You’d think that knowing the well-established fact that: correctly taken prescriptions is now the fifth leading cause of death, that physicians would step up to the plate and prescribe fewer drugs. But this has just not entered the groupthink of the medical profession. Big Pharma advertising controls both the doctor brain and yours with endless pitches for the latest and greatest pill for every ill. Only the U.S. and South Africa allow direct-to-consumer Big Pharma ads. Don’t you love the way the TV spots routinely end? A voice-over races through side effects, sometimes ending in, “may cause death.” Unfortunately, it might be yours.
Despite these warnings, patients are taking more prescription drugs than ever. My eyebrows shot up 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 ten prescription drugs?”
Not surprisingly, most can’t. Doses are skipped, or accidentally doubled or tripled; bottles are lost and never replaced. Meds discontinued by one doctor are inadvertently restarted by another, and so forth.
With this in mind, I thought, “What a coincidence!” when, just after reading this ‘ten or more’ fact, a new patient arrived with a bulky brown bag of more than ten prescription drugs, prescribed by five physicians (from three separate offices) and two nurse practitioners. The patient couldn’t remember if anyone had ever reviewed her entire list.
As I review her med list, drug by drug, you’re going to see some serious prescribing trends, namely a drug of questionable need followed by a drug actually being prescribed for its side effects. Or an unwillingness to discontinue a med prescribed in the remote past for a condition long resolved.
I am looking at a printout from her medical records. On the first page it lists “Drug Allergies.” She is “allergic” to three meds: two popular statins (lowering cholesterol), hydrocodone with Tylenol, and a blood pressure medicine called Lisinopril.
Patients are rarely actually “allergic” to a statin drug, but many can’t tolerate them because of the side effect of severe muscle pain which probably occurred with her. Since her father is alive and in his 90’s and also has high cholesterol, she probably doesn’t need a statin. She shouldn’t even have been prescribed one because it’s on her “drug allergy” list.
Her doctor apparently didn’t agree, prescribing yet another (drug #1) statin, apparently hoping any pain she might experience be covered by her (drug #2) Celebrex, which she was taking for arthritis. The main side effect of Celebrex is stomach irritation and bleeding. She became anemic, was prescribed (drug #4) iron tablets twice a day.
Really, her doctor could have ordered a Rapid Heart CT Scan and if she had a very low calcium score, the likelihood of needing anything to lower her cholesterol or developing heart disease would be so low that no statin would be needed in the first place.
Instead, she’s on her Celebrex (drug #2), gets stomach pain, is added to this a stomach acid reducer famotidine (drug #3) and for anemia, iron (drug #4).
She continued to complain of pain, likely from the statins, was referred to a rheumatologist, who (according to the patient) never looked at her med list, diagnosed her with fibromyalgia, and started her on the antidepressant, FDA approved for fibro (drug #5) Cymbalta, and two versions of a pain med (drug #6): Tramadol Immediate Release and (drug #7) Tramadol Time Release. When using Tramadol with Cymbalta, you need to keep your doses low, especially in older patients, because of the risk of Serotonin Syndrome (more later). A typical dose might be Cymbalta 30 mg a day and Tramadol 100 mg a day. Her doses had been increased to Cymbalta 90 mg a day and Tramadol 250 mg a day.
As Cymbalta, Tramadol, and iron all cause constipation, a regular bowel movement became a distant memory, so she was prescribed Miralax (drug #8).
Other common side effects of Cymbalta and Tramadol include fatigue and daytime sleepiness. For these she was prescribed (drug #9) Provigil (modafinil) FDA approved for narcolepsy which acts on the body like speed and is widely used to improve energy. An older woman might be prescribed 50 mg of Provigil. She was prescribed 200 mg a day. At this dose, Provigil is replete with doozy side effects likened to drinking Starbuck’s all day long: anxiety, insomnia, tremors nervousness. It also raises the blood pressure. Since she now had all four, she was prescribed (drug #10) Lunesta, for sleep, and (drug #11) Xanax for anxiety.
She had been already taking two meds for her blood pressure, Diovan (drug #12) and a water pill ‘diuretic’ (drug #13) but the Provigil and Cymbalta had increased her blood pressure, so these doses were increased.
In all this mess, she had, not surprisingly, developed tremors of her hands, since 15% of Provigil users and 7% of Cymbalta users do so. High doses of Cymbalta (at 90 mg a day, hers is high!), raise levels of the brain chemical serotonin, as does her pain med Tramadol which, for her age, was a high dose. This can lead to the so-called Serotonin Syndrome, usually quite rare unless drug doses are too high. As you might have guessed, the main manifestations of Serotonin Syndrome are tremors and anxiety.
When she developed tremors, she was sent to a neurologist. She had a history of multiple sclerosis in the distant past which fortunately had been of the progressive sort (and so may have been an incorrect diagnosis in the first place). She described the encounter as being less than 10 minutes and he did not ask about her other medications. Nevertheless, his Nurse Practitioner prescribed (drug #14) Ampyra, an expensive ($1,200/month) med FDA approved to
improve walking in MS patients. It is not prescribed for tremors but this, miraculously, is the one drug that the patient says seemed to help with something.
At this point, she had now seen:
- Her Primary Care Physician,
- A Cardiologist,
- A Rheumatologist,
- A Neurologist,
- A Psychiatrist,
- Two Nurse Practitioners.
She firmly believed none of them ever communicated anything about her case with one other.
Many patients in a situation like this awaken one morning and simply shout to the world in general, “Get me off of all this crap!” and are willing to throw caution to the wind. As a doctor, I can sympathize with this, but it just can’t be done in one day. Her body has gotten so used to this chemical swill that stopping them all abruptly could be dangerous. It needs to be a slow process and if she’s going to stick with her primary care doctor, I would need to contact her first. It can be a slow process taking weeks and weeks.
And, let me add one very important point:
Most doctors on looking this list over would not see anything really wrong here. This is the way medicine is practiced in the U.S. in 2026. “Good medical care” dictates to prescribe statins for cholesterol, antihypertensives for high blood pressure, Cymbalta and Tramadol for fibromyalgia, etc. etc. There’s no malpractice here. This is the medicine that results when Big Pharma is in charge: paying the researchers, controlling the FDA, buying TV spots, sending drug reps into the waiting rooms of doctors’ offices.
A quick calculation sums her meds at approximately $35,000 a year. She’ll swallow approximately 5,500 pills a year (not including nutritional supplements).
Does anyone sense something amiss?
Be well,
David Edelberg, MD