Overprescribing drugs has become a major public health problem. This issue has been called a silent epidemic, however, because it often goes unnoticed. It is most common among older people, but it affects all age groups. For example, young people may be taking too high doses of antidepressants due to the pandemic. If we want people to reduce their medications, we need to offer them alternatives, says Camille Gagnon, a pharmacist and associate director of the Canadian Deprescribing Network.
Founded in 2015, the Network initially focused on reducing the use of certain classes of inappropriate medications in older adults, such as sleeping pills and proton pump inhibitors. Over time, it broadened the spectrum of molecules to include inappropriate drug use in general.
The Canadian Institute for Health Information (CIHI) estimated in 2016 that almost half the seniors in the country were using a potentially inappropriate medication. Among chronic users, that is those who used the same drug in two consecutive quarters, the ratio was about 1 in 3 people. People over 65, women, and those taking multiple medications are at higher risk. Taking more than five medications at a time is called polypharmacy. The more medications a patient takes, the greater the risk of harmful side effects, drug interactions and hospitalizations. Two out of three Canadians (66 per cent) over age 65 take more than five different prescription drugs and about one in four (27 per cent) seniors takes more than 10 different prescription drugs.
A litany of harmful effects
Above all, polypharmacy takes a toll on patients’ general health, raising the likelihood of falls, fractures, hospitalizations, accidents, and cognitive problems. Some medications used alone or with others can have an impact on memory and ability to function, which can lead to an incorrect diagnosis of dementia.
On its website, the Network provides a partial list of medication classes that may be harmful in combination. It includes sleeping pills (Ativan, Serax and Valium), non-benzodiazepine sedatives or “z-drugs” (zopiclone and zolpidem), antipsychotics (Seroquel® and Risperdal®), some antidepressants (Elavil®, Aventyl®, Paxil®), muscle relaxants (Flexeril®, Robax Platinum, Robaxacet®), opioids (Tylenol NO. 3®, Statex®, Dilaudid®, Percocet®) and some nerve pain medications (Lyrica® and Neurontin®).
Financial costs of overprescribing
The other major impact of overprescribing is financial. For seniors alone, the costs of simply purchasing these inappropriate medications were estimated at $419 million per year in Canada. The consequences of these medications, such as hospitalizations, rehabilitation, and physiotherapy, generated additional costs of $1.4 billion, bringing the total cost to almost $2 billion per year, again for people ages 65 and over exclusively.
When he was Minister of Health, Philippe Couillard said: “In Quebec, when you leave the doctor's office without a prescription, you feel like you missed an opportunity.” This is why patients are putting pressure on their doctors to prescribe medication. “When you go to a doctor for a cold and you want an antibiotic, you're more likely to leave with a prescription for antibiotics even if it won't do anything against a virus,” notes Camille Gagnon, who worked as a pharmacist in a family medicine group.
Factors behind overprescribing
The Network defines deprescribing as stopping or reducing medications that may not be beneficial or may be causing harm. “This process is always done in partnership, and the patient must be supervised,” Gagnon stresses. “The last thing we want is for deprescribing to cause deaths.”
Several factors fuel overprescribing. Physicians often prescribe at the end of the consultation and may add molecules without necessarily considering what the patient is already taking. Specialists, in turn, may add drugs on their own without looking at what a colleague has prescribed. As a result, polypharmacy is on the rise. Patients’ expectations are also driving this trend: Many prefer a pill to a change in their lifestyle, and don’t spare a thought for its impact on their general well-being.
Drugs are also prescribed to compensate for the harmful effects of certain medications. Camille Gagnon calls this phenomenon the “drug cascade.” The best way to deprescribe, she says, is when we can identify these cascades and address them properly.
Another major cause of overprescribing is that physicians lack the time to propose alternatives to medication. “If we can avoid starting treatment in the first place, that's even better. But if there's an underlying problem, we want to offer the patient an alternative like physical therapy or behavioral therapy for depression or insomnia. This is one of our big battlegrounds at the Network,” Gagnon explains
Her organization has an important message for public and private insurers: People need access to alternatives to medications. When they go to the doctor, they should not automatically expect to leave with a prescription, but should be given other options. De-prescribing should target not only seniors, but all age groups, such as young people or workers, who are taking or continue to take harmful and unnecessary medications.
Who should make the first move? The doctor or the patient? What about the pharmacist, who has access to the patients’ entire medication record onscreen, and who should easily be able to avert the risk of overprescribing? “All three,” says Camille Gagnon. It's easier to deprescribe if the patient is on board. The family physician and the pharmacist can jointly review the patient's medication and determine what should be removed and what should be substituted for potentially harmful drugs or combinations. This can be a time-consuming process, she admits. Given the pressures health care professionals currently face, the challenge is huge, even if the results would be beneficial.
Could insurers play a role in raising their client’s awareness of overprescribing and deprescribing? “The more education, the better,” Camille Gagnon says, adding that “it shouldn't be seen only as a cost-saving measure if it comes from the payer. If it's based on scientific evidence, everyone will win in the end, but the message needs to be communicated well.”
