“You need this drug,” and other things clinicians should stop saying

Millions of older Americans are at risk from medication overload— harm caused by too many medications. And with the aging of the population, this problem is likely to get worse.

Fortunately, there is a lot we can learn from clinicians like Dr. Tom Perry, who have made it their life’s work to recognize the signs of medication overload and educate others on how to avoid it.

Perry is a Clinical Associate Professor at the Department of Anaesthesiology, Pharmacology and Therapeutic, at University of British Columbia in Vancouver. He is also Co-chair of the Education Working Group at the Therapeutics Initiative, an independent organization that provides evidence-based, practical information on health care interventions.

We spoke with Dr. Perry to ask him about the origins of TI, practical ways to avoid medication overload, and the assumptions about medications we need to rethink in our society.

Lown Institute: How did the Therapeutics Initiative get started?

The project started out of the idea that my colleagues and I had, that if we can educate medical students and practicing doctors better about the rational use of medications, that we can reduce overprescribing. A lot of university-based education was contaminated with messages from pharmaceutical companies, so I thought that if our provincial government gave us funding for independent education, we could improve teaching and that would make a significant contribution.

Looking back, it seems incredibly naive to think that we could be such wonderful teachers to overcome the flood of propaganda from pharma. But we did establish a small group, which was the Therapeutics Initiative. This was in the 1990s, at the dawn of evidence-based medicine. Suddenly many people began looking at real scientific evidence about what drugs were doing, and challenging the relevance of surrogate outcomes, such as changes in blood pressure, blood glucose or A1C, bone density, or cholesterol.

At the same time, the BC government realized they were losing too much money covering drugs that were too expensive and weren’t effective. They wanted us to do an non-conflicted assessment of new drugs. We discovered things that no one else was noticing about new drugs. For example, we found that Alzheimer’s medications only improved clinical outcomes by 1 point on a 30-point mental state examination scale, but also caused adverse events like falls, incontinence, and weight loss. So the government said they wouldn’t pay for it. That drove the industry crazy.

So doing evidence-based assessments of new drugs and giving advice about evidence to the payer ended up being more important than our educational goal. But we’re still working to educate as well.

What common assumptions about medications should clinicians and patients be questioning?

I like to say that our job as clinicians is to liberate people from ill health and move back toward good health. We often don’t have the power to stop cancer, we can’t stop dementia, and we can’t stop aging. But if I can liberate people from substances that are harming them, that’s an extremely gratifying feeling.

We have to start by questioning the notion that everybody “needs” the drugs they are getting. Language is extremely powerful in medicine. When it comes to medications, we use a lot of military metaphors: “We’re going to treat this aggressively,” “We will hit this with everything we’ve got,” etc. We also use language without a lot of nuance, like telling patients “you will benefit” from this drug, when in reality there is only a slight probability that they will benefit.

Another common assumption to question is that taking a large number of medications is normal. Doctors are conditioned to think this is normal, because it is common to see. But older people know that fifty years ago, we weren’t taking that many medications. Blister packs for pills didn’t even exist until 20 years ago.

And we have to realize that most patients don’t actually want to be on so many drugs. Patients taking many drugs have an enormous burden of time, and some have a financial burden as well. When you ask patients how they feel about it, they don’t necessarily see this as normal. They are conditioned by doctors saying, “You will need this the rest of your life.” But when you get older, how does anyone know what you really “need”?

How do you discuss the potential benefits and harms of medications with patients?

You have to look at the evidence to be able to talk about the benefits and harms. What is the probability that this patient will benefit from a drug? There are very few treatments that 100% of patients benefit from all the time.  Oxygen for severe Covid pneumonia might be one. But for most drugs, the chance that patients will benefit is closer to 1%-2%. For people who had a heart attack, statins will help 5% of them over five years avoid a subsequent heart attack. For someone with dementia, the calculation may be different. It’s important to recognize that a medication that has a small or modest benefit on a population level might not be right for an individual patient.

How do you recognize medication overload?

For the last ten years, I’ve been working on how to examine patients, to recognize potential medication side effects. What I try to do is get students to describe a patient politely and accurately in real time in the clinic setting (or at the bedside), similar to how we do rounds. Here are few of the things I look during an interview, which could indicate a drug side effect:

• Is this person alert?  How does that compare with how alert they should be?
• Does the person demonstrate complete facial expression? Can they smile and frown?
• Can they make eye contact?
• Are there unusual movements or tics that weren’t present before?
• Is their speech articulate or slurred?
• If the speech is slurred, is it dry mouth (anticholinergic effect)?  One can test this by having the person take a sip of any liquid and swish it around. Then speak again.

It also helps to do basic physical exercises with patients. If a person is taking a beta-blocker, they may feel loss of energy. I will take them down and up the stairs once. If their heart rate goes up and blood pressure goes up, it means they’re not profoundly blocked. Alpha-blockers can make blood pressure drop down when a person stands, and they could faint or fall, so I assess blood pressure both when the patient is lying down and standing up.

You don’t have to be a professional to do all these things. You just need to know about the drug side effects, which often can be found online as well as the drug insert. And family members are usually best positioned to notice drug side effects, because they may see a change and think, “Mom or Dad didn’t seem to be like that before.” But they may not feel empowered to talk about these changes with the clinician, or they had not been warned about side effects before. Patients and families can help prevent adverse drug events by keeping a lookout for new symptoms — but it will only work if the clinician is willing to listen.