When Margaret Herlth wakes up in the morning, 13 prescription drugs like Coumadin and Advair and two over-the-counter supplements are as much a part of her routine as a first cup of coffee. That's a lot of pills, but not an unusual number for an 80-year-old with serious health problems, including cardiovascular disease and breathing difficulties.
"They do make me feel better if I take them," says Herlth, who lives in Southwest Baltimore. "I've been in and out of the hospital so many times. Each time they give me new pills, but they never take any away."
These days, if you're elderly, a medicine cabinet full of prescription drugs is par for the course. But even relatively young, healthy adults may be prescribed medicine as a pre-emptive strike to lower their bad cholesterol and blood pressure, to deal with a touch of arthritis, to ward off osteoporosis, to stop the symptoms of seasonal allergies or to fight depression.
Many of those who grumble about being prescribed too many drugs are adding to the list by taking herbal supplements. They also reach for the Advil bottle at the first sign of a headache and chew antacids when they get heartburn.
This month, the federal Centers for Disease Control and Prevention reported its latest data on prescription drug use. The agency estimates that nearly half of all Americans take at least one prescription drug and one in six takes at least three. Over the past decade, the percentage of people taking one or more prescription medicines has increased from 39 percent to 44 percent.
We are a medicated society, but are we an overmedicated society?
Pharmaceutical breakthroughs are obviously a major reason life expectancy has increased to a record 77.3 years at birth in 2002, the most recent data available. But the market is also filled with what critics call "me too" drugs. These are drugs people assume are more effective because they are new, but may not perform any better than older, perhaps safer drugs. Doctors and patients don't always have an easy time sorting out which are which.
Americans are living longer because of the many different medications they take, but that creates its own problems.
"One of the issues we have to deal with is 'polypharmacy,' " says Dr. Stuart Bell, an internist and vice president of medical affairs at Union Memorial Hospital. This is the term the medical profession uses to describe the taking of a number of drugs at the same time -- drugs that can have unwanted interactions.
"We've identified it as an actual problem, like hypertension," Bell says. "Often there's a rationale for each of these medications, so these are not easy decisions."
Not only are we using more drugs, but they are more expensive than they used to be. The cost of prescription medicines rose 5 percent in 2002, says the recently released CDC report, but because people are taking more drugs, spending increased 15.3 percent. Costs continue to rise, but the rate is slowing, says the Pharmaceutical Research and Manufacturers of America, the industry's trade group, reporting that prescription drug prices increased by 3.1 percent in 2003.
Relying more on drugs
There isn't one simple answer as to why Americans are taking more medicines. The most obvious reason is that baby boomers are getting older, and therefore a large bulge of the population is dealing with problems like arthritic knees and high blood pressure. Older patients may go to several physicians, each prescribing medication.
"As people get older, the risk of side effects goes up," says Dr. John Meyerhoff, a rheumatologist at Sinai Hospital. "It's a balance between physicians overmedicating for relatively minor complaints and giving medicines for conditions for which we have effective solutions."
But increased drug use can't be blamed just on the graying of America. Most notably, as a society we're getting fatter. Last month, the U.S. surgeon general reported that 61 percent of adults were overweight or obese, leading to an estimated 300,000 deaths a year. Doctors may treat obesity and obesity-related conditions with drugs if eating less and exercising more proves too difficult for patients.
For some patients, medication may be the only answer. For others -- why skip the Krispy Kreme or walk 30 or more minutes a day, as the surgeon general has recommended, if you can pop a pill or two instead?
Patients at St. Joseph who are diagnosed with pre-diabetes are given three months to improve their condition by changing their diet and exercising more. If that doesn't work, their physician may then start drugs.
Pre-diabetes is just one of several preconditions identified in the past few years that have resulted in more people taking more medication -- potentially for the rest of their lives.
Last year, the National Heart, Lung and Blood Institute named a new precondition, prehypertension, which put 45 million Americans whose blood pressure readings used to be considered acceptable outside the normal range.
In July, the federal government issued guidelines that added 7 million Americans to the 36 million already being urged to take medication to lower their LDL, or "bad" cholesterol. The new guidelines for LDL were set so low it would be difficult for most people to achieve them without the help of prescription drugs.
Labeling these preconditions, says Dr. Robert Blumenthal, a Johns Hopkins cardiologist and a spokesman for the American Heart Association, "is a good way to get people's attention. "
Blumenthal always tries to get his patients to make lifestyle changes first -- lose weight, stop smoking, start exercising. But, he says, "my philosophy is it's good news we do have good medicines that can help the quality of life."
Part of the increase of prescription drug use can be attributed to the fact that pharmaceutical companies do a good job of marketing their products to doctors and patients alike. Sometimes they are a physician's primary source of information about new products. It's difficult for physicians to be knowledgeable about every new drug, even with continuing education requirements and the help of professional societies.
"We don't want the pharmaceutical people to be the main source of information," says Blumenthal, "but sometimes it's hard for doctors to keep up."
These days, if a physician isn't quick to prescribe, the patient may well ask for a drug by its brand name.
Meyerhoff, the Sinai rheumatologist, has found that simple leg lifts to strengthen the quadriceps can work as well as anti-inflammatories to reduce knee pain caused by osteoarthritis. But it takes more time to teach patients the exercise -- time busy primary care physicians may not have -- and patients may not be willing to continue the exercise indefinitely. It's easier for them to ask for an arthritis drug they've seen advertised like Celebrex.
Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, says that the TV and print ads for prescription drugs have one positive effect: They get patients into the doctor's office.
"There have been a number of studies that show direct-to-consumer ads are a source of education," he says. "The discussion of symptoms has compelled a number of patients to have medical checkups they should have received earlier."
In 1997, the FDA eased restrictions and allowed pharmaceutical companies to market directly to the consumer. The companies spend billions of dollars in the process, which has almost certainly resulted in more drugs being prescribed, says Larry Sasich, pharmacist and research analyst for the consumer advocacy group Public Citizen.
The recent Vioxx controversy, in which the heavily advertised drug was withdrawn because of safety concerns, may make consumers more skeptical of new drugs and less likely to ask for them over older drugs. Doctors say Vioxx was never shown to be a better anti-inflammatory than other medicines that had been on the market for years. Its selling points were that it was easier on the stomach and it only needed to be taken once a day -- important but not worth the increased risk of heart attack or stroke.
Critics of pharmaceutical companies warn that patients shouldn't be taking a new drug unless there's documented evidence that it's better than one already on the market.
"Since the 1990s, 13 new drugs have been approved and then withdrawn for safety reasons," says Sasich. "These drugs were not unique in any way."
He says he doesn't take a drug unless it's been available for at least seven years. "Within seven years, half of all new drugs come off the market or need expanded safety warnings," he says.
Even those who don't take such an adversarial position are cautious with the newest drugs. "I won't prescribe a new drug for six months," says Bell. "Often severe but infrequent side effects show up."
Relationship with doctor
With direct-to-consumer marketing of drugs and the instant availability of medical information on the Internet, the doctor-patient relationship has changed, with people taking a more active role in their treatment. Health care professionals see this as a good thing, but it may not go far enough.
Cannon of St. Joseph urges patients periodically to review their medications with their physicians. One of the people she saw for counseling had been taking prednisone, a steroid, for 10 years. No one knew why. "You have to ask why you're taking them, and see if you can get off them," she says.
One of the biggest problems with our medicated society may not be that we take too many drugs, but that we don't take the ones we should be taking. Before former President Bill Clinton had emergency bypass surgery in September, he had stopped taking his cholesterol-lowering drug because he felt he had his condition under control, points out James Rybacki, a clinical pharmacist and author of The Essential Guide to Prescription Drugs 2005 (HarperCollins, 2004).
"Over time, people tend to stop taking medicines," Rybacki says. In one study, two-thirds of those surveyed underused or stopped their medication and didn't tell their doctors. "Fifty percent of people fail to take drugs correctly over time," he says.
Sometimes it's because they can't afford the drugs. Sometimes it's because of a perceived lack of benefit for a chronic condition without symptoms, such as high blood pressure. Sometimes it's because of "pill burden."
Like Margaret Herlth, who has been prescribed 13 medicines, people tend not to be good about taking multiple drugs for an indefinite period. That's why pharmaceutical companies are developing combination drugs like Caduet, which treats both abnormal cholesterol and high blood pressure.
"These are safe, good medicines," says Blumenthal, "and they help compliance."
Too many pills?
James Rybacki, a clinical pharmacist who lives in Easton and is author of The Essential Guide to Prescription Drugs 2005, has this advice for patients worried about taking too many prescription drugs:
* Ask questions. If you don't get them answered, stay in the doctor's office until you do.
* Tell your doctor if you're worried about "pill burden." Say, for instance, "I'm not sure I can take pills three times a day." There may be alternatives.
* Ask for specific goals for medications, and what the time frame is.
* Tell your doctor about all drugs you're taking, including over-the-counter, herbal remedies, nutritional supplements, alcohol and recreational drugs. There could be unwanted interactions. Some herbal extracts, for instance, can blunt the effectiveness of a prescription drug.
* Ask if this medicine is the best balance of price and outcome.
* If money is a problem, visit the Web site www.helpingpatients.org, which lists programs that can help with costs. Other useful sites online: www.needymeds.com, www.rxassist.org and www.medicare.org (click on "online databases" and then "drug search").