Bioethics Discussion Blog: Polypharmacy: Is It Truly Beneficent?

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Sunday, March 11, 2007

Polypharmacy: Is It Truly Beneficent?

I recently received the following poem from
a physician with no particular attribution:

SPECIAL POEM FOR SENIOR CITIZENS



A row of bottles on my shelf



Caused me to analyze myself.



One yellow pill I have to pop



Goes to my heart so it won't stop.



A little white one that I take



Goes to my hands so they won't shake.



The blue ones that I use a lot



Tell me I'm happy when I'm not.



The purple pill goes to my brain



and tells me that I have no pain.



The capsules tell me not to wheeze



Or cough or choke or even sneeze.



The red ones, smallest of them all



Go to my blood so I won't fall.



The orange ones, very big and bright



Prevent my leg cramps in the night.



Such an array of brilliant pills



Helping to cure all kinds of ills.



But what I'd really like to know...........



Is what tells each one where to go!





To me, “where they go” is not the issue with the prescription of and the daily use of multiple different medications (polypharmacy). To me, the issue is whether the medical practice of polypharmacy is a truly beneficent practice both to the individual patient but also to society. The goal of the physician prescribing a medication is that of providing a therapeutic benefit to the patient. The benefit should not be looked upon simply as the value of each drug to relieve a specific disease or symptom. Consideration of the benefit should include whether the drug is contributing to the total health benefit to the patient. Physicians and patients should keep in mind that the effect of one drug on the total health benefit is dependant not only it’s direct effect on the condition for which it was prescribed but whether the drug itself has harmful or detrimental potentials such as side-effects, toxicities or harmful interactions between the prescribed drug and the other medications that the patient is already taking. Benefit should also be measured by whether the addition of another drug with its own schedule for administration will disrupt the patient’s compliance with the taking of the other medications. Will the shape and color of the new pill be confused with other pills the patient, especially the elderly, is taking? Benefit should not only be measured by the parameters noted above but also whether the net wanted results of prescribing and taking a drug are sufficient to trump the drug’s expense to the patient and the healthcare system. Drugs that are very expensive might either not be purchased by the patient or the patient may discontinue or reduce the prescribed dosage of other drugs in order to afford the new one.

If the physician fails to include in the history of the patient identification of the medications already being taken and not consider the potential interactions with the new drug or the potential disruption of the dosing schedules or the costs, the physician is not performing a service. There is also the need for the physician at the outset to be confident that the patient truly needs an additional drug added to the list of drugs already being taken. Are there indications based on the patient’s symptoms, disease or lab tests that require instituting a new medication? Or is the medication being prescribed either out of a unsupported assumption, out of patient demand or out of a desire to relieve the patient’s concern that by, the conclusion of the office visit, something is accomplished. And that “something” is a prescription.

Finally, I would like to make a comment that ties into the previous thread on the media an medical practice. I think that direct-to-consumer advertising should be discontinued and there should be further ethical restrictions on direct-to-physician advertising. I don’t think any of this should represent a limitation to ordinary free speech. I think that such advertising is education slanted away from education of unbiased evidence-based pharmacology and is directed to the pharmaceutical companies own pocketbook and shareholders. These directed advertising practices, I think, inappropriately influence the public to unwarranted use of the advertised drugs for their own symptoms or illness concerns and encourages physicians to inappropriately add another drug, perhaps one that has not yet been fully tested over time, to their patient’s “row of bottles on the shelf.” ..Maurice.

(By the way, how many pills do you take?)

7 Comments:

At Monday, March 12, 2007 7:45:00 PM, Blogger Lisa said...

So, am I to assume that my doctor has complete knowledge of every drug I could possibly need, and if I must consult with another physician who is not familiar with a medication I use (which has happened), I must not need it? Bans on DTC advertising assume that a) patients are too stupid to process information and put it to use and b) doctors know everything their patients ever need to know. If your doctor isn't aware of the newest drug the FDA just approved for your condition, you don't need it.

 
At Monday, March 12, 2007 9:00:00 PM, Blogger Maurice Bernstein, M.D. said...

Lisa, doctor's, of course, do not have "complete knowledge of every drug" the patient needs. Hopefully, most doctors know the drugs that have been used sucessfully and safely for the patient's conditon especially in the doctor's specialty. "Knowing" the drug means more than knowing a name or knowing its approved use but it also means knowing the history of that drug's use in medical practice including its benefits and its toxicities and its known interaction with other drugs the patient may be taking.
New drugs, usually more expensive drugs, are often the ones which are broadcast on direct to consumer (DTC) advertisements. Those drugs, have a limited history for the physician to be aware, both in terms of benefit or toxicity which is based on very small population research studies and over usually a relative short period of time. It is when these drugs are approved by the regulatory agencies, like the FDA, and enter a national or world market that their true benefit and harm more clearly become known to physicians and the public.

I am against DTC advertising, not because I think that the public is "too stupid to process information". My problem with DTC is that the information presented to the public is misdirected. It is broadcasted to everyone who reads or watches the ads. It is not narrowcasted to the very patients for whom the drug would be an appropriate consideration. (A physician advising one patient who has a diagnosed condition is performing that narrowcast.) That means that the others may feel that the ad with its symptoms and advice is directed to their own symptoms. And who knows what disease or condition their symptoms might represent? Why do they need advice for an undiagnosed condition or a condition with similar symptoms but not the condition for which the drug is approved? I see what the pharmaceutical companies are saying to the public "if you have these symptoms or think you have this disorder, go check with your doctor to remind him or her that there is our medication that may help you."

Why not skip all the advertising and simply make a public health statements about the significance of various common symptoms which can be important and tell the public that if they have such symptoms it would be wise not to wait but contact your doctor. Then let the doctor, who is aware what to do when such symptoms arise, begin workup and treatment as necessary.

As I have indicated, a physician not aware of the latest drug means nothing in terms of the efficacy of the drug for the patient's condition. It does mean, however, that the increased costs and unknown, unestablished issues regarding that drug for which the physician is unaware may turn out to be not the appropriate drug for a thoughtful physician to prescribe. What medications a patient needs comes from a careful history, physical and appropiate lab work performed by a physician and not out of a newspaper, magazine or television set. ..Maurice.

 
At Tuesday, March 13, 2007 9:55:00 PM, Blogger Maurice Bernstein, M.D. said...

You might want to read a followup thread to this one which I posted today. ..Maurice.

 
At Wednesday, March 14, 2007 6:18:00 AM, Blogger Placebogirl said...

In theory, I take 14 pills a day, and one shot per month, representing a minimum of five medications. For many medications, I am suboptimally compliant at best, simply from the pill fatigue that is the natural result of needing to take all those pills for the rest of my life.

As is almost certainly obvious, I have more than one diagnosed medical condition. What is not obvious is that none of these conditions are affected or altered by DTC advertising. What is also not obvious, is that my doctors often ask me about my preferred medication (notably in the case of any antibiotics; rather than following prescribing guidelines I have had three separate general practitioners ask which one works best in my situation). Moreover, it has not been my doctors who picked up on contraindications or reactions, it has been my pharmacist (or indeed me when I read the patient information sheet and realise the doctor has forgotten about something).

I am not an especially complex patient. I have two chronic conditions (if we do not consider that my natural fertility is a condition I am medically suppressing), one of which requires no medication unless I am to have surgery, and yet my doctors cannot cope with my medication regime when prescribing for me.

Dr. Bernstein, I think it is a little disingenuous for you to put doctors on a pedestal when it comes to prescription medicine information, and yet tell patients that they should demand good care (thus implying that they know what that is), and that if they get bad care and accept it they accept partial responsibility for that bad care (this has come up, for example, in the impolite patient thread).

You can't slice it all your own way: either doctors have an obligation to provide good care regardless of the patient's knowledge and attitude, or patients are smart enough to comprehend and assess advertising. Your call.

 
At Wednesday, March 14, 2007 8:27:00 PM, Blogger Maurice Bernstein, M.D. said...

Placebogirl, I never have placed physicians on a pedestal and I never teach my students that doctors should rise above the patient and be out of reach. As I have noted in previous threads, both the physician and the patient has something to offer each other with regard to helping to establish the diagnosis and participate in the therapy. Both parties have the potential of making mistakes in the development of an effective doctor-patient relationship and it is not unusual for these mistakes to happen. Both parties should remember that each are human and have frailities.

The pharmaceutical industry and the FDA are not perfect either. Look at the news today that the well-publicized via direct-to-consumer advertising of sleeping medications are now the subject of concern of side effects of allergy and potentially dangerous sleep behavior such as driving a vehicle while asleep. Too many medications, many unneeded or distributed to the public too soon ..Maurice.

 
At Friday, March 23, 2007 11:16:00 AM, Anonymous Moof said...

Medications, and their effects and side effects, are always a concern for me ... and not just for myself. I'm concerned when my mother-in-law, who has CRF, HTN, CHF and diabetes, doesn't know which pill does what, or which one is causing which side effect ... and then doesn't mention the problems to the doctor, because "he knows what he's doing."

I'm concerned for her, and other elderly friends, when a new physician gives them something they've never taken before without asking what they're already taking ... or when their primary care physicians just keep loading on the pills without occasionally going over what they're taking to see if it's doing what they expected ... or if it's even still needed.

And worst of all, seeing someone I love dearly put on hospice because of the side effect of a medication ... there's a long, heartbreaking story behind that one.

As for myself, I went from never taking anything but NSAIDS to quite suddenly taking 3 rugged HTN meds, calcitriol, a statin, darbopoetin, and an anticoagulant ... and finding that the "cure" (or in my case, the "control") was, in practice, far worse than the illness. I've always wondered if there might be another, better, way to do things ...

As far as the pharmaceuticals advertising to the public, I believe it's a conscienceless practice which should never have been allowed to begin. It's one thing for patients to actively participate with their physicians in their care, and another to see the physician as the fellow who can provide some of that "stuff" they saw on TV, and which they're convinced they need.

Dr. Bernstein, healthcare is really topsy turvy ...

 
At Friday, March 23, 2007 1:59:00 PM, Blogger Lisa said...

Have you ever had a conversation with a physician about a medication in an ad, or witnessed such a conversation? People can't seem to conceptualize an exchange based on DTC ads as being anything other than a whiny, stupid patient demanding "gimme the drug!" like a 5-year-old while the poor put-upon doctor tries to decide how to handle the tantrum. Does it ever occur to you that that's not what all of these encounters are like, and that some patients are understanding enough to have a mature, intelligent conversation with a doctor about whether something is or is not a good idea for them? It makes it seem like some opponents of DTC don't think much of other people's ability to take care of themselves with their physician's help.

 

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