polypharmacy

Saturday, June 10, 2017

The problem with fame is that privacy is hard to come by. The problem with social media is the willingness of people to give up any privacy that they might have. Michael Oher, a lineman for the Carolina Panthers, posted an Instagram picture of the 10 prescription medications that he takes for concussion symptoms, and then quickly deleted the post. Nothing is ever truly deleted on the internet and the photo made its rounds. The need for ten prescriptions is a private matter between Mr. Oher and his physician, but that numbers of medications is not a rare occurrence but it is a big problem, especially in the elderly.

Many people suffer from multiple chronic conditions that can be interlinked and each might need specific treatment. Polypharmacy describes a patient taking more than four medications at a time and it especially affects the older population. Up to 40% of people older than 65 take that many pills and more than 10% take ten or more. Those aren’t just prescriptions, but also include over-the-counter medicines, herbal medications, and dietary and vitamin supplements. While each pill may have a benefit, interactions and complications increase with each added drug.

Ideally, chronic illnesses would not need any medication treatment. Some patients with high blood pressure and diabetes might be able to be treated with diet, exercise and weight loss, but may need medications to maintain lifelong control of their disease to prevent complications like heart attack and stroke. Some patients with high blood pressure (hypertension) may need two or three medications to keep their blood pressure controlled. In addition to insulin, some diabetics may need oral medications to lower blood sugar. Add high cholesterol and then the need for aspirin to help prevent heart disease and the number of pills needed on a daily basis grows quickly.

With each medication added, the risk of a significant complication or interaction increases. Drug interactions can happen inadvertently, even with over the counter pills.

  • patients with kidney disease or ulcers shouldn’t take ibuprofen or naproxen. NSAIDs can worsen kidney function and can cause bleeding in the esophagus, stomach or intestine
  • patients with liver issues should avoid acetaminophen (Tylenol), since it can be toxic to the liver. If there is major liver disease like cirrhosis, the NSAIDs might not be a good idea either because of the potential risk of bleeding. Patients with cirrhosis cannot make enough blood clotting factors and can have varices (swollen veins that can bleed)
  • those with high blood pressure should avoid cold medications containing phenylephrine, because it looks like adrenaline to the body increasing blood pressure readings
  • people on antidepressants that can cause drowsiness should not take Benadryl (diphenhydramine) which is used for allergies but is also the active ingredient in over the counter sleeping medications

There are plenty of drug interaction between prescription drugs. So many exist that electronic medical records and computer programs continually remind and warn doctors and pharmacists about what is safe to prescribe and what might cause problems. There are so many warning that error fatigue can occur…there are so many warning that they get ignored.

All may be well and good if there is just one provider coordinating medical care, but too often, there are lots of specialists trying to look after their one part of the body and nobody is charged with looking after the whole person. Adding to the confusion and potential for error is the mail-order pharmacy and lack of face time with the patient. But most importantly, it’s the patient who may not keep track of their pills and thinks nothing of walking into a convenience store to pick up a cold or pain medication without appreciating the potential harm that might occur.

And then there is Michael Oher. 10 prescription medications for a concussion is a whole bunch. He signed off his Instagram post with “SMH”, shaking my head…well, we are too.

 

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narcotics role is changing

Monday, August 29, 2016

Football is a violent sport and with it comes injury and that begets pain. Some injuries are self-evident, like the tibia and fibula fracture sustained by Chicago Bears quarterback, Connor Shaw. His leg was splinted and he was carted off the field in obvious pain. Other injuries take some time to sort out, like the Cowboys’ Tony Romo, who failed to talk his way into playing in the same game and was later found to have a compression fracture of his lumbar spine. Both injuries hurt and both players will likely be prescribed narcotic pain medication in the first few days of recovery. NFL players have been known to take a variety of legal and illicit medications to allow them to play through the pain each weekend, but that mindset does not translate well into the real world off the playing field.

The Fifth Vital Sign

Not too long ago, pain was added to the medical mind frame as the fifth vital sign. It followed blood pressure, pulse respiratory rate and temperature. Regardless of the reason for the doctor’s visit, patients were often asked whether they were having pain and their assessment, often on a scale of zero to ten. Kids had the smiley/ frowny face pain scale option. Pain is not normal and medicine is all about keeping vital signs in their normal range. Patients didn’t want to hurt and it was easy for a doctor to write a prescription for narcotics.

Doctors like to make their patients feel better but there was another benefit to writing the prescription. Patient satisfaction scores for doctor performance might have been tied to giving patients what they want. Who knew that excessive narcotic prescribing habits might lead to an increase in drug dependence, addiction and become a gateway to the increase abuse of heroin and other illegal street drugs.

The pendulum is beginning to swing back and patients might take a while to understand that a pain-free life may not be available through the use of narcotics. They may not like the doctor who says no to their request and those negative feelings are being expressed by examples of falling patient satisfaction scores.

Wisconsin Prescribing Guidelines

The Wisconsin Medical Examining Board, the governing agency that licenses doctors in the state) has published guidelines about prescribing narcotics, including when to use them what drug to prescribe, how many pills and the expectation to look for patients who exhibit drug seeking behavior. Doctors in the state need to listen and act according. Without a medical license, their career has effectively ended. Just a few of the highlights:

  • It is difficult to know how much a patient hurts. Find out why there is pain and treat the underlying cause. Use non-opioid (non-narcotic) medicines like acetaminophen, ibuprofen or naproxen.
  • If prescribing narcotics, use the lowest dose and fewest number of pills. Most patients will need less than three days of treatment and rarely more than five.
  • There is little evidence that narcotics should be used to treat chronic pain.
  • “Physicians should avoid using intravenous or intramuscular opioid injections for patients with exacerbations of chronic non-cancer pain in the emergency department or urgent care setting.
  • Physicians are encouraged to check Wisconsin Prescription Drug Monitoring Program website to see whether the patient is already receiving narcotics from other doctors. This becomes law in April, 2017 before prescribing any controlled substance for greater than a three-day supply.
  • “The use of oxycodone is discouraged.”

Patient Satisfaction

Patients may not be satisfied with the result of their doctor visit if expectations for pain control are not met. This might be especially true for chronic pain patients who have come to rely on narcotics for their symptom control. It may take time to consider treatment alternatives and still meet the needs and demands of the patient.

The New York Times reported on the experience at Marion (Indiana) General Hospital. Over the course of 18 months, emergency physicians decreased their narcotic prescribing by 50%. Patients weren’t happy and ER satisfaction scores fell from the 58th percentile (of 1100 similar hospitals) to the 14th. Does that mean that the doctors practiced bad medicine or did it mean that there was a disconnect between what the patient wanted and what they received. The words of Mick Jagger and Keith Richards might have been ahead of their time describing this phenomenon.

You can’t always get what you want…you get what you need.

 

 

 

 

 

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