Researchers Address Dangers of Polypharmacy and Inappropriate Medication Use

A new special issue brings together articles exploring the harmful effects of simultaneous multiple medication use.

Ayurdhi Dhar, PhD
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In a foreword to Therapeutic Advances in Drug Safety’s special issue, “The role of de-prescribing in polypharmacy and inappropriate medication use,” authors Dee Mangin of McMaster University and Doron Garfinkel of Israel Cancer Association, address the insidious and widespread effects of inappropriate medication use and polypharmacy (IMUP).

The authors write that the harmful effects of IMUP are well documented and include detrimental influences on physical and mental well-being, the burden of expensive treatments, and problems in mobility. They state that the problem with multiple medication use can be described as “the point when the burden of treatment outweighs the capacity to benefit.”

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The harms of polypharmacy among psychiatric patients are well-known, and there is a growing critique of these practices. Studies have linked polypharmacy to higher mortality rates. More recently, it has been associated with cognitive decline in the elderly population, and this scrutiny has reached mainstream media outlets like The New York Times.

These effects are even more evident when it comes to antipsychotic medication, which has been associated with higher mortality in patients, often due to neuroleptic malignant syndrome. Despite the availability of this knowledge and the presence of guidelines that warn against the simultaneous use of different antipsychotics, studies still show that patients are regularly sent home with multiple prescriptions.

It is not only research that has cautioned medical professionals of the dangers of IMUP, but patients have also shared harrowing tales of their experience on multiple psychiatric drugs.

As the emphasis on deprescribing grows, the authors of this foreword worry that the response from the medical community has been less than enthusiastic. This is troubling, especially when studies show that in the older population, one in five prescriptions is inappropriate. They write:

“Older adults prescribed more medications are likely to be hospitalized for an adverse drug reaction. Moreover, adverse drug events account for more morbidity and mortality than most chronic diseases, with death rates higher than many common cancers.”

Mangin and Garfinkel note that the problems related to polypharmacy and inappropriate medication are so well-known among medical professionals that it is often called an “iatrogenic epidemic.” Yet it has remained invisible and unaddressed, a form of “systematic blindness.” As a result, IMUP is often associated with both over-diagnosis and over-treatment.

The authors believe that practitioners feel immense anxiety when faced with the scope of the problem, and both clinicians and patients find it difficult to accept that medicines that once helped them can turn harmful. They suggest that a paradigm shift is needed to address its intensity and spread and provide solutions like interdisciplinary communication, subverting existing ways of thinking about treatment, and appreciating the input of patients as experts of their bodies and lives.

The special collection articles chart the history of these problems and propose ways to address them. They call for attention to both reducing current medications and increasing awareness around prevention. The authors insist that this emphasis on prevention is a critical way to address the problem at a deep and systemic level. Thus both clinicians and patients must be educated about de-prescription. At the same time, studies show that educating psychiatrists and patients about IMUP and giving them better prescription guidelines tends to have little effect on prescription patterns.

The massive scope and depth of this problem are evident in the fact that there is a global community of physicians who have contributed to this special issue, and who are intent on solving it. They aim to draw attention back to patients by listening to their concerns, priorities, and experience with multiple medications. Additionally, the authors hope that increased awareness will help flag dangerous medications that have higher chances of being prescribed inappropriately.

The articles in the special collection address issues like initiating shared decision making with patients, a critique of the single disease approach and the ways it contributes to health inequities for vulnerable populations, and the importance of de-prescription conversations with patients.

Despite their efforts, Mangin and Garfinkel admit that the current system of treatment is resistant to de-prescribing. They write:

“Embedding these in routine systems of care…is challenging. One of the papers by Okeowo et. al. highlights just how skewed current systems are towards initiating and multiplying treatments with an inexorable progression of cumulative complexity. They found few if any support for thinking about the appropriateness of stopping, let alone when and how to do so.”

Despite these problems, other studies in the special collection have shown promise with inpatient programs that focus on de-prescription before patients are sent home. Others point to the benefits of the same in community settings.

To counter this resistance, the special collection issue attempts to come up with novel and nuanced solutions like spreading awareness about IMUP, focusing on prevention, patient advocacy, and other tools that might be beneficial to physicians who want to de-prescribe in a system that is not conducive to change. It also focuses on problems like legacy prescriptions, which is when a medication meant for a short duration is then continued indefinitely.

 

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Mangin, D. & Garfinkel, D.  (2019). Foreword to the first special collection: Addressing the invisible iatrogenic epidemic: the role of deprescribing in polypharmacy and inappropriate medication use. Therapeutic Advances in Drug Safety (10), 1-5. (Link)

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Ayurdhi Dhar, PhD
MIA Research News Team: Ayurdhi Dhar is assistant professor of psychology at Mount Mary University. She is the author of Madness and Subjectivity: A Cross-Cultural Examination of Psychosis in the West and India (to be released in September 2019). Her research interests include the relation between schizophrenia and immigration, discursive practices sustaining the concept of mental illness, and critiques of acontextual and ahistorical forms of knowledge.

14 COMMENTS

  1. INITIAL BATTERING NOV 1980.
    The “medications” I was given Every Day for two months were: 100 mg Haloperidol per day; 1000 mg of Largactil per day; 50 mg of modecate per month; and ECT and Lithium towards the end of my stay:-

    Daily Drugs Chart example 1
    https://drive.google.com/file/d/1R20LgbJwIDqd0VTp755vTBjeEI5hZDaD/view?usp=drivesdk

    Daily Drugs Chart example 2
    https://drive.google.com/file/d/1sJT81-n1RsZ_bJ4g-dA8P20_wHBEkPKd/view?usp=drivesd

    DOSAGE EQUIVALENTS
    (comparison-of-the-defined-daily-dose-and-chlorpromazine-equivalent-methods-in-antipsychotic-drug-utilization-in-six-asia.pdf)

    Haloperidol 100mg is on average equivalent to 4,250mg of Chloropromazine (Thorazine).

    My Polypharmacy Cocktail would have been roughly equivalent to 6,000 mg of Thorazine per DAY for 2 MONTHS, after which I was a PHYSICAL MESS and have never fully recovered.

    MAD
    But Psychologist Dr Richard Bentall went MAD on a lot less (of the same drug Haloperidol)

    https://drive.google.com/file/d/1IlzqwNraKOFLxIU7TjC2tCMTh1fB6tu4/view?usp=drivesdk

    The Study (above) was undertaken by Dr David Healy, who had witnessed (in his training) my recovery as a result of carefully tapering from “my medication”.

    DR HEALY LETTER
    https://drive.google.com/file/d/101SjCQ-o4-_Qhm7o9dh24QQ6QKgTlkWj/view?usp=drivesdk

    SLOW TAPER
    By 1990 I had tapered down to 25mg per DAY of Thioradazine equivalent to 25mg of Chloropromazine/Thorazine which would be LESS than .05% of what I had consumed per DAY in hospital in 1980. Thioradazine at 25 mg per DAY would also be equivalent to about 8%of a daily maintenance dose of 300mg Thorazine.

    WHAT HAPPENED
    I had originally returned to London in August of 1980 after spending a number of months living and working in Amsterdam Holland. In London after some contact with the Police my passport was not within my belongings.

    • WHAT HAPPENED Contd.

      I ended up in a Bail Hostel; then in the Maudsley Psychiatric Hospital, and was in November 1980 transferred (door to door) to the Psychiatric Unit at Galway, Southern Ireland.

      AMSTERDAM
      The UK side of the Irish notes contains no mention of Amsterdam. A confused History is provided by the UK accompanying Doctor (on Admission at Galway in November 1980) and written up and signed for by the Admitting Irish Doctor, Dr Fadel. The UK doctor signs nothing.

      In Amsterdam I had been socially acquainted with a Northern Irish Born Again Christian that closely matches the person in the description (below)..

      https://en.m.wikipedia.org/wiki/Kevin_McGrady

      ..who had been concerned about a conversation we were supposed to have had – that I couldn’t place.

      MAUDSLEY PSYCHIATRIC HOSPITAL
      On arrival at the Maudsley Hospital in 1980 I walked through one door and then through another – and then I was in.

      MAUDSLEY “DISCHARGE SUMMARY”
      There exists a handwritten “Discharge Summary” (as described by my Historical Irish Psychiatrist Dr PA Carney – to the Irish Medical Council) from “My” UK Maudsley Psychiatrist in my Irish Notes.

      But this “Discharge Summary” contains NO date of Arrival to the Maudsley Hospital; NO Mental Health Diagnosis; NO identification of the Professional that accompanied me to the hospital; NO evidence of any Admission Procedure; and NO mention of Amsterdam.

      Within the “Summary” “My” UK Psychiatrist does not mention ever having met me, and is very vague on nearly everything, Bar a strong suggestion of suspected Street Drug Taking by me (even in hospital). He says I had consistently denied Street Drug Taking, as I would, as I had never Knowingly or Willingly consumed Street Drugs.

      My Mental Health Experience
      https://www.madintheuk.com/2018/08/a-disorder-for-everyone/#comment-49

    • INITIAL BATTERING NOV 1980.
      The “medications” I was given Every Day for two months were: 100 mg Haloperidol per day; 1000 mg of Largactil per day; 50 mg of modecate per month; and ECT and Lithium towards the end of my stay:-

      Daily Drugs Chart example 1
      https://drive.google.com/file/d/1R20LgbJwIDqd0VTp755vTBjeEI5hZDaD/view?usp=drivesdk

      Daily Drugs Chart example 2
      https://drive.google.com/file/d/1sJT81-n1RsZ_bJ4g-dA8P20_wHBEkPKd/view?usp=drivesd

      DOSAGE EQUIVALENTS
      (comparison-of-the-defined-daily-dose-and-chlorpromazine-equivalent-methods-in-antipsychotic-drug-utilization-in-six-asia.pdf)

      Haloperidol at 100mg is on average equivalent to 4,250mg of Chloropromazine (Thorazine).

      My DAILY Polypharmacy Cocktail would have been roughly equivalent to 6,000 mg of Thorazine per DAY for 2 MONTHS, after which I was a complete PHYSICAL MESS and have never fully recovered.

      MAD
      But Psychologist Dr Richard Bentall went MAD on a lot less (of the same drug Haloperidol)

      https://drive.google.com/file/d/1IlzqwNraKOFLxIU7TjC2tCMTh1fB6tu4/view?usp=drivesdk

      The Study (above) was undertaken by Dr David Healy, who had witnessed (in his training) my recovery as a result of carefully tapering from “my medication”.

      SLOW TAPER
      By 1990 I had tapered down to 25mg per DAY of Thioradazine equivalent to 25mg of Chloropromazine/Thorazine which would be LESS than .05% of what I had consumed per DAY in hospital in 1980. Thioradazine at 25 mg per DAY would also be equivalent to about 8%of a daily maintenance dose of 300mg Thorazine.

      WHAT HAPPENED
      I had originally returned to London in August of 1980 after spending a number of months living and working in Amsterdam Holland. In London after some contact with the Police my passport was not within my belongings.

    • INITIAL BATTERING NOV 1980.
      The “medications” I was given Every Day for two months were: 100 mg Haloperidol per day; 1000 mg of Largactil per day; 50 mg of modecate per month; and ECT and Lithium towards the end of my stay:-

      Daily Drugs Chart example 1
      https://drive.google.com/file/d/1R20LgbJwIDqd0VTp755vTBjeEI5hZDaD/view?usp=drivesdk

      Daily Drugs Chart example 2
      https://drive.google.com/file/d/1sJT81-n1RsZ_bJ4g-dA8P20_wHBEkPKd/view?usp=drivesd

      DOSAGE EQUIVALENTS
      (comparison-of-the-defined-daily-dose-and-chlorpromazine-equivalent-methods-in-antipsychotic-drug-utilization-in-six-asia.pdf)

      Haloperidol at 100mg is on average equivalent to 4,250mg of Chloropromazine (Thorazine).

      My DAILY Polypharmacy Cocktail would have been roughly equivalent to 6,000 mg of Thorazine per DAY for 2 MONTHS, after which I was a complete PHYSICAL MESS and have never fully recovered.

      MAD
      But Psychologist Dr Richard Bentall went MAD on a lot less (of the same drug Haloperidol)

      https://drive.google.com/file/d/1IlzqwNraKOFLxIU7TjC2tCMTh1fB6tu4/view?usp=drivesdk

      SLOW TAPER
      By 1990 I had tapered down to 25mg per DAY of Thioradazine equivalent to 25mg of Chloropromazine/Thorazine which would be LESS than .05% of what I had consumed per DAY in hospital in 1980. Thioradazine at 25 mg per DAY would also be equivalent to about 8%of a daily maintenance dose of 300mg Thorazine.

      WHAT HAPPENED
      I had originally returned to London in August of 1980 after spending a number of months living and working in Amsterdam Holland. In London after some contact with the Police my passport was not within my belongings

  2. Dear Moderator,

    I was putting the above comments together on my mobile while the battery kept running out, and I had difficulty editing them.

    Of the above moderated comments (originally December 6, 2019 at 4:39 pm), I have provided three nearly identical versions. Please take which ever one suits you.

    There’s another two empty comments – please remove them.

    Thanks a lot.

    Fiachra

  3. Dr. Dhar,
    Send Mangin and Garfinkle to Dr. David Healy’s RxISK.org “A Unicorn: Changing a Medical Record” August 2018, 4-part series describing over-diagnoses (adult bipolar-X 3 in U.S., 2004) produced by financial conflict of interest (Dr. listed in “Dollars for Docs” ProPublica), overprescribing (13 drug changes in 9 months=hospital/bradycardia, etc), ‘legacy’ prescriptions and assessments in public and private care (2006 SMI certification by marriage counselor-2013-“We don’t do that anymore”), and 2 NMS-ADR’s (paralysis) that culminated in anaphylaxis, rebound, withdrawal and brain lesions….resulting in 2.5 years of ‘guided’ withdrawal (liability concerns) and a promised vacated ‘lifelong’ bipolar diagnosis……. IF I DIDN’T SUE.

    So much for psychiatric absolutes and integrity. Turns out it’s negotiable.

    Followed by 17 seizures in the ensuing 3 years of ‘clean’, free living and evaluation by Barrows Neurological Institute in Phoenix, Az (“We’re seeing a lot of this…good luck”).

    I think that covers it….Oh, except for the text (I still have ALL of them) from my ‘exit’ doctor asking me out on a date 30 days before my promised release. Ethics, anybody?

    This is the cesspool they are researching.

    Contact me; Emmeline Mead (editor) has my info and this is my release. I’ll name names….. and I have nearly 10 years of records I would love to share for the sake of ‘research’….and according to THEM, I’m rational with a GAF of 75. ‘Normal’ as pie.

    • Good luck with this, Krista. You have all my admiration and respect for speaking up/speaking out.
      If I make it through Cymbalta withdrawal in one piece (the last in a long line of psych drugs over 35 years), I want to speak up about my experience also. So much of it right now is a blur; I remember things in bits and pieces.

      • Would dearly love to find a way to spike the food supply of a couple dozen shrinks with SSRI drugs in therapeutic doses. My guess is out of 30 approximately 5 would develop psychotic mania within a week or two.

        When they find out, remind them that according to their alleged science this reaction means they were Bipolar all along. The drugs just unmasked that condition. Then tell them they’ll have to take cocktails for the rest of their lives. Watch them wriggle out of that. Record the whole thing for social media.

        It would have to be publicly recorded to work. They never play by their own rules. (Whining how lack of government funds is forcing them to commit suicide instead of getting “diagnosed” and “hospitalized” and “treated” for suicidal desires like the rest of us.)

        Public exposure of the profession’s bovine excrement would be great.

  4. “provide solutions like interdisciplinary communication, subverting existing ways of thinking about treatment, and appreciating the input of patients as experts of their bodies and lives.”

    I’m not sure that “interdisciplinary communication” is reliable. All this means is we will talk about it amongst ourselves and pretend to appreciate “patient input”. It is not fixable.
    It has long been recognized as causing harm, it is getting worse not better. If they had any concern, they would not need outside bodies or clients to try and get them to gain insight.
    What we are endlessly doing is trying to convert them. Once beliefs are fixed, this is not doable and ends up forced, with the same uninsightful bunch at the helm.
    No one is psychiatry wants a patient’s input.

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