Prescription-itis: When are too many drugs too many?

I’m a neurologist and I specialize in working with people with multiple sclerosis (MS). Since I am not a surgeon, I am well trained in the use of medications to treat people. Because MS can cause many different symptoms, we often use medications to try to alleviate these symptoms. As a consequence, it’s not unusual for me to see people with MS who are taking a half dozen or more medications to treat various symptoms.  While these medications may be helping people, they also can cause side effects that may be just as troublesome as the symptoms for which they were prescribed.

Let me illustrate the problem with a hypothetical patient. Common symptoms among people with MS include fatigue, depression, insomnia, pain and stiffness or spasticity in their legs. So I meet for the first time our hypothetical patient with MS and she tells me that fatigue is her number one problem. Research indicates that the most effective treatment for MS-related fatigue is exercise and I recommend that she start exercising. But she says she is too tired and busy to exercise. So I prescribe a medication.

A few medications, all of which function as stimulants, have modest benefits in improving fatigue and I prescribe one. She returns in a few weeks and tells me her fatigue is better but the medication interferes with her sleep at night. That is easily solved. I prescribe a medication to help her sleep.

A few months later she reports some depression so I add an anti-depressant. Later she tells me she has some stiffness or spasticity in her legs from the MS that interferes with walking and with her sleep so I add an anti-spasticity medication; one may not work so well, so I  end up prescribing two anti-spasticity drugs.

Finally, she develops some distressing burning pain in her legs that bothers her at night so I add another medication for “neuropathic pain.”  Now she is on six medications that all enter her brain and affect brain chemicals and function. Perhaps not surprisingly, she may begin to complain about difficulties with concentration and remembering things.  So I think about prescribing yet another medication to help her cognition. A year later, she is on several medications and may not even remember the purpose of each one or be certain whether they are helping her.

Polypharmacy — the use of multiple medications by a patient — is a big problem not just in treating people with MS but in treating many chronic illnesses.  So how can doctors and patients work together to make sure whatever medications people are taking are necessary?

First, understand why your doctor is prescribing a medication. If it is to help prevent a serious problem, like a stroke, then it is much more important to take that medication then if it is being prescribed to help control a symptom. All of the medications prescribed for our hypothetical patient were just to help with symptoms and were going to do nothing to prevent the patient’s MS from worsening. Symptomatic medications are optional; if they don’t help the symptom or they cause more problems than the symptoms, don’t take them.

Second, understand why your doctor is prescribing a medication and write it down. If it is to control your blood pressure so you can reduce your risk of stroke, you should know that. If it is to help your spasticity, you should not only know that but you should be able to determine whether it is helping you. The positive effects should be obvious in your day-to-day life.

Third, ask your doctor whether there are non-drug approaches that you can pursue and if there are, do so.  If your doctor says that your blood pressure would be under better control if you lost 50 pounds and exercised regularly, get on a weight reduction and exercise program. Doctors and their patients too often opt for the easy way out (taking a pill) when we would all be better off if we changed our lifestyle and ate right, exercised and managed stress.

Finally, periodically review the medications you are taking with your doctor. Maybe you don’t need that anti-depressant any more. Maybe you don’t need to be taking two medications for the same symptom. If you are on multiple medications, chances are you can find at least one or two that you no longer need.

Medications can do wonderful things. But too much of a good thing is bad and too many medications can cause problems.

Dennis Bourdette, M.D.
Professor and Chair, Department of Neurology
OHSU Brain Institute

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Comments

  1. Good article. I wonder about my Ms drugs, only 3, and future medications, as my Ms progresses

  2. I agree that side effects can be bothersome, no matter what the medication. Given that we are offered treatments for the the progression of the disease itself drugs that have modest efficacy at most for only some of us, we do have to have some relief. I have no problem with being on four daily meds., including the DMD, and two PRN. I do homework myself before agreeing to begin a medication or therapy course. I also report side effects and reactions promptly that are intolerable. Patients who fail to do so and specialists who fail to remain vigilant regarding over-medicating or inapproriately medicating do have a jointly shared responsibility for the failure. I suspect, sadly, this will remain the case until the day that highly effective treatments are found to stop the progression of this very complicated, incredibly challenging disease.

  3. I so agree I was on more medicines then you can count and my general doctor was horrified. She asked me what is troubling you the most and I said PAIN. Since I have seizures from Tegretol and Neurontin those were a no go. My memory was not great with pain pills so she prescribed a low dose of Fentenyl patch 4 years ago. What a huge difference, I can do Yoga now have dropped 55 pounds and can now sleep. Same dose for 4 years never adjusted and 6 less pills a day. Sometimes it’s so simple, but all the specialists just choose to make it difficult!

  4. As always, moderation is key. The ironic thing about the article to me would be if she forced herself to exercise regularly, she may have circumvented a lot of the medicines…..
    I know it helps me….

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