Overprescribing
Maria G. Tanzi, PharmD
Older Americans are increasingly facing the issue of medication overload—use of multiple medications that pose a greater risk of harm than benefit. Researchers estimate that more than 40% of older adults take five or more prescription medications, and when use of OTC medications and supplements is added, this percentage increases to more than two-thirds of older Americans who take five or more medications.
In January 2020, the Lown Institute released Eliminating Medication Overload: A National Action Plan. The report recommends implementing medication check-ups; raising awareness among clinicians, policymakers, and the public; improving information at the point of care; and educating and training health professionals on how to reduce medication overload.
“This report provides pharmacists with a number of valuable tools to better frame this issue with their patients and other clinicians in an effort to break through the current overprescribing culture (i.e., ‘a pill for every ill’),” John W. Devlin, PharmD, BCCCP, MCCM, FCCP, professor in the department of pharmacy and health systems sciences at Northeastern University’s Bouvé College of Health Sciences in Boston, told Pharmacy Today.
“Pharmacists have an important professional responsibility, no matter the setting where they practice, to educate patients and prescribers about the adverse outcomes and costs associated with medication overload,” Devlin said.
Kristin Zimmerman, PharmD, CGP, BCACP, associate professor in the department of pharmacotherapy and outcomes science at Virginia Commonwealth University’s School of Pharmacy in Richmond, echoed Devlin’s words.
“Pharmacists should see this report as a call to action,” Zimmerman said. “Pharmacists are on the front lines of medication-related patient care and have an obligation to learn about the risks of medication overload, especially for older adults with multiple chronic conditions, and have an opportunity to raise awareness among patients and clinicians about these risks. Raising the profile of the issue is critical to creating a momentum for change.”
The Lown Institute report highlights numerous issues that may be driving medication overload. Among these are a culture of prescribing for both patients and clinicians. Clinicians are typically urged to do something for every medical condition, and this often results in overprescribing of unnecessary medications.
There is limited guidance on effective prescribing in older adults with multiple chronic conditions and how to safely stop medications. The highly fragmented health care system is another contributing factor, with patients seeing numerous prescribers across different care settings; often no single clinician or team keeps track of all medications.
Pharmacist-driven medication checkups
Medication checkups are a key strategy to reduce medication overload, as they offer an opportunity, using shared decision making with the patient, to eliminate or lower the dose of unnecessary or harmful medications. This intervention focuses primarily on medication deprescribing, whereas other interventions have focused on medication optimization.
For example, medications used to treat symptoms (e.g., proton pump inhibitors) are usually not meant for continuous, long-term use and should be considered for discontinuation. Other medications may offer limited benefit in some patient subgroups (e.g., use of a statin for primary prevention in older adults).
The Lown Institute report notes that a medication checkup should be available to all patients who request it but should be standard practice for patients taking five or more medications, patients who have had an adverse drug event, and those who are having trouble managing their medications. Medication checkups should also be performed during transitions of care and when life-changing events occur.
“Assuming pharmacists have the dedicated time to conduct these [checkups], they certainly have the knowledge and training to complete these in select patients,” Devlin said. “Patients who are older, who have been recently discharged from the hospital, and/or who are complaining of new symptoms that could be drug related are prime candidates for pharmacist-driven medication checkups,” Devlin said.
Four key components
Medication checkups have four key components: inventory, inquiry, intervention, and follow-up. The pharmacist first takes an inventory of all the medications the patient is taking, including OTC medications and supplements.
Next, the pharmacist has a conversation with the patient to understand their values, preferences, and goals; and assesses each medication with these in mind.
Shared decision making occurs during the intervention stage, with the pharmacist, patient, and family or caregiver creating a plan of action for medication use and necessary follow-up.
Finally, the pharmacist communicates medication changes to other clinicians and gives patients updated medication lists to ensure they understand their current regimen.
The Lown Institute report lists 11 guiding principles when performing a medication checkup. To review these principles, clinicians are encouraged to access the full report at https://lowninstitute.org/reports/eliminating-medication-overload-a-national-action-plan.
Principles of deprescribing
Sunny Linnebur, PharmD, BCGP, BCPS, a professor at the University of Colorado and president of the American Geriatrics Society, talked to Today about the issues of medication overload, the prescribing cascade (in which medications are given to treat adverse effects from other medications), and the need for deprescribing efforts.
“When we assessed our patients, we found that 85% of them were taking medications differently at home than on their current medication lists,” Linnebur said.
She noted that the issues were multifactorial, stemming from patients failing to inform providers about additional OTC medications and supplements they were taking at home, patient confusion about drug regimens, and patients taking multiple medications from the same class without realizing it (e.g., two ACE inhibitors, two statins).
Linnebur provided some general deprescribing considerations for pharmacists, including asking some of the following questions when reviewing medications:
- Is the patient receiving a benefit from the drug?
- Do the harm(s) outweigh the benefit?
- Are the patient’s symptoms stable?
- Is the purpose of the drug preventive or treatment?
- Will withdrawal symptoms or disease recurrence occur if the drug is stopped?
- Is tapering required?
- How should the patient be monitored?
Linnebur stressed that tapering is important for select therapies (e.g., benzodiazepines, antidepressants, opioids) to avoid unwanted adverse effects.
She also discussed key questions to consider when assessing the use of OTC supplements, as most supplements have limited to no evidence of their effectiveness and may actually be harmful. Questions may include
- What is the patient’s life expectancy, indication, and benefit/risk?
- What brand of supplement are they using?
- How many ingredients are in-
- cluded?
- Are the vitamins/minerals actually indicated, such as use of vitamin D for bone health, vitamin B12 for neurologic function, calcium for bone health, or iron for anemia? If not, deprescribe the rest.
Patient education
Pharmacists should engage their patients in conversation about why they are on a particular medication and whether they are actually taking it.
“When patients are prescribed two medications with a similar pharmacologic profile, probe them about the rationale for these treatments,” Devlin said.
He encouraged asking patients direct questions about whether they are experiencing any adverse effects from medications, and where appropriate, asking patients if they feel the symptoms of the condition they are being treated for are adequately controlled with the prescribed medications.
“This pharmacist–patient communication will help identify situations where inappropriate or unnecessary medication is being prescribed and help facilitate deprescribing efforts by the pharmacist with the prescriber,” Devlin added.
Zimmerman highlighted additional educational pearls, such as providing insights to patients on how the body’s interactions with and response to a medication may change with age, clinical conditions, and other medications.
She encouraged pharmacists to empower their patients to ask for medication checkups, but she cautioned not to incite unnecessary fear of medications in patients.