January/February 2009

America’s Other Drug Problem
By Mark A. Stratton, PharmD, BCPS, CGP, FASHP
Aging Well
Vol. 2 No. 1

America has a drug problem. It’s not the methamphetamine epidemic that prompted legislation to put your favorite cold medicine behind the pharmacy counter. It’s not the growing abuse of prescription medications by America’s teens. And it doesn’t involve society’s fringe groups. It’s mainstream, it’s costing us billions of dollars, and it’s harming and killing thousands of our most vulnerable citizens—our older adults.

While there has been a virtual explosion in the number of medications prescribed in the past decade, this has not necessarily translated into better health for older adults. In fact, for elders, more medications often mean greater risk, especially when medicines are prescribed inappropriately or unnecessarily. While those over the age of 65 make up only 13% of the U.S. population, they consume more than 30% of the prescription drugs sold annually in this country, as well as an estimated 40% to 50% of the over-the-counter medications and an unknown number of alternative or herbal remedies.

The consequences of this overuse, coupled with medications’ inappropriate uses, translate into a public health catastrophe. More than 50% of the deaths each year due to problems associated with prescription drugs occur among older adults. This translates into 50,000 to 75,000 deaths annually, making drug-related mortality the fifth leading cause of death among America’s elders. Nearly 40% of the hospitalizations that occur each year due to problems associated with prescription drugs involve this population. One third of all hospitalizations of older adults over the age of 65 are thought to occur as a consequence of some type of problem with their medications. The added cost burden to the healthcare system approaches $200 billion per year.

In 2000, nearly 2 billion prescriptions were sold in the United States. By 2006, that number had grown to an estimated 3.5 billion prescriptions. This remarkable growth has been attributed largely to direct-to-consumer advertising. While this has undoubtedly been good for business, we should question whether it has been good for public health, particularly that of older adults.

In light of such unsettling statistics, it’s no wonder that this issue is now referred to as “America’s other drug problem.” There are a multitude of reasons for this problem, including issues of polypharmacy, poor compliance or adherence, and a lack of understanding about how older adults change in their responses to medications. While this is a very real public health problem, experts in the field of aging estimate that at least one half of these deaths are entirely preventable through better education of healthcare professionals and older adults.

Root Causes
The term polypharmacy implies not only the use of too many medications but also the use of inappropriate and/or unnecessary medications. Inappropriate medications are defined as those for which the risk exceeds the benefit. A list of these potentially inappropriate medications has been available for nearly two decades. Generated by noted geriatrician Mark H. Beers, MD, and colleagues in 1991, the list has been published twice since then, most recently in 2003. The list of potentially inappropriate medications, now referred to as the Beers list, has been adopted by the Centers for Medicare & Medicaid Services as a benchmark for quality measures.

Numerous studies have revealed that 25% of older adults are receiving at least one medication on the Beers list. This increases the risk among elders of an adverse event with potentially significant consequences. The decrease in physiologic reserve among older adults impairs the ability to recover from physiologic insults such as adverse drug events, leading to increased morbidity and mortality. Another consequence of this prescribing cascade is the continuation of unnecessary medications. Physicians are often reluctant to discontinue a medication prescribed by another physician.

Failure to take medications as prescribed can also lead to adverse consequences in older adults. Prior to the implementation of Medicare Part D on January 1, 2006, one third of older adults failed to take medications as prescribed due to cost issues. Since the advent of Medicare Part D, accessibility to medications for elders has improved. However, 10% to 15% of older adults continue to report accessibility problems, especially when they hit the “doughnut hole,” or when they remain unaware that they may qualify for low-income subsidies to help pay premiums or copayments for prescription drugs.

Another contributor to America’s other drug problem is prescribers’ insufficient awareness of the changes that occur in the processes of absorption, distribution, metabolism, and elimination of medications (i.e., pharmacokinetics) as a result of the aging process and diseases that often accompany aging. There is also a considerable pharmacodynamic change that occurs with the aging process. When not considered in the prescribing process, such changes lead to increased risk along with the associated increased morbidity and mortality. While a sizeable knowledge gap still exists in the areas of pharmacokinetic and pharmacodynamic changes that occur with aging, we have sufficient information for numerous classes of medications to make safer decisions that can lead to improved outcomes.

Awareness Is Key
To improve outcomes from prescription medications and avoid unnecessary risk, at the time a decision is made to use a medication, the prescriber must integrate the knowledge of an older adult’s age, frailty, comorbidities, other medications, and abnormalities in organ system function that will affect the pharmacokinetics and pharmacodynamics of a chosen medication. Consideration of this information at the time a prescription is written will lead to the improved likelihood of making the right decision regarding the proper drug, dose, and administration route. This fundamental principle is essential to minimize risk and maximize benefit, since risk must be minimized in an older adult population whose physiologic reserve is decreased.

The effects of aging and associated diseases on medication pharmacokinetics and pharmacodynamics are progressive through the age spectrum. Effects are not readily evident in a healthy 70 year old, but by the time the patient reaches the age of 80 or develops multiple comorbidities, these effects become more significant. It’s important to recognize that older adults take an inordinate number of over-the-counter medications and herbal or alternative remedies and with the changes previously described that occur with aging, these agents become potential toxins.

In addition to avoiding potentially catastrophic consequences associated with inappropriate and excessive medication use among older adults, another goal should be to either maintain or improve elders’ quality of life. Due to a reluctance to complain, all too often older adults suffer a substantial decline in their quality of life because of medications. Healthcare providers and caregivers should be aware of changes that occur in older adults’ day-to-day lives and consider unusual declines in quality of life to be drug induced until ruled otherwise. Because the medication side effects often present atypically in older adults, even if a side effect is not listed in a drug monograph, it’s not impossible that it could occur in an older adult. A general rule followed by geriatric experts is to expect the unexpected.

Improving the Game Plan
Solutions to America’s other drug problem are numerous and include the following:

• Minimize the number of medications used and, when appropriate, attempt gradual dose reduction.

• Maximize nonpharmacologic alternatives whenever possible.

• Prescribers should titrate drug therapy for older individuals. This speaks to the principles described previously and to the heterogeneity of the elder population.

• Prescribers and pharmacists should educate both elders and caregivers about medications.

• Review all medications annually. Have elders bring in all medications—prescription, over-the-counter, and herbal or alternative remedies—and analyze for appropriateness, need, drug-drug interactions, and outdated medications.

• Improve communication skills by urging older adults and caregivers to become more active in the decision-making process regarding medications. Improve interdisciplinary communication and cooperation.

• Encourage older adults to use a single pharmacy so the pharmacist has a complete record of all medications used by the individual. Use the pharmacist to help the prescribers and older adults manage their medications.

• Primary care providers should assume a more active role regarding medications prescribed or recommended by consultants.

• Be aware of the potential for medication-related problems when older adults transition between care facilities and home (medication reconciliation).

By following these guidelines, prescribers, other healthcare providers, caregivers, and older adults can make considerable progress toward solving this public health problem. Such progress can significantly decrease older adults’ decline in quality of life, hospitalization rates, and deaths from inappropriate and unnecessary medications.

— Mark A. Stratton, PharmD, BCPS, CGP, FASHP, is a professor of pharmacy and the Herbert & Dorothy Langsam Endowed Chair in Geriatric Pharmacy at the University of Oklahoma College of Pharmacy in Oklahoma City.