Rising prescription drug use points to deeper problems
When Margaret Herlth wakes up in the morning, 13 prescription drugs and two over-the-counter supplements are as much a part of her routine as a first cup of coffee. That’s a lot of pills, but not a highly unusual number for an 80-year-old with serious health problems, including cardiovascular disease and breathing difficulties.
“They do make me feel better if I take them,” says Herlth, who lives in southwest Baltimore. “I’ve been in and out of the hospital so many times. Each time they give me new pills, but they never take any away.”
These days, if you’re elderly, a medicine cabinet full of prescription drugs is par for the course. But even relatively young, healthy adults may be prescribed medicine as a preemptive strike to lower their cholesterol and blood pressure, to deal with a touch of arthritis, to ward off osteoporosis, to stop the symptoms of seasonal allergies or to fight depression.
Many people add to the list by taking herbal supplements. They also reach for the Advil bottle at the first sign of a headache and chew antacids when they get heartburn.
This month, the federal Centers for Disease Control and Prevention reported its latest data on prescription drug use. The agency estimates that nearly half of all Americans take at least one prescription drug and one in six takes at least three. Over the last decade, the percentage of people taking one or more prescription medicines has increased from 39% to 44%.
We’re a medicated society, of course. But the sheer number of drugs we take suggests that we may be an overmedicated society.
The widespread reliance on medications creates several potential problems.
For starters, some medications may not be as effective as their users believe. People often prefer newer drugs, even though they may not perform any better than their older, perhaps safer counterparts. Doctors and patients don’t always have an easy time sorting out which are which.
Then there’s the problem of “polypharmacy,” the term the medical profession uses to describe the taking of a number of drugs at the same time -- drugs that can have unwanted interactions.
“We’ve identified it as an actual problem, like hypertension,” says Stuart Bell, an internist and vice president of medical affairs at Union Memorial Hospital in Baltimore. “Often there’s a rationale for each of these medications, so these are not easy decisions.”
Meanwhile, drugs have become more expensive than they used to be.
The cost of prescription medicines rose 5% in 2002, says the recently released CDC report, but because people are taking more drugs, spending increased 15.3%. Costs continue to rise, but the rate is slowing, says the Pharmaceutical Research and Manufacturers of America, the industry’s trade group. It reported that prescription drug prices increased by 3.1% in 2003.
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Age, weight factors
The most obvious reason Americans are taking more medicines is that baby boomers are getting older, and therefore a large bulge of the population is dealing with problems such as arthritic knees and high blood pressure. Older patients may go to several physicians, each prescribing medication.
“As people get older, the risk of side effects goes up,” says Dr. John Meyerhoff, a rheumatologist at Sinai Hospital in Baltimore. “It’s a balance between physicians overmedicating for relatively minor complaints and giving medicines for conditions for which we have effective solutions.”
But increased drug use can’t be blamed just on the graying of America. Most notably, as a society we’re getting fatter. Last month, the U.S. surgeon general reported that 61% of adults were overweight or obese, leading to an estimated 300,000 deaths a year. Doctors may treat obesity and obesity-related conditions with drugs if eating less and exercising more proves too difficult for patients.
“Lifestyle management can work,” says Anne Cannon, a nurse and diabetes counselor at St. Joseph Medical Center in Towson, Md. “It’s just much harder. We’re geared to the quick fix.”
Pre-diabetes is just one of several preconditions identified in the last few years that have resulted in more people taking more medication -- potentially for the rest of their lives.
Last year, the National Heart, Lung and Blood Institute named a new precondition, prehypertension. It put 45 million Americans whose blood pressure readings used to be considered acceptable outside the normal range.
In July, the federal government issued guidelines that added 7 million Americans to the 36 million already being urged to take medication to lower their LDL, or bad cholesterol. The new guidelines were set so low that it would be difficult for most people to achieve them without the help of prescription drugs.
Labeling these preconditions “is a good way to get people’s attention,” says Dr. Robert Blumenthal, a Johns Hopkins cardiologist and a spokesman for the American Heart Assn.
Blumenthal always tries to get his patients to make lifestyle changes first -- lose weight, stop smoking, start exercising. But, he says, “my philosophy is it’s good news we do have good medicines that can help the quality of life.”
Part of the increase of prescription drug use can be attributed to the fact that pharmaceutical companies do a good job of marketing their products to doctors and patients alike. Sometimes they are a physician’s primary source of information about new products. It’s difficult for physicians to be knowledgeable about every new drug, even with continuing education requirements and the help of professional societies.
“We don’t want the pharmaceutical people to be the main source of information,” says Blumenthal, “but sometimes it’s hard for doctors to keep up.”
These days, if a physician isn’t quick to prescribe, the patient may well ask for a drug by its brand name.
Meyerhoff, the Sinai rheumatologist, has found that simple leg lifts to strengthen the quadriceps can work as well as anti-inflammatories to reduce knee pain caused by osteoarthritis. But it takes more time to teach patients the exercise -- time that busy primary care physicians may not have -- and patients may not be willing to continue the exercise indefinitely. It’s easier for them to ask for an arthritis drug they’ve seen advertised, like Celebrex.
Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, says that the TV and print ads for prescription drugs have one positive effect: They get patients into the doctor’s office.
“There have been a number of studies that show direct-to-consumer ads are a source of education,” he says. “The discussion of symptoms has compelled a number of patients to have medical checkups they should have received earlier.”
In 1997, the FDA eased restrictions and allowed pharmaceutical companies to market directly to the consumer. The companies spend billions of dollars in the process, which has almost certainly resulted in more drugs being prescribed, says Larry Sasich, pharmacist and research analyst for the consumer advocacy group Public Citizen.
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A changed relationship
With direct-to-consumer marketing of drugs and the instant availability of medical information on the Internet, the doctor-patient relationship has changed, with people taking a more active role in their treatment. Healthcare professionals see this as a good thing, but it may not go far enough.
Cannon of St. Joseph urges patients periodically to review their medications with their physicians. One of the people she saw for counseling had been taking prednisone, a steroid, for 10 years. No one knew why. “You have to ask why you’re taking them, and see if you can get off them,” she says.
One of the biggest problems with our medicated society may not be that we take too many drugs, but that we don’t take the ones we should be taking. Before former President Bill Clinton had emergency bypass surgery in September, he had stopped taking his cholesterol-lowering drug because he felt he had his condition under control, points out James J. Rybacki, a clinical pharmacist and author of “The Essential Guide to Prescription Drugs 2005.”
“Over time, people tend to stop taking medicines,” Rybacki says. In one study, two-thirds of those surveyed underused or stopped their medication and didn’t tell their doctors. “Fifty percent of people fail to take drugs correctly over time,” he says.
Sometimes it’s because they can’t afford the drugs. Sometimes it’s because of a perceived lack of benefit for a chronic condition without symptoms, such as high blood pressure. Sometimes it’s because of “pill burden.”
Like Herlth, who has been prescribed 13 medicines, people tend not to be good about taking multiple drugs for an indefinite period. That’s why pharmaceutical companies are developing combination drugs like Caduet, which treats both abnormal cholesterol and high blood pressure.
“These are safe, good medicines, and they help compliance,” says Blumenthal.
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Too many pills?
James J. Rybacki, a clinical pharmacist and author of “The Essential Guide to Prescription Drugs 2005,” has this advice for patients worried about taking too many prescription drugs:
* Ask questions. If you don’t get them answered, stay in the doctor’s office until you do.
* Tell your doctor if you’re worried about “pill burden.” Say, for instance, “I’m not sure I can take pills three times a day.” There may be alternatives.
* Ask for specific goals for medications, and what the time frame is.
* Tell your doctor about all drugs you’re taking, including over-the-counter, herbal remedies, nutritional supplements, recreational drugs and alcohol. There could be unwanted interactions. Some herbal extracts, for instance, can blunt the effectiveness of a prescription drug.
* Ask if this medicine is the best balance of price and outcome.
* If money is a problem, visit the website www.helpingpatients.org, which lists programs that can help with costs. Other useful sites online include www.needymeds.com, www.rxassist.org and www.medicare.org (click on “online databases” and then “drug search”).
