The Perils of Polypharmacy

Happy New Year. It’s great to be back in the swing of things.

Over the Christmas break, I caught up with a ton of reading, and one of those pieces—a recent investigation by the Chicago Tribune—got me thinking about a critical, if rarely discussed, link in our healthcare chain: the neighborhood pharmacy.

A Trib reporting team tested 255 Chicago-area pharmacies to see how many druggists would (without warning customers) dispense pairs of medicines that had potentially dangerous interactions when taken together. The short answer? Fifty-two percent of them. “In test after test,” the reporters wrote, pharmacists “failed to catch combinations that could trigger a stroke, result in kidney failure, deprive the body of oxygen or lead to unexpected pregnancy with a risk of birth defects.”

It’s a story that sheds light on a genuine problem: In an age of rampant, promiscuous polypharmacy, many of us are just one unfortunate prescription away from an ER visit. Unfortunately, the story misses the boat on some of the main causes (though I’ll get to those in a bit).

First, the drug–drug interaction (DDI) issue. We are—how shall I put this?—a nation of pill poppers: a hardscrabble citizenry who stand firm in the face of terror, but who, at the slightest sniffle, will storm the doctor’s office to demand a Z-Pak. According to the CDC, more than a fifth of Americans (21.8%) took three or more prescription medicines over the past month, and nearly 11% used five or more—figures that are significantly higher than they were even at the start of the previous decade. Throw in over-the-counter nostrums and the complexity of our daily drug diet grows ever more.

With that many folks taking multiple meds—and with a projected 100,000 or more DDIs possible among the drugs we have in the current pharmaceutical armamentarium—cross-reactions are bound to arise with startling frequency.

And that’s precisely the problem. They come up so frequently—and, whether serious or not, are flagged with such regularity by the pharmacists’ clinical decision-support software—that they often lead to “alert fatigue.” As academic researchers at the University of Arizona’s College of Pharmacy describe it: “Too many intrusive alerts are mentally draining and time-consuming, and result in providers ignoring both relevant and irrelevant warnings.”

Pharmacists—and full disclosure, I’ve been good friends with a bunch for years—have been using such computerized drug-interaction alert systems since the 1970s. (They may well be the earliest soldiers in the digital health revolution.) And their experience with alert fatigue—particularly when the warnings are non-specific or inconclusive (or inaccurate)—is an important consideration for anyone designing new digital health systems and applications today.

Problem Two is that pharmacists are, too often, inheriting the inappropriate choices from physicians, who are actually prescribing the drugs. Physicians have the responsibility of asking patients what other medications they might be taking—and, yes, like pharmacists, they have applications (called Computerized Provider Order Entry) that warn of potentially dangerous interactions. And yup, they override them, too. With abandon, it seems. In 17 different studies that examined the issue, according to one review, the lowest estimate had physicians overriding their drug safety alerts in 49% of cases. (The high estimate was 96%.)

But Problem Three is the biggest and thorniest of all: Our health system is squeezing pharmacists hard—and, if we continue in the same vein, we might possibly squeeze them out of their role as “frontline” care-givers altogether. Gross margins and reimbursement rates for pharmacists have been shrinking for years while the cost and regulatory burden of doing business have risen sharply. It’s a particularly hard slog for independent pharmacies (more than 80% of which are in communities of 50,000 people or less), which often try to make ends meet (and compete with the big chains) by filling more prescriptions at a faster pace with fewer pharmacists. That, of course, is when mistakes happen.

And my guess is, they’ll happen all the more when every one of us is getting our meds from mail order.