TI Podcast [90]: Reducing polypharmacy: A logical approach

02 Sep 2014 TI Podcast [90]: Reducing polypharmacy: A logical approach

This Therapeutics Initiative podcast features Ms. Johanna Trimble in conversation with Dr. Tom Perry of the UBC Therapeutics Initiative discussing polypharmacy and approaches to reducing it, the topic of Therapeutics Letter 90, June – July 2014. Scroll down and click play to listen to this podcast.

Read the Letter 

PODCAST OUTLINE:

A) Family members can help advocate for patients taking multiple drugs

• Introduction of Johanna Trimble, patient-family representative, patient advocate for improved health care systems for the frail elderly
• Johanna’s mother-in-law Fervid Trimble was overmedicated, with multiple adverse effects – removing the drugs restored Fervid Trimble to her former self
• Johanna realized that other residents of long term care could benefit from thoughtful medication reviews
• But she thinks this happens rarely in routine care

Johanna recommends these links for family members and patients:

• Johanna Trimble’s website: http://www.isyourmomondrugs.com
• Link to Johanna Trimble’s presentation to BC Patient Safety and Quality of Care 2014 symposium: http://www.slideshare.net/bcpsqc/is-your-mom-on-drugs-optimizing-medication-jan-17-2014-30318224
• Link to Dr. John Sloan website: http://sunshiners.ca
• Link to Dr Dee Mangin (McMaster University) presentation: http://sellingsickness.com/wp-content/uploads/2013/04/Dee-Mangin.pdf
• Link to B.C. Polypharmacy Initiative: https://www.doctorsofbc.ca/polypharmacy-initiative
• Link to CLeAR (B.C. Call for Less Antipsychotics): http://bcpsqc.ca/clinical-improvement/clear/
• Link to New Zealand government MedSafe information site: http://www.medsafe.govt.nz/
• Link to Swedish “Phase-Out” program website (English translation pending): http://phase-out.org/About-us.htm

B) Is “medication reconciliation” the answer?

• How can patients or families who think they are on too many drugs get prescribers to reconsider whether polypharmacy is excessive?
• Johanna Trimble thinks a 7-minute GP visit can’t do it – a periodic specific careful medication review, considering the goals of care, is essential
• “Medication reconciliation” by itself is not the answer – enforcing the administration of prescribed medications in long term care (the “compliance trap”) may be worse than when people choose not to take some

C) Why do people take drugs to relieve symptoms even if they don’t seem to work?

• Why do people take drugs to relieve symptoms even when they don’t seem to work?
• Johanna thinks some people indulge in “magical thinking” – if it hasn’t worked yet, it might be my fault and I may as well keep trying it.
• Mixtures of drugs may not be rational (multi-modal analgesia, or “augmentation therapy” for depression) – or at least not evidence-based

D) Does it make sense for very old people to take preventive medicines near the end of life?

• See Dr. W. David Robertson article in B.C. Medical Journal about his elderly mother-in-law’s decision to stop taking pointless drugs near the end of her life: Open access BCMJ article: http://www.bcmj.org/premise/thoughts-occasioned-dying-my-mother-law
• Johanna sees it as pointless to use “preventive drugs” meant to slightly reduce risks of long term outcomes if they end up compromising quality of life (see references below under section G)
• Quality of life, function, and freedom from pain should trump other goals

E) Considering basic pharmacology and physiology – can patients be involved?

• Do people understand that many drugs they take at night work 24/7?
• How can we encourage people to learn enough about drugs to use them safely?
• Johanna thinks most prescribers do not adequately explain probable adverse effects of a drug in a way useful to patients
• Risks much higher for older patients due to their impaired kidney/liver functions or altered physiology
• Johanna recommends a number of independent sources of information including www.ti.ubc.ca and also United States Public Citizen’s www.worstpills.org (annual $15 subscription fee) – she finds it encyclopedic and very useful because format is simple with solid information on adverse effects

F) Avoiding unnecessary drug costs

• Saving money is not something to be ashamed of

G) Applying common sense and the Golden Rule

• Prescriptions may be an easy answer to avoid more demanding but useful interventions such as exercise and appropriate diet
• Some people “learn helplessness” and lose confidence in their own bodies under the deleterious effects of drugs
• Do some people and their families develop a “Stockholm Syndrome” acceptance of inappropriate drug therapy?
• Is there any point to asking the prescriber whether (s)he would take this drug?
• Johanna refers to careful counseling for frail elderly about the real impacts of treatments in the face of rapidly declining health
• Dr. Perry recommends references in Letter 90: Open access Dutch study from 2012 on how very elderly patients welcome conservative treatment: http://www.biomedcentral.com/1471-2296/13/56
• Open access BMJ Analysis article by Dr. Tricia Greenhalgh reviews the uncertain scientific basis for many guidelines in people with multiple medical problems: http://www.bmj.com/content/348/bmj.g3725
• Open access BMJ Analysis article arguing that preventive care in elderly people needs rethinking: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941858/#!po=8.33333

H) How to encourage patients and families to ask intelligent questions?

• Johanna thinks there should be more publicity about inappropriate polypharmacy
• Can patients and families accomplish more than medical educators or experts?
• Everyone talks about this, including health professionals, but much of the talk if “behind closed doors” … we need to get the discussion out in the public
• Every young doctor also needs to learn how to encourage this and to listen
• The patients and families know themselves better than anyone else