You’d think knowing that the fourth leading cause of death in the US is correctly-taken prescription drugs would push physicians to prescribe fewer of them. But the facts haven’t entered the collective brain of the medical profession.
Big Pharma advertising controls both that brain and yours with its ubiquity of magazine, internet, and TV ads for drugs. Only in the US and New Zealand are direct-to-consumer Big Pharma ads that make product claims even permitted. Don’t you love the way the TV spots routinely end with that voice-over racing through the side effects that almost always include the phrase “may cause death”? Well the ads are spot-on there. Unfortunately, it might be your own.
Despite the warnings, people are taking more prescription drugs than ever. My eyebrows shot up almost to my receding hairline when I read that 15% of women over 60 are taking ten or more prescription drugs. “How,” I thought, “could anyone keep track of them all?”
Not surprisingly, most patients can’t. Doses are inadvertently skipped or accidentally doubled or tripled. Bottles are lost and never replaced. Discontinued meds are sometimes restarted, and so forth.
With this in mind, I thought “What a coincidence!” when a new patient arrived with a brown bag containing 13 drugs prescribed by three physicians (from three separate offices) and two nurse practitioners. The patient, whom I’ll call Allie, is 59 and wasn’t sure if anyone had ever reviewed her entire medication list. She wanted to get off the drug carousel and I told her we’d see how we could help.
Allie’s list
As we review her list here, drug by drug, you’ll see a serious prescribing trend. Namely, a drug of questionable need followed by a drug prescribed to alleviate the side effects of the first. Followed by another and another.
I’m looking at a printout of Allie’s medical records. On the first page it lists drug allergies. She’s allergic to three meds: two popular statins, hydrocodone with Tylenol, and a blood pressure medicine called Lisinopril.
Patients are rarely actually allergic to statins, but many can’t tolerate them because of the side effect of severe muscle pain, which is what probably occurred with Allie. Her father, who also has high cholesterol (he took statins for a while but stopped them on his own), is alive and in his 90s, a combo that strongly argues against Allie needing a statin, which she shouldn’t even have been prescribed because it’s on her drug allergy list.
Her doctor apparently didn’t agree, prescribing yet another statin (which we’ll call drug #1), apparently hoping any pain she might experience would be covered by her Celebrex (drug #2), which Allie was taking for arthritis. The main side effect of Celebrex is stomach irritation and bleeding. As a result, Allie became anemic and was prescribed iron tablets (drug #3) twice daily.
She continued to have pain, likely from the statins, and was referred to a rheumatologist, who, according to Allie, never looked at her medication list but diagnosed her with fibromyalgia and started her on Cymbalta (drug #4), an antidepressant that’s FDA-approved for fibro, plus two versions of a pain med, Tramadol Immediate Release (drug #5) and Tramadol Time Release (drug #6).
When you take Tramadol with Cymbalta, you need to keep your doses low, especially if you’re an older patient, because of the risk of serotonin syndrome (more on this below). A typical dose might be Cymbalta 30 mg a day and Tramadol 100 mg a day. Allie’s doses had been increased to Cymbalta 90 mg a day and Tramadol 250 mg a day
And because Cymbalta, Tramadol, and iron all cause constipation, regular bowel movements became a distant memory and Allie was prescribed Miralax (drug #7).
Side effects galore
Other common side effects of Cymbalta and Tramadol include fatigue and daytime sleepiness. For these Allie was prescribed Provigil/modafinil (drug #8), FDA-approved for narcolepsy. This drug acts on the body like speed and is widely used to improve energy. A woman Allie’s age might be prescribed 50 mg of Provigil daily and yet one of her doctors had prescribed 200 mg a day.
At this dose, Provigil is replete with side effects like the ones you’d experience drinking high-test Starbuck’s all day: anxiety, insomnia, tremors, and nervousness. Provigil also raises blood pressure. Since Allie now had all these side effects, she was prescribed Lunesta (drug #9) for sleep and Xanax (drug #10) for anxiety. Also, her blood pressure medication was increased.
Allie had been taking Diovan (drug #11) and a diuretic (drug #12) for blood pressure. A typical dose of Diovan is between 40 and 80 mg, but Allie’s had been bumped to 320 mg. At high doses, the side effects of Diovan are fatigue, dizziness, and back pain. Diuretics can cause weakness, drowsiness, and muscle pain.
Serotonin syndrome
In all this mess, Allie had unsurprisingly developed hand tremors. 15% of those who take Provigil and 7% of people taking Cymbalta do. High doses of Cymbalta (at 90 mg a day, hers is definitely high) raise levels of the brain chemical serotonin, as does Allie’s pain med Tramadol. This can lead to serotonin syndrome, in which too much serotonin accumulates in the body. It’s usually rare unless drug doses are too high and its main manifestations are tremors and anxiety.
When Allie developed tremors she was sent to a neurologist. She’d had a history of multiple sclerosis (MS) in the distant past, which fortunately had been the non-progressive type, though this may have been an incorrect diagnosis in the first place. Allie described her encounter as lasting less than 10 minutes and said the neurologist had not asked about her other medications.
Nevertheless, he prescribed Ampyra (drug #13), a $1,200-per-month drug the FDA approved to improve walking in MS patients. It’s not prescribed for tremors, but this single drug, almost miraculously, is the one Allie told me seemed to help her.
Can’t take it any more
Many patients in Allie’s situation awaken one morning fed up with all the medications and shout to the world “Get me off of these drugs!” Some think they can simply stop taking them. As a doctor, I can sympathize, but it must never be done quickly. I told Allie her body had grown so accustomed to the chemical swill that stopping her drugs abruptly could be dangerous, that it needed to be a slow process but we’d get there. Also, if she were going to stay with her primary care doctor, I’d need to contact her first to inform her of our plan.
Let me add one very important point.
Most doctors looking over this list wouldn’t see anything really wrong with it. This is the way medicine is practiced in the US in 2017. “Good medical care” dictates that doctors prescribe statins for cholesterol, antihypertensive drugs for high blood pressure, Cymbalta and Tramadol for fibromyalgia, etc. There’s no malpractice here.
But make no mistake. This is the medicine that results when Big Pharma is in charge, paying the researchers, controlling medical schools and the FDA, buying ads in all media, and sending drug reps into doctors’ offices.
A quick calculation puts the cost of Allie’s meds at about $35,000 a year. She’d been swallowing nearly 459 pills per month.
Does anyone sense something amiss?
Be well,
David Edelberg, MD
As I’d affectionately refer to it – PHARMAGEDDON –
It’s sickening how it’s all about the $$$$$ !!!!!
Melissa
You can take all your meds & shove them where the sun dont shine! I was almost killed by overmedication. I weined myself off all that crap. I can think again!!!
Terry Rosado
Just wanted to add r/t Tramadol ~ this is a great med when used appropriately. The serotonin effects and muscle relaxing properties can be helpful in halting something like acute back pain. It can be safer than ibuprofen or other antiinflammatories for someone with a propensity to GI bleeding (as after chemo/radiation or on blood thinners).
It can be addictive and can be sedating if overused. I was able to use extended release Tramadol to control and maintain some function until I was able to have a hip replacement; using thecorrect ER dose allowed me to reduce my total daily dose by 50%.
Tramadol, and any pain medication, needs to be prescribed thoughtfully as determined by dialogue between patient and physician.
https://wholehealthchicago.com/2017/08/07/dangerous-myth-opioid-addiction/
Patti Woodbury
As another retired RN, I found it challenging to help patients reduce their medications. Every summer with the influx of “baby docs” we’d have patients going into withdrawal in hospitals where I worked. Doing home healt care I’d often find patients not taking meds at all or “using up” old, inappropriate meds because of cost. Plus duplicates (Lasix and furosemide, Cores + carvedilol) or double dosing because they didn’t understand they were supposed to take just half a tablet with the expected disasterous results.
I now find myself in a struggle to limit my own drug intake. Following cardiac/lung changes after radiation for lung cancer, total thyroidectomy for medullary thyroid cancer and resection for pre-cancerous colon mass – all within a two year space, I find myself on nine prescription meds to remain functional. Any serious attempt at cutting back has landed me in the ER on IV antibiotics.
At least I’ve been able to cut out the additional meds I needed for chemo/radiation side effects. It can be difficult to make some of the lifestyle changes which will let me get back to just Singulair and the occasional ibuprofen – especially when doctors tell me “you’re in great shape for your age” and “you don’t need PT”. Most docs I encounter don’t get that a lot of us “old ladies” in their mid 70’s are caring for horses, need to be able to do manual labor like moving 100# hay bales and don’t get days off from feeding our animals.
Patti Woodbury
Oh my goodness, is this really true? It’s such a crazy story, after you get to around the 7th different drug prescription the story takes on a sort of wacky, camp feel to it!
Romanie Baines.
You say toward the end of the article, “There’s no malpractice here.” I understand you’re saying this is business as usual from an AMA/BIG PHARMA standpoint, however it seems to me, the public is being done a tremendous disservice and perhaps “malpractice” needs to be redefined.It may not be malpractice per se but it smacks horribly of widespread incompetence. This whole situation is fraud plain and simple…but to use the old phrase, “money talks.”
Thomas Dawe
Thanks for another enlightening article. I am a ‘retired’ RN (due to scleroderma) and am also trying to limit my use of drugs… One would think that the commercials for new medications would be pause for concern with all of the side effects, but instead we laugh at how ridiculous they sound. How easy it is to get out of control with taking meds to manage side effects of other meds. Before we know it, our medications are a great juggling act~I don’t think this was the original intent of these wonderful ‘chemicals’.
Christel Goetsch