The Polypharmacy Network

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Why build a Polypharmacy Network?

By Demetra Antimisiaris, PharmD

Every stake holder views the same drug differently

Working in healthcare for 30 years has taught me one thing; each stake holder has a different view of a medication than the other. These different perspectives lead to a frustrating level of miscommunication amongst stake holders regarding medication use. Recall that one of the strongest drivers of adherence to the use of a drug is the belief that it works for a problem the person using the drug wants to solve. In the illustration above, the determination of actual efficacy of the Nite Time Cough (Nyquil® generic) OTC product could be influenced by a multitude of factors, some of which may not be considered by the person loyally taking the medication. A little information sharing would potentially alter the decision on efficacy quite a bit. What if the person taking this product nightly knew that his urologist is increasing his Flomax® dose because the sleep aid was causing him to have a more relaxed bladder and not void urine completely every time he uses the washroom? And, what if he knew the urologist would offer a different way to solve his insomnia? What if the person taking this product knew that basic scientists are now realizing that cumulative exposure to this type of drug is linked to dementia? And what if he realized his job was in jeopardy and his employer specifically has concerns over his employees using OTC sleep aids the night before work? (For example, if his job required him to be very alert in the early morning).

So how could the varying perspectives and concerns of various stake holders and stake holder groups be integrated to improve the societal understanding and ability to manage Polypharmacy? The Polypharmacy Network believes that connecting groups with specific concerns and perspectives to other groups who can help and share their perspective, will make a positive difference to benefit us all.

Stakeholder Network sharing perspectives, resources, and approaches:
Polypharmacy is here to stay

Polypharmacy is a problem that has caught society off guard and every stake holder has a unique perspective to bring to the table.

The Polypharmacy Network is a grass roots non-profit organization aimed at helping the entire range of stake holders regarding concerns about medication use.

The top cause of death in the united states is heart disease, taking 600,000+ lives annually, but if Polypharmacy related deaths were counted, it would rank ahead of diabetes and nearly in line with Alzheimer’s Disease as about the 5th or 6th cause of death. [1] Ironically insurers will pay for extended 30-minute diabetic clinic visits but not for ten minutes of polypharmacy management. Consider that the typical clinic visit is 15 minutes long and studies show that 7.5 minutes are dedicated to establishing the problem to address, leaving 3.5 + minutes for working on the problem and 3.5 minutes for medications.[2] If you are taking several medications, there’s no time to look at the overall list. So, under the societal approach to Polypharmacy, it is important that each consumer and stake holder address polypharmacy in their own lives. For the near term, the only common thread throughout the healthcare system and consumer environment (referring to the broad spectrum of OTC, herbal and supplements people can access) is the consumer themselves.

The Polypharmacy Network advocates that individuals use a process-based approach to Polypharmacy. For each product you take (prescription or over the counter medication, herbal product, vitamin or supplement) you should ensure the four following items are assessed:

  1. Purpose: there must be a valid and appropriate purpose for each product used.The determination of a valid purpose is very individual and requires some well researched considerations. "Because it was on the internet" is not a valid reason alone.
  2. Monitoring: each product must be monitored for side effects on regular intervals. Some may argue that they’ve taken a drug for years safely but consider that your body changes over time and ability to metabolize or new drugs or diseases interacting can change.
  3. Efficacy: Don’t use anything that is not effective, therefore you must be able to assess if its working. How do you know if an antidepressant works? You can try tapering the dose down and do a trial off, or you could evaluate with a scored test and compare every 6 months.
  4. Personal Experience: Keep tabs on your medication use experience. Did you struggle with taking the product? Costs? Addiction? Tolerance? Non-specific symptoms (often these are medication induced symptoms vs obvious drug effects such as blood pressure).

The Polypharmacy Network aims to provide stake holders with the skills to be able to evaluate these four items within their ability to understand the culture and science of Polypharmacy. These four items are focused on the use of medications as opposed to the science. Consideration of these items can empower every stake holder from the consumer at large to the manufacturers who create medicinal products.

Example: an application of the Polypharmacy Network 4 items process for the use of hydrochlorothiazide. Andrea, 59 years old, a new patient for Dr. X, was just prescribed a water pill for blood pressure management called Hydrochlorothiazide.

Patient (non-healthcare professional) Dr. X Next time they meet
Purpose High blood pressure High blood pressure, this is a first line recommendation. Didn’t ask about her risk of gout of other hidden causes of high blood pressure like over the counter use. Blood pressure not going down.
Monitoring
Consult drug database resources to find out about recommended monitoring and side effects (monitor for those too)
Blood pressure lowering (does it work?), read on Drugs.com that potassium must be checked, and kidney function as well as possibility of gout. Andrea has occasional gout attacks.

Also did a drug interaction checker and found out my Advil® might make hydrochlorothiazide work. She never mentioned to Dr. X that she uses Advil®.

Expects to check potassium and blood pressure. Check for dizziness. Andrea cues the doctor in the 15-minute office visit, that she gets gout occasionally (she forgot to list that on her history), and that she read that Advil® can inactivate the effects of hydrochlorothiazide.
Efficacy Checked blood pressure daily at home bring log to doctor next visit Did a blood pressure check, looked at Andrea’s home BP log to verify, and asked about dizziness? Seems not working.
Personal Experience How many times I go to the washroom daily and preoccupied with sore toe. Warn about dehydration and dizziness. Andrea mentions sore toe and frequent restroom runs. Dr. X explains the restroom frequency would go away with continued use.
Next Steps Decision made based on the risk of developing gout again, that Andrea can switch to one of two other first line choices for high blood pressure control, and Dr. X recommended that she use Tylenol® (acetaminophen) instead of Advil®.

This was a case-study where the patient’s use of the four-item assessment helped Dr. X arrive at an alternate treatment. Had Dr. X gone through the four-item check list, Dr. X may have discovered that asking her about undisclosed OTC Advil use and gout could impact her success with hydrochlorothiazide. This is an actual medical case and Andrea was tried without any blood pressure medication, but asked to not use Advil® anymore (but to use Tylenol® instead). Andrea's blood pressure normalized without the need for blood pressure medication for now! Using the four-item process showed Advil® was causing her high blood pressure condition. This OTC non-steroidal anti-inflammatory (like Advil® or ibuprofen) induced Andrea's high blood pressure. This happens with older adults and occasionally with younger people.

References:

  1. Tables, C.N.H.S., 2015
  2. Tai-Seale, M., T.G. McGuire, and W. Zhang, Time allocation in primary care office visits. Health Serv Res, 2007. 42(5): p. 1871-94.
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The Polypharmacy Network

What is Polypharmacy?

By Demetra Antimisiaris, PharmD

Dr. Demetra Antimisiaris (Dr. Dee to colleagues and associates) is a clinical pharmacist specializing in the management of multiple medications. Dr. Dee trained in clinical geriatric pharmacy 30 years ago and has witnessed Polypharmacy migrate from a geriatric syndrome to a phenomenon effecting every age group and stake holder. Dr. Dee is a regular contributor to the Polypharmacy Network and believes that safe medication use is possible for all through robust resources and communication to heighten Polypharmacy assessment skills for all.

The definition of Polypharmacy in the medical literature is not clear, but most papers identify the use of 5 medications at the same time. But another perspective about Polypharmacy, describes a healthcare risk and syndrome of harm. [1-5] In the past, the syndrome of Polypharmacy has been limited to older, frail, adults because as I teach my students, if you want a medical intervention (which is what a medication is) to reveal its toxicity, give it to a frail older adult. Older adults are at high risk for Polypharmacy because they live with multiple chronic diseases, takes multiple medications, have less physiological reserve, and often don’t respond to medications as expected (in part because the drug data we have shaping out expectations and knowledge are from tests on younger persons).[6-8]

Today, the syndrome of Polypharmacy is not limited to just older adults. Younger adults and even children live with increasing chronic disease burden such as diabetes, asthma, irritable bowel syndrome, high blood pressure, acid reflux or GERD, which combined with an exponential increase in scripts per capita, over the counter and supplement use means our society at large is experiencing Polypharmacy at unprecedented rates.[9] Younger adults are more resilient to the harmful effects of Polypharmacy and actually, the therapeutic use of medications has been an important factor in helping people to live longer and more successfully with chronic disease states that they would have died from or become debilitated by decades ago.[10, 11] The challenge we have with modern day polypharmacy are many. Some unknowns are:

  1. Do we know what happens when we expose children to multiple products over decades of life? We have evidence that the drugs being used may be effective for conditions such as asthma or allergies, but we have little data regarding what using those medications from childhood until 30 years old means, for example.
  2. Do we have evidence on the outcomes of mixing your mix of prescriptions, over the counter drugs, herbal products and supplements with your individual combination of physiological conditions and lifestyle (food, exercise and environmental exposure)? We can estimate but we have no hard evidence of individual cocktails of products used in people with individual physiology and health problem mix. Extreme examples of misguided mediation use are some of the high-profile celebrity accidental drug overdoses reported in the news. Many of those cases involved the use of seemingly safe over the counter (OTC) products with prescription products combined with lack of supervision. Heath Ledger passed due to an overdose of psychoactive medications layered upon OTC medications used for sleep and the common cold. There’s a cultural belief that if a product is out on the market for consumption, it must be safe regardless of the range of ways people can use them.
  3. Understanding the culture of Polypharmacy. What motivates stake holder decisions regarding medication use? This is my area of research and interest and the thematic framework behind my scholarship and effort. What influences the doctor or NP in medication prescribing and management choices? (is it how they are trained, is it the healthcare system and 15-minute office visit, is it the influence of patient exposure to advertising and other information, is it the insurers?) What influences the consumer (Person living with Polypharmacy or PWP), or stake holders in medication use choices? (talking to others with similar needs? the internet? access to people who can provide appropriate knowledge?)

Meanwhile, Polypharmacy is being studied from a variety of perspectives including: time to clinical benefit, number of medications used, life expectancy and goals of care (older adults with polypharmacy), high risk vs lower risk alternatives, dose intensity, indications, therapeutic duplication and omissions and efficacy of combinations of drugs. [12-16] These studies are important in our new era of high drug burden use. The challenge is that there is no unifying consensus on approaching polypharmacy.

One aspect of Polypharmacy management that does stand out in the research is that successful Polypharmacy use and management requires individualization and patient centered care.[16-19]

Although the current healthcare system is trying to provide greater individualization of care, when it comes to Polypharmacy, it is difficult for the healthcare system to push back against the forces driving random Polypharmacy such as the growing number of OTC products, direct to consumer advertising, and individual belief systems regarding medication use. The reality is that Polypharmacy goes unchecked until something goes wrong and the PWP lands in the emergency department (ED) or urgent care. Visits to the ED are on the rise, especially in adults over 65 years of age (of course because they have less physiological reserve to withstand adverse effects). In 2005-2206 ED visits in those 65 or older, for adverse drug events accounted for 26% vs. 35% from 2013-2016. Yet, adverse drug events are for the most part, preventable with appropriate medication monitoring and management.

Consumers and all stake holders (employers, caregivers, advocacy groups for disease states, teachers, athletes and more) can boost medication use individualization, and appropriate Polypharmacy by self-empowerment through awareness of issues regarding medications common in your stake holder group, adopting a process to analyze each product used in the effort for better health, and networking with linked stake holders. The only common thread through the healthcare system regarding Polypharmacy is the PWP themselves. If you consider the amount of time in a month that a patient spends face to face with the healthcare system, its less than 1% (even for a person who sees several specialists per month). What that person does and experiences with their medication mix is something only they can manage and monitor (or their caregiver).

  1. Denham, M.J., Adverse drug reactions. Br Med Bull, 1990. 46(1): p. 53-62.
  2. Nobili, A., et al., Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol, 2011. 67(5): p. 507-19.
  3. Franchi, C., et al., Changes in clinical outcomes for community-dwelling older people exposed to incident chronic polypharmacy: a comparison between 2001 and 2009. Pharmacoepidemiol Drug Saf, 2016. 25(2): p. 204-11.
  4. Gnjidic, D., S.N. Hilmer, and D.G. Le Couteur, Optimal cutoff of polypharmacy and outcomes - reply. J Clin Epidemiol, 2013. 66(4): p. 465-6.
  5. Steinman, M.A., et al., Prescribing quality in older veterans: a multifocal approach. J Gen Intern Med, 2014. 29(10): p. 1379-86.
  6. Inouye, S.K., et al., Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc, 2007. 55(5): p. 780-91.
  7. Gurwitz, J.H., Polypharmacy: a new paradigm for quality drug therapy in the elderly? Arch Intern Med, 2004. 164(18): p. 1957-9.
  8. J, G., Gurwitz, J., et al. "Brown University long-term care quality letter." American Society on Aging—National Council on Aging Annual Conference. 2001. 2001.
  9. Kaiser, H.J.F., Henry J Kaiser Family Foundation State Health Facts 2018 found at KFF.org. Accessed July 3, 2018. 2018.
  10. Payne, R.A., et al., Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol, 2014. 77(6): p. 1073-82.
  11. Payne, R.A., The epidemiology of polypharmacy. Clin Med (Lond), 2016. 16(5): p. 465-469.
  12. By the American Geriatrics Society Beers Criteria Update Expert, P., American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc, 2015. 63(11): p. 2227-46.
  13. O'Mahony, D., et al., STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing, 2015. 44(2): p. 213-8.
  14. Hanlon, J.T., T.P. Semla, and K.E. Schmader, Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc, 2015. 63(12): p. e8-e18.
  15. Tjia, J. and K. Lapane, Guideline-Based Prescribing in Frail Elderly Patients. JAMA Intern Med, 2017. 177(2): p. 262-263.
  16. Roth, M.T., et al., Individualized medication assessment and planning: optimizing medication use in older adults in the primary care setting. Pharmacotherapy, 2013. 33(8): p. 787-97.
  17. Crisp, G.D., et al., Development and testing of a tool for assessing and resolving medication-related problems in older adults in an ambulatory care setting: the individualized medication assessment and planning (iMAP) tool. Am J Geriatr Pharmacother, 2011. 9(6): p. 451-60.
  18. Hanlon, J.T. and K.E. Schmader, The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging, 2013. 30(11): p. 893-900.
  19. Hanlon, J.T. and E.R. Hajjar, Isn't It Time We Stop Counting the Number of Drugs to Define Polypharmacy in This New Era of Deprescribing and What Related Outcomes Should Be Measured? J Am Med Dir Assoc, 2018.
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The Culture and Science of Polypharmacy

By Demetra Antimisiaris, PharmD

Dr. Dee is developing a college course and course materials called “The Culture and Science of Polypharmacy” © and here she shares some related insights. Her contribution to the Polypharmacy Network is primarily centered on supporting innovation along the path to integrating the human aspects of medication use with the science.

To understand modern Polypharmacy, we must look back into history. Never in human history has the intersection of medication use and social opinion and attitudes about medication use intersected as during the late 20th and early 21st century. The development of the printing press and early 20th century ability to distribute news and information to masses of literate people, has played a large part in the culture of medication use. Now in the digital age of the 21st century, that shaping of social perspective has accelerated tremendously.

It is important to understand that just a couple of generations ago, people didn’t approach medications in the sense that we do today. The early days of modern pharmaceutical manufacturing arrived with the mass production of aspirin (a traditional herbal medication derived from willow tree bark) in 1899. Then the discovery of penicillin in 1928 lead to the first product manufactured and utilized in WW2, saving countless lives. It wasn’t until the mid to late 1950’s that more products emerged.

In the late 1950s-1960’s there was an acceleration of psychoactive products launched and in the 1970’s the concept that mental health disorders were merely a chemical imbalance was disseminated widely.[1] The evidence supports that this statement is not robust, yet this is an example of where the shaping of social perspective by advertising, news and information deployment worked this concept into a commonly accepted belief. Chemical imbalance is certainly an outcome or symptoms of mental health disorders, and drugs can work to improve verified imbalance, but not necessarily the root of the problem. To be clear, drugs to alter chemical imbalance have important and critical roles in managing mental health disorders, but ideally, they could be used to correct an imbalance until it can be determined if the root cause intervention can happen (perhaps lifestyle aspects or habits, unrelenting stress), or whether the pathophysiology is irreversible and lifelong treatment is needed.

There are other pathways besides chemical imbalance, contributing to disorders involving the central nervous system and those pathways can be altered through other than chemical means. For example, central nervous system mediations can be used to lose weight, but there’s evidence that movement and exercise influences the brain to positively impact obesity (aside from the calorie burning aspect) [2]

Besides the societal shaping of beliefs, there are the person centered and situational aspects of medication use which contribute to our culture of Polypharmacy. Numerous studies attempt to identify how to ensure patient adherence to drug regimens and a large metanalysis of the data essentially stated that despite complex and resource intense interventions, there is still a lack of evidence on effective methods of drug use adherence support. [3] However, we do know that the strongest driver of medication adherence is the belief that a product works for a disease or problem the user is concerned about. [4-6] For example, a medication that causes immediate feedback, like a sleeping pill, will have excellent adherence (people will refill their Ambien® monthly before their cholesterol drug!) because they take the drug, it makes them sleep, so they know it works and they are concerned about sleep.

The Polypharmacy Network
Ritalin® Circa 1960:
The intersection of mass production of pharmaceutical agents with the ability to shape public beliefs through the media. The claim is that methylphenidate is chemically unrelated to amphetamine. However, both amphetamine and methylphenidate are phenethylamines, a group of chemicals that cause increased dopamine and norepinephrine in the CNS. Amphetamine is single methylated and methylphenidate double. At the time amphetamines were gaining a poor public view, so the shaping of social beliefs that Ritalin® was safer relied on the public inability to verify and understand the relation between amphetamine and methamphetamine. Note the promoted use for increased alertness and depression which was the first goal. Ritalin® was later rebranded for ADHD treatment and it’s sales have increased 700% since 1990. It took 30+ years for the science to align with the needs of the culture.

You can see from these examples that the cultural aspects of medication use don’t always align with the science. That is in part because the science is so technical that even healthcare professionals have difficulty understanding and healthcare professionals are the traditional conduit to help translate the technical aspects of drug use to the actual therapeutic clinical use. The “learned intermediary” legal doctrine places the primary responsibility for the use of the product (drug in this case) off the manufacturer and onto the learned intermediary (prescriber, recommendation conduit which in the case of OTC products could be the store clerk recommending it). This is a 1950’s era rule which may have had its place in medicine regarding pharmaceutical products back in the day when there were just a handful of products on the market. But the PDR (physicians’ desk reference listing all drugs on market annually) consisted of about 900 pages in 1969 with both OTC and prescription products, and by 2012 it was about 1500 pages of just prescription drugs with a separate 800-page OTC PDR. It is literally impossible for doctors and NPs to have the ability to know what a wide and random mix of Polypharmacy will do to the medication they recommend and prescribe. For this reason, the consumer must be conservative in their exposure to mediations.

On the other hand, those who create the technical data (the pharmacologists, and basic scientist) often have little awareness of the cultural aspects. They design a drug to be used under certain specifications (conditions), such as the drug is tested on an empty stomach (not in a person taking Prilosec ® acid suppression drugs) or the drug is tested in very young people who don’t take many other drugs and don’t have many other conditions. That basic pharmaceutical science (how the drug is absorbed, eliminated, distributes in the body) is then altered by development of drug use recommendations, clinical experience, personal experience, and off label usage. The ultimate off label use of any drug is use along with lots of other drugs because the scientific data and studies have no experience random Polypharmacy which creates conditions under which the scientists haven’t tested.

The Polypharmacy Network

To live successfully with polypharmacy, we will need to close the gap between the culture of polypharmacy and the science;
this can be accomplished through awareness of all stake holders

  1. Leo, J., The Media and the Chemical Imbalance Theory of Depression. Society, 2008. 45(1): p. 35-45.
  2. Alonso-Alonso, M. and A. Pascual-Leone, The right brain hypothesis for obesity. JAMA, 2007. 297(16): p. 1819-22.
  3. Haynes, R.B., et al., Interventions for enhancing medication adherence. Cochrane Database Syst Rev, 2008(2): p. CD000011.
  4. Bokhour, B.G., et al., How do providers assess antihypertensive medication adherence in medical encounters? J Gen Intern Med, 2006. 21(6): p. 577-83.
  5. Kressin, N.R., et al., Hypertensive patients' race, health beliefs, process of care, and medication adherence. J Gen Intern Med, 2007. 22(6): p. 768-74.
  6. Clifford, S., N. Barber, and R. Horne, Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: application of the Necessity-Concerns Framework. J Psychosom Res, 2008. 64(1): p. 41-6.