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