As a doctor, it’s my goal to help patients as much as I can, with whatever I can, as long as they are under my care. The last thing I would ever want is to prescribe medications that cause harm rather than good. That’s why I am so grateful for the research of Dr. Sara Guilcher in the area of polypharmacy and her work to bring person-centered care to the forefront of the medical system. It’s easy to see a patient’s medical issue and immediately jump to a pharmaceutical solution. But what often isn’t being considered is how many medications a single patient is being prescribed and the effect that may have on them medically and logistically. Could our eagerness as physicians to solve problems with another prescription actually create bigger ones for our patients down the road?
Understanding the complexities of polypharmacy
If I were to describe Dr. Guilcher’s assessment of the polypharmacy problem in one word, it would be complicated. Rather than one big problem, polypharmacy seems to be a web of smaller, interconnected issues that touch every area of the medical system and the overall patient experience. Most in the medical field understand polypharmacy to mean a patient who is taking five or more medications at the same time, yet Dr. Guilcher feels few truly understand the impact of that level of prescription. More accurately, few are taking the necessary steps to prevent it from happening.
A big gateway to polypharmacy is what Dr. Guilcher described as “the prescription cascade”. Again, jumping to a pharmaceutical solution is an easy knee-jerk reaction for most doctors and a fundamental part of the problem. The “cascade” happens when doctors try to ease side-effects from the first medication with another medication. Then the second medication creates side-effects that require a third medication and so on. It can become an endless chase that leaves a patient managing an overwhelming amount of prescriptions. This often leads to accidental overdosing and non-adherence to critical medications that can ultimately result in death and polypharmacy as comorbidity.
Another piece to this puzzle is a lack of effective communication and record-keeping within the medical ecosystem. Comprehensive medical and medication records often do not exist between medical providers and pharmacists. This places an unrealistic responsibility on patients to keep track of complex medical information while simultaneously managing an illness or chronic condition. This is the definition of a systemic failure within the medical community to provide the best quality of care for our patients. The need for change is clear and urgent.
Systemic problems require holistic solutions
The problem of polypharmacy can not be solved overnight. Changing the nature of patient care from formulaic to person-centered will not be an easy shift. Dr. Guilcher believes one of the first steps is for doctors to consider a de-prescribing perspective that provides patients with non-pharmacological options for treatment. It’s not that medication is bad, it’s that it is not always the best option for every patient. There is an entire world of alternative treatments waiting to be discovered with proper research and funding.
However, when medication does need to be prescribed, doctors should think critically about what that prescription will mean for the patient. That includes doing a proper medication review to understand any potentially harmful interactions that medication could have with existing prescriptions AND what it would look like to integrate that prescription logistically into the patient’s everyday life. For instance, does the medication have specific consumption requirements like time of day or a need to be taken with food? What are the consumption requirements for the other medications they are taking? How does the new medication integrate with the existing ones? Is the treatment plan realistic or am I trapping my patient at home by creating an unrealistic medication schedule? Is there a better option? These questions are critical when putting the patient first and the problem is that few doctors are asking them.
The final way Dr. Guilcher suggests we tackle the problem of polypharmacy is through education. Prescribers need to be educated on the complexity of conditions like spinal cord injury and the various therapies available to patients that don’t include another pill bottle. Patients could also benefit from learning how to prevent polypharmacy in their treatment plans. An easy patient solution is sticking to one pharmacist who can manage all of their medications and counsel them on how to best adhere to the treatment. Of course, universally shared and detailed medical records between all providers and pharmacies would make this a non-issue, but there is still much progress to be made. In summary, it’s going to take a massive effort from all sides of the medical field to address the problem of polypharmacy, but I am glad Dr. Guilcher is helping to lead the charge.