Americans take a lot of medicines. I am a Primary Care Physician, and much of my life's work is helping people prevent health problems. I recommend a growing number of medicines to guard my patientsâ€™ health. Still, when I look from top to bottom of a patientâ€™s long list of medicines, I do wonder if this chemical soup that I prescribe and manage can truly be healthy. And even if it is, can it be worth it for my patients to take so many pills every day?
Twenty five percent of us are taking more than five medicines, and a much larger percentage of people older than 65 are. One out of every eight women over 65 takes more than ten medicines. It wasnâ€™t always like this. Doctors used to use medicines mostly to treat acute conditions -- giving a person medication when he was sick and stopping it when he was better. But during the past few decades, we have shifted our medical attention towards managing chronic illness. Now, in addition to helping people to get past abrupt episodes of illness, we are preventing complications, prolonging life, reducing the need for hospitalizations or surgeries, and minimizing symptoms from continuing illnesses.
These are worthy goals, for sure. But with the number of medicines now available to benefit chronic illnesses, patientsâ€™ drug lists build up inexorably. Nowadays on rounds, instead of talking about whether a patient is on a â€œgood drugâ€ for their illness, doctors discuss whether the patient is taking a good â€œmed package.â€ Consider two common chronic illnesses, and what they mean to the number of medications a person needs:
- Type 2 diabetes: When you improve your blood sugar average from fair control to good control, you will have far fewer medical complications in the following 10 years. You will lower your risk for retina damage by 35%, your risk for heart attack by 18%, your risk for kidney damage by 35%, and your risk of dying over a 10-year period by 7%. At least two drugs are usually needed for blood sugar control, and one out of every three diabetics eventually needs insulin. To get your risk of medical complications lowest, you also need aspirin, a cholesterol-lowering statin and an ace-inhibitor drug to protect the kidneys. For most people, this means taking five medicines.
- Coronary artery disease: If you have this diagnosis, three or four drugs taken together can lower your heart attack risk to a third or less of what it would be without them, and can add an average of an extra two years of life expectancy. The drugs are aspirin, a beta-blocker, and a statin drug, and for certain people an ace inhibitor or other blood pressure medicine. For most people, coronary artery disease means at least four medicines.
Once you have any of these chronic conditions, you keep the diagnosis (and the medicines) for life. When you add drug to drug to drug, are the benefits of all of these medicines cumulative? For some conditions, evidence shows that "combination" drug therapy is effective. I also believe from experience that these drugs are beneficial -- it feels terrible to see patients get sick when they fail to take their medicines.
Still, I do wonder whether we are tough enough with our standards about adding new medications to the â€œmust haveâ€ list for reducing risk. Take cholesterol treatment for example. About 60 people who have a fairly low risk for heart disease would have to be treated for four years to prevent one of them from having a heart attack. Many more people need to be treated to prevent one death. Does it really make sense for us to be treating more than 22 million people with cholesterol-lowering statins, which is the number of people who received one of those prescriptions in 2004?
Long drug lists have dangers. Side effects are frequent, and drug-drug interactions can occur. Many people find it hard to remember to take their many medications, and sometimes taking medicines can put a person into the â€œsick roleâ€.
Long drug lists are also expensive. In 2003, prescription drug costs made up about 20% of the ballooning total that Americans spend on health care. A yearâ€™s supply of medicine for a typical American now costs about $1000.
The best way to shorten your medicine list is to talk with your doctor about what drugs are the most expendable. I am always looking for ways to shorten patientsâ€™ drug lists, and your doctor probably is, too. Drugs that donâ€™t have a very strong reason for staying should be jettisoned off the list.
That said, most of the time I see good reasons for the drugs on our long medicine lists. We are working to outsmart chronic illness. If taken regularly, drugs for chronic illness can truly limit complications and delay when a disease might get the â€œupper handâ€ and become a threat to a personâ€™s life. I often think of this musing by Dr. Don Berwick, president of the Institute for Healthcare Improvement:
"The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been."
The quote brings some sanity into my practice, after I have spent a day poring over my patientsâ€™ long drug lists.
Do you think we are on track in managing chronic illness? Or are we over-crediting drugs in our zeal for best health?
Mary Pickett, M.D., is an Associate Professor of Medicine at Oregon Health & Science University where she is a primary care doctor for adults. Her field is Internal Medicine. She is also a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.
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