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Over-Reliance on Medications: A Pharmacist’s View

By Kim DeRhodes, RPh

Wendy, age sixty-eight, made an appointment at an integrative medicine clinic because she wanted someone to look carefully at her medications; she felt she was taking too many. She was diabetic and had been diagnosed with early Alzheimer’s disease about five years before. She lived alone and had been self-reliant for a long time, but she now feared the loss of her independence. Her main complaints were confusion, headache, jaw pain, and nausea, which occurred almost every day and had a significant negative impact on her life. She had difficulty sleeping and was drowsy during the daytime. Having lost thirty pounds over the past year, which she attributed to changes in her diet and level of activity, her diabetes was well controlled. She had seen three different doctors for her various health issues, who had put her on thirteen different prescription medications daily. In addition, she was taking several over-the-counter (OTC) medications and supplements. The integrative medicine physician referred her to a pharmacist for a medication therapy management (MTM) review, a service pharmacists are trained to provide.

What can you do to ensure that all the medications prescribed for you are appropriate? First, you should not assume that your medication list is being carefully reviewed at each doctor visit. Almost certainly, it is not. Even though your doctor may ask about all your medications, usually that is done just to meet the requirement of keeping an accurate and complete medication list in your medical record. An accurate medication list is not the same as an optimal medication list—especially if you are seeing more than one doctor. Doctors are hesitant to change medications prescribed by colleagues, even when they think a particular one is not right for a patient. Here is where pharmacists can help. They are truly the drug experts, yet they are an underused resource. Pharmacists have at least six years of professional training that equips them to do much more than just fill prescriptions. They serve in both hospitals and outpatient settings, dosing and managing drug therapy, counseling patients, and working with physicians and other health care professionals to provide drug information and optimize therapy. And their advice is often free.

It is important for every patient who is on five or more drugs to have an MTM session with a pharmacist, because the risk of an adverse drug reaction or drug interaction goes up exponentially when more than that number are prescribed. It is imperative for patients over the age of sixty-five to have this done. MTM can be thought of as a “medication checkup.” Pharmacists provide the service to help patients get the most benefit from their prescription and OTC medications. They actively manage drug therapy by identifying and preventing medication-related problems as well as working with physicians to resolve them. People who may benefit the most include those who use several medications, have several health conditions, have questions about or problems with their medications, have been recently hospitalized, or obtain their medications from more than one pharmacy or physician.

MTM works best as a partnership among patients, pharmacists, physicians, and other caregivers to ensure safe, effective use of medications and achieve the desired outcomes from therapy. A well-trained pharmacist can also identify possible problems or interactions with vitamins, other dietary supplements, and herbal and other natural remedies. (One caution: At present, colleges of pharmacy do not provide adequate education about these products, covering them in just a few lectures or brief elective courses. All pharmacists have access to online information about interactions between drugs and supplements. They may not, however, be knowledgeable about the benefits of supplements.)

If you are on an expensive medicine, a pharmacist can often recommend a lower-cost alternative. It is not at all unusual for patients who are on multiple medications to save hundreds of dollars per year in prescription costs after optimizing their medication regimen. Here are some important questions to ask your pharmacist:

• Why am I on this medication?

• When and how should I take it?

• How long should I take it for?

• What are the side effects?

• Is there a less expensive alternative that would work just as well?

• Are there medication or supplement interactions I should be aware of?

• Does this medicine interact with alcohol or certain foods?

• Does this drug cause any nutrient deficiencies?

• Is there a medication I might benefit from that I am not taking for my condition?

Let’s return to Wendy’s situation. Remember that her main complaints were memory issues, headaches, nausea, jaw pain, difficulty sleeping, and daytime drowsiness. After the pharmacist reviewed her medication list, the following problems were identified:

• There is a well-documented drug interaction between two of the drugs she was taking, leading to adverse reactions including nausea and confusion.

• One of the drugs she was using is on the Beers List, a compilation of medications that are considered inappropriate for those over the age of sixty-five. The side effects of this particular drug include excessive central nervous system stimulation, sleep disturbances, and nausea. It is also associated with bruxism (teeth grinding at night), aching jaw, and headache, as well as severe memory loss.

• She was on a sleeping pill at night (also on the Beers List as inappropriate for someone her age) and a medication to increase alertness during the day with known side effects of headache, nausea, and dizziness. This is a glaring example of polypharmacy at its worst.

• She was on two different drugs for stomach acid. Long-term use of acid-suppressive drugs can cause deficiencies of vitamin B₁₂ and magnesium; B₁₂ deficiency is associated with cognitive problems.

• Memory loss and cognitive problems are also associated with the drug she was taking for high cholesterol.

When Wendy’s physician made the changes the pharmacist recommended, Wendy regained normal cognitive function and most of her daily complaints disappeared.

Pharmacists are often able to spend thirty to sixty minutes with a patient, reviewing every aspect of drug therapy and uncovering hidden problems. They can help patients understand why they are on certain medications, whether there are less expensive but just as effective alternatives, whether a drug needs to be added to the treatment regimen, and whether a medication is no longer needed.

So, how do you go about having a medication therapy management session? Ask at the pharmacy where you get your prescriptions filled if one of the pharmacists there can provide one. If not, try asking the pharmacist at a local independently owned pharmacy (as opposed to a chain store); some even specialize in this service. MTM is usually provided for a nominal fee and can be free for Medicare patients. The money it can save will usually offset any cost involved.

You may ask, “Why can’t doctors perform this service?” The sad fact is they just don’t have the time. They also do not have as much in-depth knowledge of drugs, mostly relying on information from manufacturers rather than from objective sources. Your pharmacist will not make any drug therapy decision without first discussing it with your doctor. Your doctor is ultimately responsible for making any needed changes in your drug therapy, as pharmacists cannot prescribe medications unless they are working directly under the supervision of a physician.

In integrative medicine, we strive to use the best of all available therapies, both conventional and unconventional. In many cases, a prescription drug may well be the “best medicine.” In other cases, the best medicine may be something else. Natural alternatives to drug therapy and treatments that do not involve drugs at all are often effective and less expensive. Don’t expect a pill to cure everything that ails you. Take advantage of the little-known but extremely useful service: a medication therapy management session with a pharmacist. It could improve your health, save you money, and spare you the pain and suffering of drug interactions and side effects.