Modern medications can be miracles that save us or our loved ones. But they come with complexities.
No medicine goes straight to its desired target and does just what you or your doctor want it to do. Almost all medicines have over a thousand actions, many of which we still do not know about or understand. The desired action may not even be the most common thing your drug does.
When our lives are threatened, and it is worth taking some risks, most all of us will, without thinking, take the risks that come with taking one drug for the benefit of the treatment. Even if things go wrong, the human body is great at bouncing back.
The calculations we need to make become more complicated when we are faced with taking several medicines at the same time and taking them for longer periods of time or indefinitely.
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Understanding Medications Research Limitations
Everything we know about drugs comes from seeing what one drug does, for short periods of time, in clinical practice or in controlled trials. It has only recently been recognized that, in the case of people on several drugs at the same time, we simply do not know for instance which of the multiple drugs they may be on that can cause a fall, for example.
In addition to drugs that can all cause falls by making us dizzy or dropping our blood pressure, taking several drugs together can lead to interactions. From blood levels, to nausea, there are countless side effects, some of which are still unknown or unresearched.
Each Person Is Unique
To add to that confusion, a person’s unique physiology will also contribute to how the body reacts. The technical term for studying this phenomenon is “pharmacokinetics.” Researchers use four main topics to examine in this field, including: absorption, distribution, metabolism, and excretion (ADME).
Because some of us also have genes that break down certain drugs very slowly, even if that is the only one we are taking, or the opposite, very quickly, such studies can be limited in addressing risk over benefit.
An Age Factor
There are other factors for us to take into account as we age, too. The clinical trials of drugs have rarely been done on older adults. They are usually done on young people. This means that we may effectively end up on higher doses of drugs if we take the dose that is right for a younger person. Women may also need to adjust doses that are set for younger men.
Many factors contribute to your individual reaction to medication.
Combining Different Medications
In addition, in the presence of other drugs, some drugs can do things they never do when given on their own. The technical term for this is pharmacodynamics. Added to that, some of us are just plain wired differently so that a drug that slows a heart rate in me might increase it in you.
Your doctor will not know about some of the things going on in you. But we do not do trials of drugs in people who are on multiple other drugs, so you may be the first case of something your doctor has come across.
Studying Polypharmacy
With so many variables, not to mention the uniqueness of each person’s reactions, it is clear that the research of drugs and their interactions and side effects has a long way to go. There have been some notable progressions in recent years.
What Is Polypharmacy?
It is only in the last decade that we have seriously begun to take polypharmacy into account – this is the problem of being on three or more drugs every day of the year.
There are several factors that lead to polypharmacy. Let’s explore some of those most common issues.
Medicating Our Risk Factors
One is that a large proportion of the drugs we now take are not to treat an acute illness like pneumonia that could kill us, but, instead aim to treat what are called risk factors – matters like raised blood pressure, high cholesterol, or bone-thinning.
When we treat a risk factor, we are giving a prescription drug to a healthy person. Prescription drugs are not vitamins. By treating risks with prescription drugs, we might save the life of one healthy person in 100, but at the cost of causing problems to the other 99.
Bodies Differ as They Age
The trials that showed we could help 1% of people were done on younger people. Using such data to set the “correct” level for blood pressure or cholesterol accordingly means it was right for those young people, but not per se for everyone. As we get older, some increase in blood pressure is normal and healthy, and the same is true for cholesterol.
As we get older, some bone thinning is inevitable. This can be handled by keeping fit. We have drugs that can thicken bones. There are good grounds to think that some bone-thinning in a fit person is less hazardous than abnormally thickened bones in an unfit person.
Prescription Cascades
Prescribing cascades are another trigger to polypharmacy. Many drugs like proton-pump inhibitors (PPIs) for acid reflux, for example, can lead to anxiety which then gets treated with other drugs, which may cause further problems that lead to further treatment. It becomes a vicious cycle. It is always worth looking back through a drug history to see if one drug might have led to another.
Legacy Prescriptions
Legacy prescribing can lead to polypharmacy. Many drugs like PPIs or antidepressants are only supposed to be given for a short period of time. But when they work well, sometimes this leads to the prescription being continued for much longer than is recommended.
Many patients remain on such medications for years. Often, even after switching doctors or providers, the medications are just continued as a matter of routine. The patient does not question it, and a doctor may not take the time to analyze it.
Each Medication Is Different
Another factor is that not all drugs are the same. For example, antidepressants, antihypertensive, or anti-diabetic drugs are grouped into categories, but are not all the same. Some drugs in what seem to be the same class of drugs work in very different ways, only one of which may be right for us.
If we have raised blood pressure, for example, we may be put on four different drugs, one after another, with none working very well until, all of a sudden, the fourth seems to work well. This may happen because the fourth one was the right drug for us and would have settled things if we had been given it first. But often the system seems to think we need all four drugs, and leaves us on all four, rather than stopping the first three that are not working – but will still be doing things to us that it might be better if they were not.
This is true of psychotropic drugs given for nervous problems, drugs for diabetes, for asthma, and for most medical problems.
Habit-Forming Medications
A final contributor to polypharmacy is the drugs we get put on that can be hard to stop. This is most clearly true for psychotropic drugs, which don’t fix anything in us, but rather tide us through problems. When the crisis has cleared, we can have great difficulties stopping these drugs. This might not be a problem in the short term, but later, when we need to be on less drugs to make way for something we need to take to save our lives, it may become a very real problem.
How You Make a Difference
There are so many challenges to knowing all the true impacts of our medications. Clearly, it is an imperfect science, to say the least.
There is one saving grace in this – you. Your sense of what might now be going on in your body is the most sophisticated scientific instrument we have. There can be all sorts of effects and interactions happening that we know nothing about, but, if they aren’t causing you an obvious problem, we may be able to ignore them.
You are the “canary in the coal mine,” so to speak, or the one who is most likely to be the first to detect that something is not right. Without your individual input, these interactions may go unnoticed, undocumented, or unresearched.
Speak up! Advocate for yourself. Tell your doctor about how you are feeling. Be honest about changes in your overall health.
Keep Track of Side Effects of Your Medications
If you are trying to find the right medicine for you, or if new symptoms seem to come out of nowhere, it is a great idea to keep track of your daily lifestyle. Sometimes, the simple act of writing down your experiences can help you more clearly explain them to your doctor.
Using a simple symptom tracker can give you a place to track such changes, and, in addition, give you a written record to discuss with your health care provider.
Always Be Honest
Another wise tip is to always keep track of any and all medications you take each day. This should include over-the-counter treatments, herbal remedies, and supplements, too. Your doctor cannot fully understand interactions if you are not disclosing all of the factors.
Much like the side effects tracker, noting impacts such as your common diet, the amount of exercise you do, your alcohol or smoking habits, or the use of illicit drugs can also help your doctor (and you!) to narrow down the source of any unwanted side effects, interactions, and efficacy.
David Healy, MD, FRCPsych, is a professor in the department of Family Medicine at McMaster University in Hamilton, Canada. He’s also the author of Shipwreck of the Singular.
