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Case History: The Madness of Overmedication

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 2018. “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

Leave a Comment


  1. Maybe clean up her diet, wean her off all drugs and medical cannabis for symptoms that remain.

  2. Patti Woodbury-Kuvik says:

    Fascinating (not). I saw a lot of polypharma as a VA nurse – it was always a battle with the new docs to not cold turkey these patients.
    I recently was coerced into an overnight stay for chest pain as my own cardiologist was not available. It was a comedy of errors…some useless expensive tests and I’m pretty sure my labs were switched with my roommates who was diabetic. No one ran magnesium or noted my low sodium – an expected consequence of lung cancer. On discharge I was given scripts for a beta blocker (I have asthma), aspirin (I have a history of GI bleeding with aspirin and blood thinners), a statin (my lipids were all wnl) and told to stop my NatireThroid (I had a total thyroidectomy two years ago for medullary thyroid cancer). I left the hospital feeling much worse than when I arrived. I’m working closely with a good cardiologist to improve my cardiac function which is slowly recovering from chemo/radiation damage – try to explain to a clueless hospitalist that my tachycardia is not from excessive thyroid meds.
    I’ve finally successfully weaned myself off prednisone and am working to modulate thyroid meds with the help of an integrative doc and nurse prac.
    Without my own medical background I’d probably be on a lot more meds than the basic five I need for asthma and thyroid. I haven’t really counted VM supplements as “meds” but the ones I take hav,e been carefully thought out to avoid excess and complement my diet.
    After packing a hip replacement and three separate cancers into a two year period, I’m still upright, taking care of my horses and patching up two years of neglect to my little ranch. And did I mention I’m kind of old (74)?

  3. Laura Fortney says:

    This one really hit home for me.
    This is what is wrong with healthcare today. It’s less personable!! Most doctors don’t seem to care anymore or they are too busy to notice. It’s why we need more doctors like Dr. E! More doctors to sit down and talk with us, take time to get to know us and our medical problems/histories. Sadly most doctors spend less than ten minutes in the room with you-even on first visits! I know some doctors that triple or double book themselves all day long. It’s now become more about how many patients they can see or how much money they can make and less about treating a person and helping them.

  4. David Bailey, DC says:

    Every time I see a pharmaceutical add on TV I want to scream. I once had a patient taking seventeen meds daily. I got him down to seven over time. I have a nephew that takes fourteen meds which includes Ambien; he regularly sleep walks, and is in terrible health. Will he listen to me? No, because I’m not a real doctor. Sad, indeed.

  5. Ana Benitez says:

    I totally feel bad for Allie. I do feel that one needs to take control of your own health n not fall for doctors that prescribe drugs for every little thing you go to the doctor for.
    I feel we the people need to put a stop to the pharmaceutical companies, the FDA and even the insurance companies stealing our money. What can we do, go to Washington, boycut prescription drugs n go natural medicine.
    Let’s fight for our rights

  6. Excellent insights, Dr Edelberg! You have hit it out of the ballpark. And yes, this roller coaster our older adults are on is just a sick over dose of drug after drug. Why don’t we educate our 20-30 and 40 year olds on the value of healthy foods, exercise, self-care and stress coping strategies so they won’t find themselves on the drug treadmill later in life. Once we are sick, it is a money grab of hospitals running more tests, hoping to find something to do a procedure for. I have known you Dr Edelberg, since October of 1993, and have been grateful for your common sense wisdom and Holistic approach to WELLNESS! Keep up the great work and I always recommend my friends, contacts and clients subscribe to your excellent newsletter!

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