The Problem of Polypharmacy: When More is Less
When three or more medications are prescribed at the same time, and drugs are being prescribed to treat the side effects of other drugs, the results can be potentially dangerous.
The percentage of workers’ compensation claims with multiple chronic medical conditions appears to be growing.1 With an increase in medical conditions there is an accompanying rise in medications prescribed. The use of multiple medications by an individual has been termed polypharmacy. Polypharmacy can be seen in many workers’ compensation scenarios. While definitions vary,2 polypharmacy has most commonly been defined as use of three to five or more different medications taken by a patient at the same time.3 In addition to other medical conditions, another “risk factor” for polypharmacy is having workers’ compensation medications in addition to medications for non-work-related conditions.4 Often these combined treatments go undetected.
Polypharmacy is not inherently bad. Rational polypharmacy is based on the safe and appropriate use of multiple drugs. The patient may benefit from combined therapies that reduce the symptoms of disease, cure or prevent disease progression, and minimize disability. For example, five drugs are recommended for the initial treatment of tuberculosis, and four drug polypharmacy is recommended for treating stomach ulcers caused by bacteria called H pylori. In workers’ compensation, guidelines for the treatment of nerve pain find certain antiepileptic drugs can be combined with certain antidepressants and a non-opioid analgesic to effectively reduce neuropathic pain. Another workers’ compensation example is treatment of frequent migraine headaches by adding a headache prevention medication to the immediate-treatment medication to reduce headache frequency and disability.
But when more drugs are prescribed and taken than are clinically warranted, the patient is at risk of serious harm including death5 from adverse effects, drug/drug interactions, drug/disease interactions, and incorrect dosing. To illustrate these potential harms, an example of runaway polypharmacy in workers’ compensation appears in the above graphic. Such inappropriate polypharmacy is associated with significant morbidity and mortality, costing United States health plans more than $50 billion per year.6
The Cost of Polypharmacy
If early detection and clinical intervention do not occur, instances of polypharmacy can quickly grow out of control
Polypharmacy costs can certainly add up:
Delayed return to work + dangerous drug/drug interactions + incorrect dosing
Drug costs can exceed
$7,000 + per month (or more)
Clinical Intervention is Imperative. Intervention can lead to:
Decreased drugs, improved patient outcomes, increased safety, reduced costs
To reduce the risks of polypharmacy, a comprehensive review of each drug in the patient’s drug regimen should be performed by prescribers at least annually.7 PBMs should proactively uncover instances of polypharmacy and report this data to payers so they can request patient drug regimen reviews as needed. Eliminating unnecessary or potentially problematic medications can simplify medication use for the patient, and reduce the risk of adverse drug reactions and excessive healthcare expenditures. It is also an opportunity to ensure that the patient understands why the medications have been prescribed, how to take them, and what to do in the event of side effects. Clinical tools are available to assist in the review of complex drug regimens, such as the Hyperpharmacotherapy Assessment Tool (HAT) which can help identify polypharmacy and all sources of medications, direct a decrease in inappropriate drug use, and optimize the dosing regimen.8 Prescribers can access the HAT and request permission to use the tool by clicking here .
“Most individuals who are prescribed five or more drugs are taking unique drug combinations … [representing] an ‘uncontrolled experiment’ with effects that cannot be predicted from the literature.”9
— Werder. J Family Practice. 2003.
When reviewing polypharmacy, some questions to ask include:
- Does the patient use multiple prescribers and multiple pharmacies?
- Is the patient taking the medications as prescribed?
- Can the patient describe the purpose, dosing, and side effects of the drugs?
- Are there any adverse effects that may be caused by the medications?
- Are there any drug-drug or drug-disease interactions suspected?
- Does the dosage or frequency need to be adjusted based on patient-specific characteristics such as age, liver or kidney function?
- Is the medication even appropriate for the age of the patient? (Older patients require special consideration.)
- Is there another, equally effective, lower cost drug available?
- Is there a non-drug therapy option?
- Is there a risk of addiction from long-term use?
- Have treatment goals been achieved?
After review, a treatment plan should be developed by the prescriber to slowly eliminate inappropriate medications, unless serious drug-related problems have been identified, in which case immediate action may be necessary. It is recommended to avoid making multiple drug changes at one time. Instead, one drug should be discontinued at a time by tapering dosage and closely monitoring the patient for possible withdrawal symptoms and worsening disease. A PBM should help identify instances of potential polypharmacy and work with payers to optimize the drug therapy regimen. Ultimately, eliminating inappropriate polypharmacy may enhance drug therapy outcomes and improve the patient’s quality of life while reducing healthcare expenditures.
“Healthcare practitioners have a societal obligation to simplify approaches and curb excessive prescribing of drugs while honoring their commitment to improving health and curing, mitigating, and preventing disease.”10
— Zarowitz. Pharmacotherapy. 2005.
Examples of Inappropriate Polypharmacy11
(as seen in a typical workers’ compensation claims population)
|Harm||Select Drugs in Regimen||Result|
|Adverse Effect||Multiple high dose short-acting opioids: fentanyl lozenges, oxycodone||Opioid-induced hormone deficiency, constipation, and narcotic bowel syndrome causing additional prescriptions for testosterone, Viagra®, laxatives, and an ulcer medicine (e.g., omeprazole)|
|Drug/Drug Interaction||Multiple drugs causing similar and additive effects: Cymbalta®, cyclobenzaprine, Nucynta®, tramadol||Serotonin syndrome resulting in anxiety, insomnia, and additional prescriptions to counteract these effects (alprazolam (Xanax®) and other sedating drug)|
|Drug/Disease Interaction||Tramadol, tizanidine, Lyrica®, and ibuprofen in a patient with chronic kidney disease||Increased kidney toxicity and possible adverse effects due to enhanced drug toxicity|
|Incorrect Dosing||Diclofenac DR 200 mg/day long term regular use||Higher doses and longer duration of use are associated with greater risk of gastrointestinal bleeding/ulcers and high risk for serious cardiac events|
A recent study, Comorbidities in Workers’ Compensation, by the National Council on Compensation Insurance (NCCI) observed that workers’ compensation claims for patients with multiple chronic conditions were associated with double the medical costs than a claim without additional medical conditions. They were also more likely to accrue more time away from work.17 NCCI found that drug abuse, diabetes, hypertension, and chronic pulmonary disease were common, costly, and seem to be increasing. Another common condition, obesity, was observed in 29% of musculoskeletal injuries and in 27% of sprains/strains. There is currently not enough published research available to determine if there is a correlation between obesity and cause of injury, and what treatments are directly associated with injuries versus other conditions present outside of the work-related injury.