Medication Mayhem

As a physician who spends much of his day prescribing, renewing or monitoring medications you may find it unusual for me to advocate using less of them.  As with the air we breath, the food we eat, the beverages that we drink and the supplements we consume, we should be mindful of everything that goes into our bodies.  This applies particularly to prescription medications.  There have been wonderful scientific advances in the development of medications.  The incidence of rheumatic heart disease (basically strep throat of the heart valves) is almost nonexistent now.  The incidence of death due to heart disease has dropped dramatically to the point that this number one cause of death is now being rivaled by cancer.  There now exists for cancer, many treatments that can cure or at least greatly prolong life.  Medications have been developed that have transformed the AIDS epidemic from a universally deadly infection to one of managing chronic HIV infection.

As great of an effect that medications can have, there are possible down sides as well.  Some medications which were thought to provide benefit have been taking off of the market when they were later found to increase disease or death in unforeseen matters.  A commonly prescribed group of anti-inflammatory drugs were found to increase the risk of heart attacks.  A diabetic medication was found to cause liver failure.  Devastating birth defects occurred due to an anti-nausea medication used by pregnant mothers.  Certainly, if medications are used they should be used for well established needs in a setting where one is watched and monitored so that the desired effects are achieved and regular reappraisals are made to ascertain if untoward effects are being experienced.  As time goes on, there may be better options available or new information while come to light that would indicate a better coarse of action.

Of particular concern in my mind are medications that are not used to prolong or save life but rather to improve symptoms.  Pharmaceutical companies are particularly interested in developing these medications because they can be marketed to a large number of people.  Immense profits have been made from these drugs.  The marketing of these drugs has advanced the thought that there is "a pill for everything."  The peril comes when a patient takes one medication to assist in maintaining attention and focus only to be stimulated to the point of not being able to sleep well at night.  A sleeping pill may be prescribed only to find that the system as a whole has been slowed down causing daytime sluggishness and constipation.  Similarly, the need for pain medications needs to be monitored closely.  I have seen patients come to the hospital due to life threatening bleeding from stomach ulcers.  Upon further questioning it was found that the patient had ingested a large amount of common, over the counter anti-inflammatory medications to treat chronic headaches.  The medication not only caused the ulcer but in and of themselves were perpetuating the headaches.  In other situations, if narcotic based medications are used for more than a few weeks, the dose invariably will be escalated as the body will build up tolerance to them and they will lose their effectiveness.  In addition to the constipation that almost all who use these medications experience, we are now finding syndromes of inappropriate nerve activations, that can also be debilitating.  If a medication is to be used, it should be given for a clear reason and for a predetermined length of time.

Lastly, if one has multiple chronic medical conditions, I feel that it is imperative that the patient regularly sees a primary care Internal Medicine physician to coordinate care between specialties.  An extreme example is a patient I saw once who was taking over twenty different medications.  The patient was seeing about five sub specialists, each of whom prescribed three or four medications.  There have not been any studies performed with patients in a similar situation.  We have no idea what kind of interactions may occur.  This is especially true in the elderly where medications are not metabolized as efficiently as they are in younger people.  If you are concerned that you may be on too many medications, it is perfectly reasonable to ask your physician if any of them can be cut back or discontinued.  This is especially true if changes in life style can result in reducing the need for many of these medications.  Make sure your medications make a difference, not mayhem!