The Danger of Overmedicating Older Americans

For millions of older Americans, their everyday morning ritual begins by opening up the medicine cabinet and swallowing a handful of pills to lower blood pressure, reduce cholesterol, control blood sugar levels, alleviate heartburn, and treat acid reflux (among other things). For many older individuals, taking a daily assortment of prescriptions is an inevitable process of aging. But ingesting ten, fifteen, or even twenty pills every single day is anything but normal or natural. In the United States, older adults are suffering from a silent but deadly epidemic of adverse side effects from excessive, unnecessary, and inappropriate use of medication to treat chronic symptoms. As life expectancies increase and the number of adults over the age of 65 grows exponentially, prescribing medications for older patients has become significantly more popular and normalized as they face more age-related diseases.

“More than four in ten older adults take five or more prescription medications a day, an increase of 300 percent over the past two decades. Nearly 20 percent take ten drugs or more. When over-the counter medications and supplements are included, the number of older people taking five or more drugs rises to 67 percent.”

The regular use of five or more medications to treat a patient with multiple chronic conditions is commonly known as polypharmacy. Polypharmacy is becoming more and more problematic and developing into one of the biggest public health concerns for elderly individuals. Taking too many medications or the wrong mixture of pills increases the risk of serious side effects, dangerous drug-drug interactions, emergency department visits or readmission, and increased mortality rates. Adults over the age of 65 are much more vulnerable to potentially life-threatening side effects like heart attacks, stroke, internal bleeding, delirium, and dementia. In fact, older individuals who take five or more medications are 88% more likely to seek medical care from an harmful side effect than older individuals taking only one or two prescriptions. With every additional drug taken, the likelihood of suffering from negative side effects increases an average of 8.5%. The long term risk factors of taking multiple drugs for older populations increases the risk of hospital admissions and mortality rates and contributes to the expensive cost and inefficiency of healthcare:

“Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events (ADEs) and were hospitalized more than 2 million times due to ADEs.”

To contextualize, older citizens are being hospitalized from adverse side effects of prescription drugs more than the general public is being hospitalized from negative side effects of opioids. Since older individuals are more likely to experience multiple chronic conditions, they are also the most vulnerable to the harmful interactions between various medications. Due to the influence of polypharmacy, over two-thirds of the largest age demographic in the U.S. are at risk of adverse medical outcomes due to excessive medication. As more hospital admissions occur, more expensive emergency services are used, and the overall cost of healthcare increases. Not only that, older patients are burdened by the costly expenses of taking numerous pills every single day. If nothing changes in the next ten years, it's been estimated that $62 billion dollars will be used on medical services to treat patients with adverse side effects from overmedication, all of which could be avoided.

How did such a widespread and devastating epidemic affect millions of people and waste billions of dollars, but remain relatively silent? If we’re pointing fingers, the main culprit to blame is the pharmaceutical industry and its extensive influence on modern primary care. Big Pharma has completely corrupted the practice of medicine and infiltrated every process in the development, production, advertisement, and medical education of drugs. In the past few decades, they’ve tightly moderated critical aspects of healthcare, controlling basic drug research and clinical trials, exploiting consumers and patients, and tainting the integrity of physicians and healthcare professionals. By endorsing medication as the first and sometimes only reaction to alleviating chronic illnesses, drug companies drive a distorted culture of healing based on marketing incentives. The chronic overconsumption of pills diverts attention away from greater social, environmental, and socio-economic disparities that explain many of the chronic diseases that plague this nation. Instead of cultivating a low-cost, preventative, holistic lifestyle approach to wellness, the drug industry is promoting a reactive, disease-oriented healthcare system that is not only inefficient and expensive, but unsustainable in the long run.

For these pharmaceutical companies, the first step to driving a culture of overmedication is to infiltrate the production and testing of new prescriptions. Big Pharma regulates most of the guidelines for drug research and conducts most of the clinical drug trials in America. Clinical treatments, research, and guidelines for prescription drugs are deliberately arranged to increase the chance of favorable outcomes and drug companies often pay medical experts to twist stories in their favor. Not only are these research experiments incredibly biased and sometimes unreliable, but they rarely reflect real-life scenarios by failing to include older participants or test for drug-drug interactions over a long period of time. To make matters worse, after a prescription is approved by the FDA and on the market, drug companies will fund research for benefits that haven’t been approved. They’ll promote these “off label” uses and advertise new drugs with benefits that haven’t been safely authorized by the government.

To maximize their profits off of new drugs, pharmaceutical companies directly advertise to consumers with deceiving product claims, convincing more and more individuals to consume more pills, and inflating the cost of medications.

“From 1997 through 2016, medical marketing expanded substantially, and spending increased from $17.7 to $29.9 billion, with direct-to-consumer advertising for prescription drugs and health services accounting for the most rapid growth”.

In 2016, pharmaceutical companies spent $6 billion on drug advertisements directly targeting consumers and patients. These ads often downplay or negate the severity of side effects, quickly gloss over the fine print, and glorify the “magic pill” as an end-all-cure-all solution. In public media platforms, drug advertisements often showcase depressing, gray weather with a miserable grandmother suffering from terrible back pains or chronic migraines. But with the help of one pill, the sun suddenly begins to shine and all her problems disappear. She freely laughs with friends at a family potluck and smells the fresh flowers in her beautiful garden. In the last ten seconds of the ad, a voiceover hastily lists fifteen complications, including increased risk of death, while the sun shines on the happy-go-lucky grandmother. Such distorted imagery and false promises can have fatal and undesirable consequences.

In 2015 and 2016, an analysis on drug commercials revealed that “not a single one included a quantitative presentation of the risks. This lack of context leads viewers to overestimate the benefits of drugs while underestimating the potential harms.”

Unfortunately, the United States is only one of the two countries in the world that allow pharmaceutical companies to directly advertise to patients and make product claims on prescription drugs. The incongruence between the cheerful background music and the warning of life-threatening complications causes people to take the side effects less seriously and feeds into the culture of depending on drugs as the first step to addressing chronic illnesses.

Drug companies not only deliberately target consumers, but they also infiltrate hospitals and directly advertise to physicians and other healthcare care professionals:

“The drug industry also markets heavily to health care professionals, spending more than $20 billion a year on face-to-face promotion, free samples, promotional meetings, continuing medical education, and other marketing activities. While the industry is not allowed to market drugs for unapproved conditions, companies often fund studies designed to prove their efficacy for common ailments. Subsequently published abstracts and papers act as a marketing blitz, telling prescribers that medications are safer, more effective, and appropriate for a larger population of patients than they actually are.”

Through financial incentives, doctors are being swayed to recommend certain drugs to their patients, even when their patients don’t actually need them. An analysis found that doctors who were paid by pharmaceutical companies to promote a certain drug were on average 58% more likely to prescribe the medication than doctors who weren’t sponsored. Drug companies are encouraging physicians to prescribe unnecessary drugs and influencing providers to waver in their integrity and prioritize financial gains over their patient’s wellbeing.

The quick fix of prescribing drugs is also due to the limited amount of office hours. Healthcare providers can also feel that they don’t have enough time to discuss more long term solutions rather than medications, feel inadequate in a specific expertise, or believe that a patient wouldn’t be receptive to alternative options.

In fact, there are “numerous barriers stop clinicians from reducing or eliminating medications from a patient’s regimen. Patients may resist going off a drug they believe is keeping them healthy. Clinicians may fear a bad outcome from stopping a drug more than they fear a bad outcome from starting one. They often hesitate to take a patient off a drug that was prescribed by another clinician. Even clinicians who want to deprescribe do not know how to stop or taper drugs safely.”

Since drug companies also hide and fine print the side effects of common drugs, medical providers aren’t being provided critical information on the long term usage of these prescriptions. This causes doctors with less expertise on drug-drug interactions to hesitate overriding medications that were previously prescribed by another doctor. Even physicians who reach out for help are receiving distorted instructions on how to treat patients since clinical guidelines are often written by experts with ulterior motives or connections to the drug industry. Biased medical guidelines written by pharmaceutical companies fail to provide full transparency on the negative adverse effects that specifically affect older populations. The lack of objective, neutral data can lead physicians to overmedicate their patients and increase the likelihood of future hospitalizations and readmissions from adverse side effects.

Due to misleading information, healthcare providers aren’t able to make well-informed, educated decisions when prescribing or deprescribing elderly patients with multiple chronic illnesses. Doctors are prescribing more drugs for older patients that experience symptoms of common chronic diseases even when these patients don’t meet the clinical criteria. For example, levothyroxine (LTX) is the most commonly prescribed drug for treating clinical hypothyroidism in the U.S. Hypothyroidism is diagnosed if a patient’s thyroid stimulating hormones (TSH) levels are slightly above normal blood ranges. However, TSH levels can drastically increase two or three times the normal amount in relation to sleep deprivation, location, ethnicity, exercise, pregnancy, and when taken with specific medications. Although LTX is useful for people who suffer from clinical hypothyroidism, studies have shown that LTX does not improve the quality of life for patients with mild forms of hypothyroidism. However, LTX is commonly and inappropriately prescribed for subclinical hypothyroidism. Treating mild forms of hypothyroidism with LTX increases the risk of bone fractures and heart rhythm problems in older adults, and these patients find it more difficult to get off a medication once they’re already taking them.

Furthermore, the lack of communication between specialists, even within the same hospital, could cause additional unnecessary or inappropriate medications to be prescribed that overlap, contradict, or negatively interact with existing prescriptions. Patients with multiple providers often have a difficult time transferring and presenting their full medical history to each physician. It’s laborious and burdensome for every single doctor to collaborate and communicate a patient’s comprehensive medical record. Thus, individual physicians may not be able to see an exhaustive inventory of their patients and critical medical information could be missing, forgotten, or disregarded. As a result, a patient’s symptom could actually be the side effect of a previous drug prescribed by an alternate provider. For example, a patient’s primary care doctor might prescribe statin, a common cholesterol-lowering drug, without knowing that her previous doctor had prescribed a fibric-acid drug to lower her lipid levels. The interaction between statin and a fibric acid drug greatly increases the risk of liver failure. By adding onto previous prescriptions, the list of medications can cascade from two or three pills to ten or twenty as each new drug contributes a new side effect. Once the ball is rolling, it’s much harder to stop a prescription from cascading.

However, the most detrimental influence of the drug industry is the promotion of over-medicalization, the process in which many normal conditions are being labeled as medical problems that need medical treatment.

“Twenty years of advertisements linking prescription medications to happiness and health, the increased medicalization of normal human aging and experiences, the hurried pace of medical care, and a desire on the part of both health care professionals and patients and their families to “do something” have together fostered a shared expectation that there is a “pill for every ill.” Both patients and clinicians have been oversold on the benefits of medications, to the point where a prescription is seen as caring, and withdrawal of medication connotes giving up on the patient.”

Drug advertisements portray unrealistic outcomes of prescription drugs and fail to highlight the issues. These ideas influence the modern practice of medicine to use pills as the first response to treating chronic illnesses and the best way to do so. The excessive, unnecessary, and chronic overuse of medication and inappropriate prescriptions have actually trapped patients into a physical and mental dependence on these medications to provide a sense of normalcy. But the purpose and practice of healthcare should be to free people from the need of medicine, not to depend on them.

In order to combat this epidemic, the United States must regulate and hold the drug industry accountable and shift the practice of medicine away from medicalization. Meeting the needs of patients must be prioritized over meeting the demands and interests of the pharmaceutical industry, and drug companies cannot determine the quality and type of care patients receive.

If acted upon promptly, “focusing on reducing inappropriate or unnecessary medications could save as much as $62 billion over the next decade in unnecessary hospitalization for older adults alone.”

The first step is to increase conversations about the severity of overmedication to patients, providers, healthcare leaders, and policymakers across the United States. Many people are unaware of the detrimental side effects of excessive prescriptions and are unfamiliar with the scope of the drug industry’s influence on healthcare. In order to raise awareness, public health campaigns should expose the pharmaceutical industry’s control on the research, production, and medical education on prescriptions. Advocates and other public health platforms can teach consumers how to spot misinformation in misleading drug advertisements and discourage physicians and healthcare leaders from accepting financial bribes. This includes targeting prescribing patterns of patients, healthcare providers, and pharmacists who are all influenced by the drug industry, whether they are conscious or not.

Along with more public awareness on the harmful effects of overmedication, the government should promote unbiased, reliable clinical trials on the effects of polypharmacy in relation to older individuals. Including older participants in long-term drug research provides a more accurate understanding of the potential benefit or harm of a medication. To promote the appropriate use of prescriptions, the regulation of “off label” usage of drugs must be prohibited and direct-to-consumer advertisements and marketing to clinicians must be tightly limited. The U.S. government is fully responsible for developing policy changes that regulate the frequency of drug marketing to healthcare professionals and the quantity of free samples, promotions, or other financial incentives drug companies are allowed to give. Along with these regulations, transparency must be required from all parties involved, including drug companies, healthcare providers, and clinical experts writing guidelines and giving medical advice to physicians. First and foremost, all pharmaceutical companies must also be held accountable in providing more transparency on the risk factors of their products and disclose funding for research. Likewise, physicians paid to promote certain medications must provide full interest disclosure to their patients and healthcare advisors sponsored by pharmaceutical companies must provide full transparency of their financial profits off a specific medication.

In efforts to reduce the tendency to over prescribed, efforts should be made to develop a coordinated national electronic medical system that allows every healthcare provider to see the full patient medical history. This will require coordination between various hospitals to allocate a single medical record platform across all health institutions so physicians can accurately diagnose, prescribe, and deprescribe medications as needed. Furthermore, hospitals should mandate constant prescription checkups and yearly review sessions that focus on reducing the number of medications to the bare minimum. New clinical guidelines written by unbiased drug experts should discourage prescribing medications for every symptom and as the first step in treating chronic illnesses. This includes mandating clinical education that advises physicians how and when to safely lower or stop doses, the overall benefits and harm of the most commonly prescribed drugs, and key factors to consider to avoid inappropriate prescribing. To further reduce the medicalization of healthcare, healthcare providers should promote alternative, minimally invasive services that allow patients to avoid medications. In combination with necessary medications, encouraging realistic lifestyle changes to patients will not only decrease the risk of adverse side effects of taking multiple medications and reduce the number of premature deaths, but significantly lower the overall cost of healthcare.

In parallel with regulating pharmaceutical companies and reforming medical education and institutions, the current practice of medicine must also shift towards long term, preventative primary care. Although progressive strides have been made in reducing the number of infectious diseases over the past several decades, chronic diseases are now the leading cause of death and disability for many Americans. Almost 70% of older adults in the U.S. suffer from two or more chronic illnesses. From these patients, 61% had hypertension, 32% had heart disease, 31% had arthritis, and 28% had diabetes. All these conditions are somehow connected to nutrition, exercise, stress and the environment of an individual. Although many of these diseases are preventable and reversible with lifestyle habits, they’re often only treated with medications.

In fact, the top ten most prescribed medications treat high blood pressure, heart failure, heart attack or stroke, hypothyroidism, type 2 diabetes, artery disease, gastrointestinal problems, and asthma. Although treating chronic illnesses with excessive medication is inefficient and sometimes even harmful. For example, statins is one of the most commonly prescribed medications used to lower cholesterol levels in the blood and prevent heart attacks. However, individuals who take statins are also at increased risk for type 2 diabetes. If they take certain antibiotics, HIV treatments, or other cholesterol drugs, they also face a greater risk of experiencing side effects from adverse drug-drug interactions. Ironically, medications used to treat one disease often increases the probability of developing other chronic problems.

“It seems that we have a social predilection toward treating human problems as individual or clinical – whether it is obesity, substance abuse, learning difficulties, aging, or alcoholism- rather than addressing the underlying causes for complex social problems and human suffering.”

By tackling chronic illnesses such as heart attacks and strokes with drug treatments as the first line of defense, the medical industry overlooks hypertension and other risk factors that can be prevented or significantly reduced by simply changing everyday habits. Rather than creating more drugs for every new condition, the U.S. must focus on altering the harmful environment factors and negative habits, such as sedentary lifestyles, chronic stressors, processed foods, that trigger these chronic illnesses. Other determinants such as occupation, environment, and education have all been tied to an individual’s quality of health. Relying on the quick-fix of drugs advertised by Big Pharma not only sweeps important socio-economic issues under the rug, but also contributes to more national health inequality.

Although overmedication has clearly caused billions of wasted dollars, millions of preventable hospitalizations, and thousands of premature deaths, there is no public organization or specific government agency that has taken steps at the national level to reduce the effects of polypharmacy. In the past several years, the culture of medicalization in the United States has promoted rapid growth in excessive medication of older adults and caused more harm than good.

“If current trends continue, we estimate that medication overload will be responsible for at least 4.6 million hospitalizations between 2020 and 2030. It will cost taxpayers, patients and families an estimated $62 billion.”

The epidemic of side effects from excessive and unnecessary medications has jeopardized the quality of life for many Americans.

But there’s hope. The practice of medicine is shifting towards a more co-dependent, bidirectional relationship where patients work in parallel with providers to achieve the most optimal health. This transition in healthcare will require medical institutions to educate future physicians on their role in shared decision making, empower patients and their families to take control of their own health, and remain mindful of the cultural backgrounds, abilities, and preferences of each patient. As a collective society, individuals, providers, leaders, and politicians must stop over-medicalizing the process of aging, reduce the influence of pharmaceutical companies on medical practices, and stop prescribing medications that don’t improve the overall wellbeing and safety of older adults. More than ever, the quality of life for millions of Americans depends on the future culture of healthcare. In the U.S., the healthcare system must prioritize patient needs above financial incentives, uphold the highest integrity in serving older Americans, and shift the current practice of medicine towards true patient-centered, patient-oriented care.