but there is still much misinformation and stigma to combat to ensure the health and safety of everyone affected. Rape is the most under-reported crime, with 63% of sexual assaults not being reported to police. Despite misconceptions, the prevalence of false reporting is low — between 2-7%. The consequences of sexual assault reach far into the lives of survivors, families, and communities and have a major effect on public health.

 

Victims of sexual harassment and assault are often thought of as women, but men can also be affected. Statistically, one in five women and one in 67 men are raped at some point in their lives. Nearly 50% of women and 20% of men experience sexual violence other than rape.

 

Vulnerable communities are disproportionately affected by sexual violence:

  • 44% of lesbains and 61% of bisexual women compared to 35% of heterosexual women;
  • 40% of gay men and 47% of bisexual men compared to 21% of heterosexual men;
  • 47% of transgender people are sexually assaulted at some point in their lives.

 

People of color also experience an unequal level of sexual violence in the United States:

  • 29.1% of black women, 12% of black men;
  • 37.5% of Native American women, 12.4% of Native American men;
  • 23.4% of Hispanic/Latina women, 7.4% of Hispanic/Latino men;
  • 30.2% of mixed race women, 9% of mixed race men;
  • compared to 24.8% of white women, 7.5% of white men.

 

Sex workers (escorts, exotic dancers, dominatrixes, pornographic actors, phone sex operators, nude models, etc.) are often ignored when it comes to sexual violence and have their jobs conflated to sex trafficking on a policy level, endangering people working consensually in the sex industry and their livelihoods. By omitting the sex worker community from conversations about sexual assault prevention and rape culture, it perpetuates the stigma and culture of violence that allows violence to be perpetrated against them.

 

People with a history of being victimized by sexual harassment or assault are three times more likely to have depression and twice as likely to have anxiety. Trauma can happen whether or not an individual is physically harmed, and can have lasting effects on one’s emotional or physical wellbeing. A recent study from the Journal of the American Medical Association (JAMA) found women with a history of sexual assault have higher blood pressure and poorer sleep. Unwanted sexual attention that may appear “complimentary” on the surface can affect a person’s self-esteem, body image, or sense of self-worth.

Accompanying body image and self-esteem issues, sexual harassment can lead to disordered eating or lack of appetite. Harassment can take pleasure out of experiences survivors would otherwise enjoy and cause them to withdraw from activities or places they frequent, going so far to change daily habits to avoid discomfort. One’s mind’s perception of sexual harassment as a threat can lead to chronic elevation of the stress hormone cortisol which can lead to inflammation throughout the body, lower immunity, and raise the risk for serious conditions like heart disease and cancer.

 

A disturbing trend in our culture is the blaming of survivors of sexual violence for their victimization. Sexual predators and other perpetrators of sexual violence are often given the benefit of the doubt with their supporters citing how “good” they know the accused to be, asserting that the victim is not “innocent” enough, or making victims feel responsible for their own assault.

Victims are assigned blame because of what they wear, how they behave, or where they go — none of which makes one responsible for someone assaulting them. Alcohol consumption is involved in half of all sexual assaults and is often used to shift blame away from a perpetrator, though studies have shown perpetrators of sexual violence report using alcohol at the time of the assault 10-30% more than victims. In fact, anti-social behavior and negative views about women are much stronger predictors of sexual violence than alcohol use. These factors and more contribute to rape and sexual assault being the most under-reported crime in the United States — which in turn fosters more victim blaming.

 

There are ways to take an active role in increasing safety for yourself and those you care about. The most important way to raise awareness is to talk openly and clearly to young people about consent, how to respond if someone is pressuring you or someone close to you, and following safe practices while traveling or interacting online.

It is also important to educate on what acts constitute sexual violence. A majority of Americans recognize sexual intercourse without a partner’s consent (84%) and unwanted touching, groping, or fondling (83%), but fewer are aware that voyeurism and verbal harassment also are considered assault (64% and 54%, respectively). A third of men do not recognize pressuring a partner for consent (i.e., sexual coercion) as assault.

 

For those who have been the victim of a sexual assault or other violent crime in the United States, there are victim compensation programs in all 50 states and Washington, D.C. These programs help victims of rape, assault, child sexual abuse, drunk driving, domestic abuse, as well as families of homicide victims. Compensation programs can cover medical bills, mental health treatment, and often includes crime-scene cleanup, travel costs to receive treatment, moving expenses, or even the cost of housekeeping or child care if the victim is unable to do so. The programs are often flexible with their eligibility, though most require reporting the crime to police within a specified time frame and cooperating with the investigation. You can find NeedyMeds’ listings for the crime victim compensation programs in our Diagnosis-Based Assistance Database under Violent Crimes. For more support, call the RAINN (Rape, Abuse, and Incest National Network) 24-hour hotline at 1-800-656-4673.