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 2019. “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
Boy! I thought I had a messed up med. life!! I took tramadol for many years and decided it was time to try and get my life back- it took me 2 weeks of hell to get myself off of it so I could try cymbalta- again. I think I’ve been on just about every antidepressant out there and, trying to find something that works for that and the nerve pain I have from 2 back surgeries. I’m glad “Allie” found a super dr. that is helping her get things figured out for her!!
Allen Pamela
Very interested to hear the rest of the story! So frustrating that people just keep taking what is prescribed without questioning the need and any possible drug interactions.
Joan Schwarz
This article illustrates the illogical authority figure complex and trust far too many patients have in their doctors. If you take something and it has side effects, ignoring them or attributing them to something else is irrational as an assumption. Maybe its something else, likely not. The obvious way to find out is to stop the medication unless this is immediately unreasonably dangerous dangerous and see what happens.
Why do people continue to take medication for weeks or months or years without serious questioning.
The article says, “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!” Why does it take so long for so many patients to arrive at that morning?
Gene Asner
That’s a very complex question. Most people are very passive when it comes to meds. It’s easier to swallow a pill or two than make significant lifestyle changes. As the pill numbers keep increasing, patients think they must ‘really be sick’ or they wouldn’t be receiving this many meds. They’re fearful of the consequences of stopping anything (“what if these pills are keeping me alive?”
In her final year, my 94 year old aunt kept telling me she was ready to die, she’d lived long enough, etc. I said, “Well, try stopping all those pills.” “Oh, I couldn’t ever do that!”
Dr E
Even worse than the actual active medications in prescription pills are the inactive ingredients in them.
My “favorite” inactive ingredient is titanium oxide or titanium dioxide. Why?
Well,on September 21, 2011 Science Daily wrote about an animal study done on rainbow trout at the University of Plymouth that proved Titanium nanoparticles made holes in brain tissue and kill brain cells.
Despite the proof in studies the FDA allows titanium in medications, foods like candy, cake frosting, etc. If anything is white or pastel, then it contains titanium instead of the zinc they used to use and which the body can actually use in metabolic processes. If you think only special forms of titanium contains nanoparticles, you would be wrong. All titanium used as coloring contains nanoparticles.Courtesy of the miracles of modern industry.Your clear sunscreen is pure nanoparticles of titanium.
Aelxa Hill
Better living through chemistry…
Patricia Woodbury-Kuvik
This drives me crazy! I am a multiple cancer survivor. The hardest part is recovering from the side effects of my successful treatments, weaning myself off meds I no longer need, finding safer substitutes (such as SAMe instead of NSAIDs for arthritis to avoid GI bleed), remind docs that 1) into longer have a thyroid so really do need my thyroid meds and 2) pay attention to my allergies. Antibiotic and morphine allergy bought me three extra hospital days after hip replacement.
I see a lot of other thyroid cancer survivors given meds to treat the side effects of thyroid hormone replacement over or under medication. Beta blockers are a favorite with antianxiolytics a close second for over medication and antidepressants for under medication. Plus these patients are told their symptoms have nothing to do with their thyroid, are shunted to other specialists, given new diagnosis and start wondering if they are hypochondriacs.
It also pushed my buttons as a retired ICU RN who saw patient after patient hospitalized because PF poly pharmacy.
Patricia Woodbury-Kuvik
What a travesty. It makes me sad to think of all the people suffering like this in our country. On a minor note – the tv commercial voice-over racing through the side effects also says “don’t take if you are allergic to it. How can you possibly know if you are allergic to a drug you have never taken?
Beth Wolszon
Hi Beth
I have asked myself the same question for years
Dr E
Dr. Edelberg,
You kind sir have very accurately described the “real world” of medical practice in the U S A today. Between “Big Pharma,” the insurance companies, and to some degree the Government’s intervention and failure to fully understand the entire process we patients are at the mercy of them all. Not to mention the fact that not once during my 78 years on this earth has even one Physician ever discussed the vital role that nutrition plays in our lives.
But much more importantly is the fact that we the patients have to “take charge” of our own physical well being, and not rely continuously upon the medical field to insure our good health.
Sadly, too many of us have our priorities totally misplaced, and forget that we have to practice good health practices by managing our lifestyles in order to attempt to have good health. Such things as knowing which foods to consume, limiting our respective food consumption, getting adequate and sound sleep, and plenty of exercise should totally dictate our lives. And knowing our genetic “footprints” is key as well.
Everything else will normally fall into place and when we do visit physicians we should insist that each one knows what the other one is prescribing, and that they are working together as a team. Then just maybe, the tail won’t be wagging the dog, and we will have taken ownership of our own well-being. For if it is meant to be, then it is up to me!
Sincerely,
Ken Perry (Jennifer Perry’s Dad)
Ken Perry