Orchestrating drug management (American College of Physicians annual scientific meeting)
■ Managing medications is becoming more complicated due to the aging population, use of opioids for chronic pain and increased FDA drug safety messages.
Before starting each office visit, geriatrician Holly M. Holmes, MD, reviews the medications documented in her patients’ medical records. The list often includes more than a dozen prescription drugs, over-the-counter medications and herbal supplements.
Many of the substances interact. Most have potentially negative side effects.
Managing medications, particularly among older patients, “is becoming more complex, but yet we don’t have more time to do it,” said Dr. Holmes, an assistant professor in the Dept. of General Internal Medicine at the University of Texas MD Anderson Cancer Center.
Among the challenges is caring for an aging population that is living longer due to medical advancements, health professionals say. As those patients develop chronic diseases, they are prescribed an assortment of drugs to manage the conditions.
Also complicating drug management is the movement to treat chronic pain with prescription opioids, physicians say. Doctors who prescribe those drugs must regularly monitor patients to ensure there is no substance abuse.
The frequent drug safety messages from the Food and Drug Administration add additional stress on some physicians who already feel overwhelmed by the complexity of their patients’ medication regiments, health professionals say.
As a result, it is critical that physicians regularly evaluate patients’ medication lists and determine which drugs can be stopped safely, Dr. Holmes told colleagues during a session of the American College of Physicians annual scientific meeting in New Orleans in April.
Discontinuing unnecessary medications can improve patients’ health, decrease their risk of an adverse drug event and save them money, she said. But doctors do not take this step often enough, Dr. Holmes said. Part of the problem is that conversations with patients about stopping medications are complicated and time-consuming. Some physicians also might worry about liability risks if a patient has a health complication after discontinuing a drug.
At the ACP meeting, medical experts offered physicians guidance on how to manage the challenges of polypharmacy and identify medications that can be stopped. Many of the meeting sessions focused on older patients, who the experts said are among the most complicated to treat.
“It’s so easy to give your older patients a lot of drugs, because they have so many problems,” but that’s not always the right thing to do, said Seattle internist Douglas Paauw, MD, who led a session on dangerous drugs.
If a patient is tired of taking all of his or her medications or cannot afford them, identify the essential drugs and take the person off the others, said Dr. Paauw, professor of medicine and director of the Medicine Student Program at the University of Washington School of Medicine. “This is patient-centered care,” he said.
Identifying which drugs to stop
More Americans are using prescription drugs than ever, due, in part, to the aging population and increased access to health care, medical experts say. In 2007-08, 48% of people took at least one prescription drug in the past month, up from 44% in 1999-2000, according to the Centers for Disease Control and Prevention.
The use of multiple drugs is most common among people 60 and older, the CDC said. Thirty-seven percent of this population took at least five prescription medications during the past month in 2007-08. The figure was 8% among people 20 to 59.
With the nation’s elderly population expected to more than double within 40 years, the challenges of managing medications are expected to rise.
To help lessen drug complications, “it’s important that physicians regularly look at the medications patients take and ask themselves, ‘What do they really need?’ ” Dr. Paauw said. In making that decision, he recommends that physicians consider patients’ life expectancy and treatment preferences. Doctors also can use several tools to help identify medication that can be stopped.
Dr. Holmes suggests using the medication appropriateness index, which helps determine whether a drug is appropriate for a patient based on the way the physician rates 10 criteria. Those criteria include the drug’s dosage and cost.
For older patients, Dr. Holmes recommends using the Good Palliative-Geriatric Practice algorithm, which identifies drugs to stop in elderly patients based on the physician’s response to several questions.
Talking to patients about discontinuing medications can be challenging, because they often feel strongly that they need the drug, Dr. Holmes said.
In cases where medication is negatively affecting a patient’s health, she educates the individual about the problem and says, “I think there’s harm in using this drug. We need to reduce something that is harmful.”
For less-urgent situations, Dr. Holmes talks to the patient about the benefits of continuing the medication and the benefits of stopping it. She also explains in clear terminology why she favors discontinuing the drug.
“The responses of patients vary,” she said. “A lot of times they challenge me and disagree. When it’s not harmful to stay on the medication, I’m more willing to let them continue taking it.”
Managing patients with chronic pain
That type of strong patient-physician communication is essential when prescribing opioids to people with chronic pain, said Seattle internist Barak Gaster, MD, who led a session on pain management in the outpatient setting.
He said chronic pain is one of the few areas of medicine in which patients sometimes misrepresent their symptoms to get medication. To ensure that physicians provide the most effective care and prevent substance abuse, they should talk openly to patients about the practice’s opioid prescribing policy and what types of behavior will not be tolerated, Dr. Gaster said.
“Repeating the rules of prescribing in your clinic several times is really important so you feel confident the patient got the message,” he said.
Those rules should be detailed in a concise care agreement that the patient should read and sign before starting treatment, Dr. Gaster said. He recommends that the agreement include a statement about how opioid prescriptions will be filled only after an office visit and cannot be refilled early.
“These are such high-risk drugs, the idea that we can refill them the same way we do blood pressure medications is not right. All refills should by done by clinical appointment,” Dr. Gaster told colleagues during an ACP session.
In 2008, opioid prescription painkillers were involved in 14,800 drug overdose deaths in the U.S., according to the CDC. That was up from 4,000 such deaths in 1999.
To help identify opioid abuse, Dr. Gaster encourages physicians to give random urine toxicology screens to patients they are treating for chronic pain. When doctors notice red flags, such as positive screens or patients who demand a higher dose, they should stop prescribing the drug. But they should not fire such patients, Dr. Gaster said.
“Ethically and legally, it’s not right to abandon a patient in that situation,” he said.
He recommends telling the individual, “In my medical opinion, this type of pain medicine is not safe for you, and I’m not willing to prescribe it anymore. Here’s my plan for treating your chronic pain.”
If the patient becomes upset, Dr. Gaster encourages physicians to be empathetic. He often tells them, “I’m really sorry. It sounds like this is terrible for you, but in my medical opinion, opiates just are not a safe option for you.”
Oceanside, N.Y., family physician Samuel A. Sandowski, MD, and his colleagues encountered so many red flags that they recently stopped prescribing opioids altogether for chronic pain. Dr. Sandowski now encourages patients who ask for the drugs to find a pain management specialist, and he tells them, “It’s the custom of this practice not to prescribe these medications on a regular basis.”
Some physicians are becoming burned out by the challenges of managing medications and frequent drug safety alerts from the FDA, health professionals say.
In 2011, the FDA’s Center for Drug Evaluation and Research issued 68 drug safety communications, up from 39 in 2010. As of April 27, 12 such messages had been released this year. The 2012 notices include safety-label changes to statins and information on blood clot risks for women taking birth control pills that contain drospirenone.
The uptick in messages is due, in part, to the FDA’s improved monitoring of drug safety and an emphasis on communicating that information to the public, health professionals say. But too often, the alerts give information physicians already know, said Dr. Paauw, of the University of Washington.
“There’s a fine line between educating doctors in a timely fashion and giving so much information that people just become immune to it,” he said.
Dr. Paauw recommends that physicians look at safety notices to see what drugs they involve. He encourages doctors to read the entire message if it concerns a medication they prescribe or might use.
“I worry sometimes that we’re losing the judgment that is key to being a good doctor,” he said, because of pressure from the health care industry to put even the oldest patients on an assortment of drugs to control their medical conditions.
“Just treat the patient,” he advises colleagues.