Check Your Meds
America has a drug problem. Several, in fact. But the one we’re talking about is hiding in plain sight, or at least in our medicine cabinets. Americans have a problem with prescription drugs.
In 2017, the Centers for Disease Control reported that there had been 3.8 billion prescriptions written — not pills taken, but prescriptions written. Enough for every man, woman and child to have several. In 2016, Americans spent $329 billion on prescription drugs.
The overabundance of prescriptions and dollars spent on them aren’t exactly the problem, though. The real problem is that half those prescriptions — maybe more — are used incorrectly or never used at all. “When we break that 3.8 billion down a little bit, approximately one in five new prescriptions were never filled,” said Heather Free, PharmD, practicing pharmacist in Columbus, Ohio, and spokesperson for the American Pharmacists Association. “Of the 80% that were actually filled, 50% of those were taken incorrectly in some way, either incorrect timing, incorrect dosage, incorrect frequency or incorrect duration.”
Dr. Heather Free
Free’s point is important because no medication can work as expected if not used as directed. Misusing medication is ineffective, dangerous and can be hugely expensive.
“Medication is a very complex thing,” Free said. “But people think of it in a simplistic way — they get sick, go to the doctor, get a pill and that fixes it. They don’t consider the details of this chemistry experiment that’s going on in their body and how it’s going to affect them. Every individual is unique, very often with an array of comorbidities, which are treated with other medications as well as over-the-counter drugs and herbal supplements. Not to mention food, nor the variability of scheduling and dosage. There are so many factors that can contribute to a medication not working correctly.”
Factor 1: Polypharmacy
One factor contributing to the high rate of failure to adhere to prescription directions is polypharmacy. When a patient has prescriptions for multiple medications that’s polypharmacy. When those prescriptions are from a variety of health care providers who aren’t communicating with each other, problems may arise. How does a patient know whether all of those are compatible, or if they should be taken in a specific order?
An example: You go to your primary care physician to treat a cold, then you start to have symptoms associated with a more chronic condition like cardiovascular disease or hepatitis. Instead of a general practitioner (GP), you see a specialist, who is not in contact with your GP.
Your GP might put you on a blood pressure medicine, which may not control it, so you see another doctor who puts you on another blood pressure medicine, not knowing what medicines you’re already taking. Sometimes people go home after cardiovascular complications with up to five types of pills. “That’s a lifestyle change for someone to fit five different medications into their life,” Free said. “How do you make the medicines fit in your life and not you turning your life upside down to fit in the medication’s requirements? Remembering to take the scheduled medicine all the time can be a burden. It can be very hard for patients to communicate with all their providers about all the medications they’re on.”
The simple solution would be to have a gatekeeper, someone to keep all that straight. There is no such formal role in our health care system yet, “but your pharmacist is a great resource to use to help map through all of that,” Free said. “They can help you with identifying when to take medications, what are good medications to take together, which ones should be spread out and not taken together. A pharmacist can help you map out the schedule that works best with all your medications, no matter who the provider is.”
Pharmacists are trained in medication therapy management: Is this the right medication for the right therapy taken in the right way at the right time? Are there duplicates in a patient’s regimen? Is there a way to decrease the number of pills? Are there drug interactions that require scheduling in order to produce the appropriate effect? Should a drug causing potentially life-threatening interactions be eliminated? “A pharmacist plays a key role, and nowadays it is increasingly common that they are part of a patient’s care team,” Free said. “It’s not just the doctors anymore. It’s a health care team working together, with the main focus being the patient. It’s patient-centered care.”
Even with a pharmacist on the patient’s team, polypharmacy requires regular monitoring. It is not set in stone. Perhaps a patient’s condition changes, or a new side effect arises, or a person alters their lifestyle. Regular monitoring is the idea behind brown bag sessions, in which patients put all their prescription and over-the-counter medicines and supplements in a bag and present it to their pharmacist for consultation and clarification. “Brown bag is an old term,” Free said. “The newer term is medication therapy management — when we consult with patients and help them use their medications correctly. We review dosage, schedule, duplication, drug interactions, side effects. We’re looking at this chemistry pot like a pharmacy detective. Is it working correctly? What do we need to tweak? What do we need to take away? Most importantly, how do we communicate this to the providers and patients and get everybody involved?”
Free says that when duplications or problems with drug interactions arise, it is the responsibility of the pharmacist to contact the provider and “work with them to get it prescribed correctly to treat the patient in the most proper, effective, safest way.”
If only the solution to polypharmacy could be as easy as sitting down for a consult with a pharmacist, but it is not:
Problem 1: There is typically no centralized record for any patient that is reliably updated — mistakes abound.
Problem 2: There may be no communication among multiple health care providers, who may be in different networks. “Wherever there is a break in communication, problems can arise,” Free said, “especially when you start going from an urban to a rural area and the health care systems are a little bit different.”
Problem 3: The pharmacist can only be of help if they know all your medications, but patients sometimes use two or more pharmacies, including online.
Factor 2: Complexity
Another reason that patients fail to take their medications correctly is the complexity of the prescription instructions, magnified by the reality that there is no formal gatekeeper organizing a medication map, helping to keep things clear and on track. Free emphasized that patients should not leave a meeting with their pharmacist without clarity about what’s going to work best for their life. “Again, we want the medications to fit into your life, not you fit into the medication’s life,” she said. “If a patient feels like their prescription is overwhelming from the get-go, nine times out of 10, they’re never going to fill the prescription again. Or, they’ll be one of the 50% of the population that takes it incorrectly. Before leaving the pharmacy, a patient should know that the medications are safe to take together and when they should take them. If it’s an unrealistic schedule, they should question the pharmacist right away, ‘Are there other options? Can you contact my doctor? Because this is just not going to work for me.’”
Factor 3: Other Substances
It is possible to weaken or even negate the effectiveness of a prescription by taking over-the-counter drugs or supplements. Free cautions that the potential for this is not rare: “Any substance you put in your body, whether it’s food, a supplement or an over-the-counter medication, you don’t know how it’s going to react with anything else that you’re currently taking,” she said. “It’s really important to read the label, understand if it’s appropriately useful or not and is it going to work right for your situation based on the medications you’re already taking.”
Factor 4: Out-Of-Date Medications
Another reason for not adhering is not being mindful about expiration dates on medications. “Medications can work very differently when they’re expired,” Free said. “They may have a lower potency and so not work as well. If it’s a chronic disease that you’re trying to manage, it can worsen. Your blood pressure may not be controlled anymore if you’ve taken an expired blood pressure medicine.”
Factor 5: Cost
Clearly, medications can cause a financial hardship, and this is a tough topic to address.
“There are many different kinds of foundations and assistance programs that help patients pay for their medications,” Free said. “They may provide a coupon voucher, or there may be a patient assistance program, but no question, cost can be a barrier to medication.”
Free cautions that your health care provider may not be able to help much. “A lot of times, physicians don’t really know how much a medication will cost. They can have a guesstimate, but every person’s insurance negotiates different prices. Co-pays differ, and they can’t know what a co-pay is until the pharmacy actually submits that claim to the insurance company. They may not even cover a particular drug, so we either have to select a new medication or do what we call a ‘prior authorization’ to justify why that medication needs to be covered. The pharmacy is usually the best place to investigate the cost of the medication because they’re the ones submitting the claim to the insurance company to get approval for that to be paid. Two people can both have the same provider, Blue Cross Blue Shield, for example, but work for different employers, which means different coverage. Medicare isn’t uniform either, depending on the plan chosen. One glove does not fit all when it comes to cost of medications.”
One takeaway from talking with Free is this — you and your pharmacist should not be strangers. “I don’t give my patients a choice about being counseled. Even if you’re coming to me for an antibiotic that you may have gotten from me for a year,” she said. “I’m still going to talk about it to you. I’m still going to go thoroughly through it and give you tips. It’s so important to educate before you medicate. Patients need to not be afraid to ask detailed questions. They need to know what they’re getting into when they’re taking that medication. They need to make sure that medication is right for them. It’s vitally important to communicate how you are feeling, what you are doing, what’s working for you, and what’s not.
“Every time you start a new medication, you should have a medication management session with your pharmacist. Same if you experience a new side effect. Don’t alter your prescription on your own. Talk to your pharmacist and let them talk to your provider to work together to help determine what’s the best answer for your situation.”