Solving Medication Overload: America's Other Drug Problem

The twentieth century witnessed miracles in terms of improved health and greater longevity, and certainly one of the factors in that sea change has been advances in pharmaceuticals and pharmacotherapeutics. With the advent of antibiotics, steroids, antihypertensives, statins, and lifesaving medications for diabetes, people are living longer with fewer symptoms and, in general, better quality of life.

Why then, is the Lown Institute concerned about the growing epidemic of medication overload? And why would The John A. Hartford Foundation (JAHF) be interested in this work?

The Scope And Impact Of Medication Overload

Because, despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. Medication Overload: America’s Other Drug Problem, a report released in April 2019 by the Lown Institute, chronicles the epidemic of polypharmacy in the United States (polypharmacy is typically defined as taking five or more medications concurrently). More than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the-counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different medications.

The vast majority of drugs are prescribed by clinicians with the best of intentions, and for many people with multiple chronic illnesses, several drugs may be needed. However, every additional drug increases the risk of harm. Every day, 750 people age sixty-five and older are hospitalized for an adverse drug event from one or more medications. Over the past decade, older people sought medical treatment for a drug-related side effect more than 35 million times.

The Lown Institute estimates that if nothing is done, medication overload will lead to 150,000 premature deaths over the next decade and will reduce the quality of life for millions of older people. In addition, there will be 4.6 million hospitalizations for serious adverse drug events related to medication overload and 74 million outpatient visits, at a cost of at least $60 billion.

These numbers represent a staggering impact on patients, and, as such, are of great concern to the JAHF, which is dedicated to improving the care of older adults. Families and patients can tell countless stories of the havoc wreaked by too many medications. Often, medication overload occurs when older people go into the hospital, where their medications are taken away and replaced by others. When they are discharged to another facility, new medications are prescribed, and when they are finally discharged home, they often have little idea of which drugs to continue taking and what to do with all the pills that are still at home. The burden of so many drugs can weigh heavily on older people, causing many to take the wrong pill, or the wrong dose, at the wrong time. Patients may not know which drugs are the most essential and may neglect to take a necessary medicine while adhering faithfully to a less vital drug.

Taking Action On Medication Overload

Despite the widespread harm it is causing, medication overload remains invisible to most US policy makers, health care leaders, and even many clinicians. There is no national program to address medication overload, no unified effort to teach prescribers how to avoid it or remedy it, and no campaign to increase public awareness.

Other countries are doing a bit better. For example, Canada and Australia have established “deprescribing networks”—researchers, clinicians, pharmacists, and patient advocates who have come together to share information, draft strategies, and disseminate proven interventions to help clinicians stop or pause potentially dangerous or unnecessary medications. The European Union’s (EU’s) Health Program created a consortium of stakeholders from across the EU called the SIMPATHY Project, which produced a systematic review of EU polypharmacy policies, case studies, analyses of potential actions, and a website and app with tools for conducting medication reviews.

We need a similar comprehensive effort to reduce medication overload in the US. To follow up the April 2019 report, the Lown Institute in early 2020 will release a national action plan to eliminate medication overload. This set of recommendations, developed by an expert working group, could set priorities for a coordinated effort to tackle the multiple factors that are involved in medication overload. Both the report and action plan were funded by the Gordon and Betty Moore Foundation.

This action plan will expand on the JAHF’s signature initiative, Age-Friendly Health Systems. Led by the Institute for Healthcare Improvement (IHI), the foundation’s initiative is based on a set of essential elements, the 4Ms—What Matters, Medications, Mentation, and Mobility—which should guide all treatments for older adults. It is no surprise that medications are one of the four elements. The JAHF has provided funding to the Lown Institute ($5,000) for its annual conference in the past, and more recently it made major grants to the IHI ($5,000,000) and the American Hospital Association ($2,000,000) to take on the challenge of ensuring that older adults get timely evidence-based care that is harm-free and in alignment with their goals and preferences—“What Matters” to them.

However, there is much more to be done.

The Lown Institute’s upcoming action plan will offer recommendations in five key areas: First up is the need for increasing awareness of medication overload, among patients and the health care community, as well as policy makers and the public. Second, clinicians need better information at the point of care, both in terms of being able to know what drugs their patients are already taking, and in terms of their clinical practice guidelines, which too often do not address the needs of older patients. Clinical practice guidelines should explicitly address when drugs are not needed as well as when they should be prescribed. For example, blood pressure targets in many guidelines, along with quality of care measures, often do not take into account the potential for dizziness and falls in older patients. New clinical guidelines are needed to help clinicians “deprescribe,” or take patients off unnecessary or harmful medications.

Third, clinicians need to be given the time and tools to conduct an effective “prescription checkup,” a formal process of assessing the medication burden of their patients and remedying it. Fourth, all prescribers need additional training to (a) sensitize them to the dangers of medication overload, (b) know how to avoid excess prescribing in the first place, and (c) be able to deprescribe once a patient is overloaded with too many medications. Fifth, there is a real need to reduce the influence of the pharmaceutical industry, which has helped persuade patients and prescribers alike that there is a pill for every ill.

At the clinical level, the “What Matters” component of the 4Ms should be the guiding principle for prescribing for all older adults. Have we clearly explained to the patient and caregivers what any given medication can and cannot do, as well as the side effects that might result from taking it? Have both prescriber and patient fully considered how such side effects as delirium, dizziness, bleeding, or even more serious side effects affect quality of life? Further, has there been careful consideration about how medications will interact and the chances that harm may result? When prescribers and patients think about medication, they must put it in the context of what matters to the older adult and how it will ultimately affect mobility and mentation (how clearly the person can think).

The Lown Institute’s report is a call to arms for all of us to regain our common sense about the increasing prevalence of medication overload in older adults and to take charge of this issue in partnership with older adults and their families. The upcoming action plan will help guide next steps.

The Lown Institute and the JAHF hope to work with the National Academy of Medicine to convene an expert panel, which could provide policy makers and health care leaders with a consensus document to spur real action.

Without these steps, this problem of overmedication will not only continue, it will cascade. The older people in our lives deserve better.