Pharmacists on the front line of polypharmacy
Monday, April 25, 2016
More patients are on multiple-drug regimens than ever before, and the numbers are climbing. In a study published in the March edition of JAMA Internal Medicine, the concurrent use of at least five medications in older adults increased from about 30 percent to 35 percent from 2006 to 2011. Additionally, the use of dietary supplements rose from about 52 percent to 64 percent during the same time.
The numbers corroborate with what pharmacists working on the front lines of patient care are seeing every day, and managing these patients is becoming increasingly difficult. At the same time, the pharmacist is in an ideal position (albeit with many challenges) to help oversee the medication therapies of these patients, which often include regimens from multiple prescribers as well as over-the-counter (OTC) supplements and drugs.
Physicians largely agree that the help of a pharmacist is valuable here.
"We need a team approach to monitoring medication effectiveness and adverse effects," geriatrician Michael Steinman, M.D., wrote in a JAMA commentary on the subject. "Pharmacists, nurses and other healthcare professionals can be creatively engaged to systematize the process of medication monitoring and follow-up, complementing the role of the physician."
I consider myself to be a front-line pharmacist. Like many others, I stand face-to-face with my patients and personally verify the accuracy and appropriateness of their prescribed therapies. My perspective is that of a dispensing pharmacist who appreciates the challenges we encounter in this profession, but also sees the opportunity to engage patients and providers in a way that improves patient outcomes.
What can we do? Here are five things to consider:
1. Remember it's not all bad
We as pharmacists need to remember that not all polypharmacy is bad medicine. We hear negative press all the time about patients on five or more medications and the risks of drug interactions and so on. This is a real concern.
But sometimes polypharmacy is exactly what our patient needs. For example, my patient with epilepsy, COPD and diabetes is on a lot of medications. But there is not a single one either her or I would want to see stopped merely for the sake of reducing the number of prescriptions she takes.
2. Maintain patient profiles
It is time for pharmacies and pharmacists to embrace a "full medication profile" standard for all patients. Few pharmacy software systems have the capacity to keep an up-to-date medication list that also includes all nonprescribed OTC therapies or prescriptions filled elsewhere. This needs to change.
And, alongside this development, payers need to reimburse pharmacies for such services accordingly.
3. Screen better
Drug interaction screening and interventions need to improve. In a recently published New York Times article on polypharmacy, pharmacist Dima Qato noted, "We're not paying attention to the interaction and safety of multiple medications ... this is a major public health problem."
I know from personal experience that we are catching lots of important drug interactions, but we can certainly do better. Thorough drug-interaction screening takes time, as does the process of talking with the patient to assess whether any of the potential interactions might be going on.
4. Encourage MTM reviews
It is time for all health plans to encourage MTM reviews for patients on multiple drug regimens and chronic conditions. While senior patients may be the most at risk, plenty of younger patients are on multiple-drug regimens as well, especially if you consider the inclusion of OTC medications and supplements.
5. Start small
As pharmacists on the front line with many demands upon our time, we should strive for a "do for one patient what you would like to do for all patients" approach. You simply cannot, in most settings, provide the in-depth personal level of research and assistance to every patient on multiple medications.
But can we do it for one patient today?
I had a personal call yesterday from a doctor. He thanked me for the extra time I had put into helping his patient. The patient wasn't actually a polypharmacy concern, but had other financial needs and compliance opportunities, and I had put in a couple calls to this patient over the month.
Altogether, I probably invested 10 minutes of my time over the month to helping this patient. Not a lot. But it made a difference. He told his doctor, and his doctor called me.
The front-line pharmacist has my sympathy — this is an incredibly complex setting in which to try and offer comprehensive services to patients on multiple medications.
The phones are ringing, the printer jams, the drive-through line is piling up, and someone called in sick. In the midst of all this (and often much more), we encounter a complex drug profile and a patient who needs our help. This is real-life front-line pharmacy. These are real patients.
Polypharmacy is a fact of life, and we as pharmacists have a duty and opportunity to help manage this challenge effectively.
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