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Overprescribed: High cost isn’t America’s only drug problem

By Shannon Brownlee and Judith Garber via statnews.com

The pharmaceutical industry has followed a brilliant two-pronged strategy to maximize its profits: raise prices and increase consumption of medications.


Most of the attention has focused on just one side of the equation — prices. With politicians and advocates on both sides of the aisle vowing to lower drug prices, few people are talking about Americans being overprescribed medications, which not only adds to the cost of drugs but also harms millions of Americans each year.


The number of Americans taking multiple medications has grown rapidly over the last two decades. Between 2000 and 2012, the proportion of adults in the U.S. who were taking five or more medications nearly doubled, from 8.2 percent to 15 percent.


There’s no question that some people need several medications. But too often more prescriptions simply mean more serious harm from side effects, a phenomenon we expose in “Medication Overload: America’s Other Drug Problem,” a report we co-authored for the Lown Institute.


Older Americans are particularly vulnerable to medication overload. Today, 42 percent of adults over the age of 65 take five or more medications — a red flag for harm. The rapid increase in the number of medications older people are taking has led to a sharp rise in serious side effects, known clinically as adverse drug events. We estimate that 1 in 5 older Americans — that’s 10 million people — experienced an adverse drug event in 2018. More than one-quarter of a million were hospitalized because of a reaction to medication. If nothing is done, adverse drug events over the next decade can be expected to cause 4.6 million hospitalizations of older Americans, 74 million outpatient visits, and nearly 150,000 premature deaths.


Why are so many older adults taking so many medications? There is no easy answer to that question. Numerous aspects of our health care system encourage clinicians to prescribe, or even overprescribe, medications and make it difficult for them to “deprescribe,” or take patients off medications. There is the desire for quick fixes to medical problems, among both patients and prescribers. Poor coordination across care sites and poorly designed electronic medical records make it difficult for clinicians to know all the medications their patients are taking. Disease-specific clinical guidelines that encourage more and more prescriptions and fail to identify medication risks for older patients also contribute to the overprescription problem.


Another theme we heard again and again during our research and interviews with patients, clinicians, and other health professionals was the role of the pharmaceutical industry in driving unnecessary and harmful medication use.


The most obvious influence of pharmaceutical companies is through advertising. Drug companies spent $6 billion in 2016 on direct-to-consumer drug advertisements, which heavily promoted the benefits of medication but only offered fast-spoken (or small-print) descriptions of harms. Though Americans often joke about drug advertisements, the truth is they work. When patients “ask their doctor” about a medication, doctors are likely to prescribe it — sometimes even when the medication is not indicated and could be harmful.


Direct-to-consumer advertising is just the tip of the iceberg when it comes to the pharmaceutical industry’s impact on medication use. Pharmaceutical marketing to doctors, including visits from sales reps, free samples and meals, “informational” conferences, and sponsorship of continuing medical education courses, emphasizes the benefits of medications and hides the risks. One particularly clever move by drug companies is to fund studies after a drug is on the market, to show that the drug works for other unapproved conditions (known as “off-label” uses). Abstracts and papers published about those trials act as a marketing blitz, telling prescribers that the medication is appropriate for a larger population than it may actually help.


Even doctors who avoid pharmaceutical sales reps and sponsored lunches have trouble dodging industry influence. Clinical practice guidelines, which doctors and other prescribers turn to for guidance in treatment decisions, are often written by experts with financial ties to industry. In addition, the majority of trials on which the guidelines are based are paid for by drug companies, which often design the trials themselves and hire medical writers to spin the results. To make matters worse, these trials rarely include older people, leaving an information gap about their susceptibility to side effects.


All of this leads to recommendations for prescribing medications as the first line of treatment and stepping up drug regimens when the first effort does not succeed. Take blood pressure guidelines: as the definition of “high” blood pressure has been lowered, older individuals are prescribed more medications, potentially increasing dizziness, lethargy, and falls, and diminishing their quality of life.

To solve the problem of medication overload, we need a comprehensive set of solutions, including interventions in medical education and training, care coordination, research, and health care technology.


In our report, we point to several strategies. For example, the Food and Drug Administration could require drug ads to quantify both potential benefits and harms of their products, which are, respectively, often smaller and larger than implied in current ads. The FDA can also better regulate and even restrict the promotion of off-label studies funded by industry.

 

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