Blog post by Bernadette Keefe MD
This lets you access 100 % your brain
A tablet a day and I was limitless
What’s your secret? Medication
A perfect version of ourselves…power…
What would you do??
-Excerpts from “Limitless” The Movie Trailer
Introduction: A pill for every ill.
From teenagers to granny, to the pro-athlete, and everyone in between, the United States is the most drugged nation in the world. A staggering:
70 Million Americans are taking legal mind-altering drugs
Nearly 70% of all Americans are on at least one prescription drug and 20% are on at least five prescription drugs
Americans spent more than 280 billion dollars on prescription drugs in 2013 (total healthcare expenditures in U.S. 3.8 trillion dollars)
Some citizens of the U.S. are forced to turn to the “dark web” to get cheaper prescriptions they cannot afford. This is at personal risk, as these are unregulated medications.
According to the CDC, doctors wrote more than 250 million prescriptions for antidepressants during 2010.
According to the CDC, there is an unintentional drug overdose death in the United States every 19 minutes.
In the United States today, prescription painkillers kill more Americans than heroin and cocaine combined.
The economic impact of medication related problems in the U.S. is estimated at 177.4 billion dollars/year, rivaling the economic impact of Alzheimer’s disease, cancer, diabetes and heart disease.
Adverse effects brought on by the combination of multiple drugs are thought to be responsible for nearly 1/3 of all hospital admissions.
From the 2014 WHO report The Worlds Medicine Situation:
In 1999 the 15% of the world’s population who live in high-income countries purchased and consumed about 90% of total medicines by value. This concentration in the pattern of global sales and consumption has increased over the past 15 years, with the share of the low-income countries falling and that of the high-income countries growing. The market share of the USA alone( of world’s medicines) rose from 18.4% of the world total in 1976 to over 52% in 2000.
Unfortunately, the United States is immersed in a toxic brew of four synergistic conditions. First, a robust pharmaceutical industry is ready with a pill for all that ails us as a business proposition. Second, a high incidence of common conditions for which we have little understanding (chronic pain, dementia, range of mental health disorders). Third, a high incidence of chronic disease (often due to our lifestyle) and fourth, social support and healthcare systems which continue to be inadequate to counteract the above.
This massive use of medications is neither leading us to better clinical outcomes or a better quality of life. On the contrary, we see more destructive side effects from medication overuse and abuse every day. Additionally, the huge expense of drugs in the U.S. is leading to non-refills, decreased access, and increased bankruptcy.
The overuse of medication in the United States is a massive and complex topic. I hope to provide in this piece an over view of some of the most important aspects of the issue. To this end I will divide the discussion into categories of drugs/drug uses: antibiotics, pain medication, mental health prescriptions, sleep medications, prescriptions in the older person, entertainment/party drugs, self-medication, concluding with remedies for medication overuse.
The latest figures from the Centers for Disease Control (U.S.) show that 4 out 5 Americans take an antibiotic per year. It’s the cumulative toll of yearly antibiotics which provides the setting for antibiotic resistance. The CDC also states:
Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 die each year as a direct result of these infections.
Bacteria, living, adaptable organisms, can become resistant in the setting of repeated antibiotic exposure (may allow preferential selection of resistance /survival) or genetic mutation, among other mechanisms. We know that some bacteria, over time, develop the ability to neutralize the antibiotic before it can do harm to the bacteria, others rapidly pump the antibiotic out, and still others can change the antibiotic attack site.
Multiple studies suggest that the public does not understand the term “antibiotic resistance: From the Wellcome Trust:
Why should we care if people don’t accurately understand these terms? The reason is that a large part of the problem – other than the lack of new drugs being developed is liked to people’s behavior. It’s vital that antibiotics aren’t over-used, and when they are needed, it’s important that people finish the complete treatment course.
Both acute and chronic pain is a major health problem in the United States (and globally). From The American Academy of Pain Medicine:
Pain affects more Americans than diabetes, heart disease and cancer combined. The Institute of Medicine of the National Academies estimates that up to 100 million Americans suffer from chronic pain.
There are three major points that I wish to highlight regarding pain medications: the opioid epidemic, the underutilization of palliative care and the unequal distribution of morphine around the world.
1) Opioid Epidemic Statistics:
44 prescription opioid deaths per day (U.S.)
3/4 of the people using heroin started on a prescription opioid
Most common causes of disability in the developed world are linked to physical or emotional pain: low back pain & depression
At the recent AMA Delegates meeting in Atlanta on November 16, 2015, one of the key topics was opioid addiction. I have selected the following tweets from this meeting to highlight the key points about opioid prescribing and the epidemic.
“The first time you prescribe an opioid to a patient is a momentous time.” @DrFriedenCDC #AMAmtg
— Kyle P. Edmonds, MD (@kpedmonds) November 16, 2015
Friedan MD: #AMAmtg @CDCgov we have two crises: over treatment of pain and under treatment
— ledje (@ledje) November 16, 2015
At #AMAmtg from @DrFriedenCDC: Antibiotics, Steroids and Opioids. “We treat symptoms rather than the cause because it’s faster.”
— Toluwalase A Ajayi (@tajayiMD) November 16, 2015
Anecdotes @ #AMAmtg re #opioid misuse highlight need 4 universal precautions: risk screening, PDMP monitoring. Avoid assumptions #hpm #pedpc
— Kyle P. Edmonds, MD (@kpedmonds) November 16, 2015
PDMPs must be tool 4 physicians to provide best, safest care to each pt. Not for punitive ends, population mgmt or law enforcement. #AMAmtg
— Kyle P. Edmonds, MD (@kpedmonds) November 16, 2015
When all is said & done- it’s the ‘second, third hand’ script that kills:
2) Under-utilization of palliative care, hospice care and treatment of pain in certain settings throughout the world
3) Inequity of Morphine Distribution throughout the World
Mental Health Prescriptions
Psychotropic drugs are now the number one class of drugs prescribed in the United States. 11% of the US population age 12 and older take these meds for a wide variety of mental health conditions, ranging from depression, anxiety and A.D.H.D. .Treatments (and re-imbursements for services) are based on diagnoses as defined and described in the Diagnostic & Statistical Manuel of Mental Disorders (DSM) series-current version #5. Mental health disorders are diagnosed through evaluating self-described symptoms that patients recount.
Psychiatry is a 300+ billion dollar /year industry. We, in the U.S., consume 60% of the world’s psychotropic medications. Unfortunately, the efficacy of these medications (especially those for depression) have been called into question with studies showing that taking an antidepressant was little different in effect from taking a placebo. If those studies continue to hold true that’s a very expensive placebo with many side effects!
Prescriptions in the older age person- some revealing statistics:
Are sedative hypnotics with addictive potential including dependency for sleep, cravings for the medication and memory loss
Nearly 9 million U.S. adults take prescription sleep aids.
Tripling of sleep aids prescriptions from 1998 -2006 for young adults age 18-24 yo
Estimated 50-70 million suffer from sleep disorders or deprivation
Only 1/3 of Americans get the recommended hours of sleep per night (7-9 hrs)
4% of adults age 20 and older used sleep aid prescriptions in the last month
Negative side effects include lack of coordination, dizziness, light-headedness, and hallucinations.
Entertainment/Party Drugs: psychoactive /dissociative drugs which are both used recreationally and then specifically to self-treat for social anxiety, unmet emotional needs. Commonly used by 18-30yo, these drugs include heroin, cocaine, and MDMA – 3,4 methylinedioxy methamphetamine (ecstasy or Molly).
Self Medication /Self- Soothing at all ages
Using substances for handling anxiety, stress, anger, sadness, and loneliness
Self medicating with alcohol can become an even more serious issue if mixed w/ other drugs. There are 60 million Americans that “abuse alcohol” and 22 million Americans that use illegal drugs.
Expenditures on illegal drugs are now about 100 billion dollars:
Remedies for Medication Over Use & Abuse
1) Ban Direct-to-Consumer (DTC) Ads by Pharmaceutical Companies
Reasons to do so include:
Takes up valuable time
Ads, not info
Fuels the “pill for every ill” culture
The AMA (American Medical Association) just passed resolution at its meeting in Atlanta on November 16,2015 in favor of banning all direct to consumer medication (DTC) advertising. It is notable that only two countries in the world allow DTC ads: United States and New Zealand.
2) Taking More Time to Talk
Physicians and other health care professionals need to take more time to speak with patients about antibiotic resistance, quality of life, goals of care, social supports, and coping strategies.
3) Physician education
Use strategies to say, “no” to antibiotics and to inappropriate drug seeking behavior. Know the importance of incorporating mental health/wellness strategies into the doctoring workflow, and close working relationship with allied health professionals.
4) Patient education, increasing health literacy via Public Health Messaging
One example this past week was the Antibiotic Awareness Week Campaign – includes two tweet chats: one hosted by the WHO, the other hosted by the CDC.
5) Increase mental health care access and decrease stigma
Offer more broad and accessible mental health care services on college campuses, provide insurance coverage without ‘hoops’, decrease stigma, and invest in research and community supports.
6) Increase drug addiction treatment centers
Remove bias toward those who are drug addicted, increase funding for drug treatment centers, and institute early referrals. A recent positive step is the availability of nasal spray naloxone for first responders to treat heroin overdose.
7) Increased access to palliative care & more equitable distribution of morphine throughout the world
8) Prescription Drug Monitoring Programs
Support the robust use of tracking systems for drug seeking behavior coupled with an increase in societal support and drug treatment centers for those addicted.
9) Research into and serious consideration of non-drug alternatives
Such alternatives include meditation, exercise, social interaction, community supports and underpinning all of it, education (both general literacy and health literacy).
10) Re-assess and Re-balance disease diagnostic thresholds: ‘saving normal’
Over time, the definition of disease has widened and the number of diseases has multiplied, resulting in far fewer conditions and behaviors considered in the range of normal. This results in nearly every lab value, diagnostic test and symptom being deemed abnormal (and thus requiring treatment – often a medication), ultimately medicalizing our very existence. This insidious process has made permanent patients of us all.
11) Enlightened cultural change
The political will coupled with enlightened thinking of our society, the medical profession, and healthcare system is needed to confront these issues. It will take much effort, education and courage to change what is needed to foster personal wellness self –efficacy and overall wellbeing for all our citizenry.
Notably: at a recent health technology conference, a speaker, and then the audience, (followed by twitter) jubilantly exclaimed:
Soon algorithms will be prescribing drugs.
Lest we re-live the past…..
….I suggest we get a much better handle on this abuse, and overuse issue before a destructive culture is embedded in augmented intelligence (AI) treatment algorithms. Algorithms, ingraining a flawed culture and misguided constructs, would be the worst possible outcome.
(Of interest: Mobile Health News just reported (11/20/15) that Epocrates, an AthenaHealth subsidiary just pulled its ‘Bugs + Drugs’ app from iMedicalApps. It had had history of errors but were supposedly corrected. Two other Epocrates apps were also pulled. There was no comment from AthenaHealth.)
Please join us on our weekly #hcldr chat on Tuesday December 1st, 2015 at 8:30pm ET (for your local time click here):
T1 Antibiotics: Do you handle unpleasant infection without requesting antibiotics? Thought for physician strategies to say, “no”?
T2 Overuse of Pain Meds: How to limit access for some while providing for those who need? Value of non-drug therapies?
T3 Drugs & Mental health: Are medication treatments successful? Other therapies? How to increase mental health care access?
T4 How might a society: a) decrease excess prescriptions b) change destructive culture of self-soothing with prescription & non–prescription drugs and alcohol?
References – Categorized
A Pill for Every Ill http://www.newsweek.com/2014/02/07/pill-every-ill-245476.html
Trends in Prescription Drug Use Among Adults in the United States from 1999-2012 http://jama.jamanetwork.com/article.aspx?articleid=2467552
More Americans Than Ever Are Taking Prescription Drugs https://www.washingtonpost.com/news/to-your-health/wp/2015/11/03/more-americans-than-ever-are-taking-prescription-drugs/
Popping Pills: Prescription Drug Abuse in America http://www.drugabuse.gov/related-topics/trends-statistics/infographics/popping-pills-prescription-drug-abuse-in-america
World Medicines Situation – WHO report 2004 http://apps.who.int/medicinedocs/en/d/Js6160e/6.html#Js6160e.6
The Drugging of America Summarized in 19 Mind-Altering facts http://www.zerohedge.com/news/2014-02-15/drugging-america-summarized-19-mind-altering-facts
Drug overdose rates soaring among U.S. youth http://www.webmd.com/mental-health/addiction/news/20151119/drug-overdose-rates-soaring-among-us-youth?ecd=soc_tw_111915_news_drugoverdosesyouthrising
The Elderly Are Taking Too Many Pills http://www.huffingtonpost.com/ann-brenoff/elderly-taking-too-many-pills_b_7079060.html
Why do Americans spend so much on pharmaceuticals? http://www.pbs.org/newshour/updates/americans-spend-much-pharmaceuticals/
Direct-to Consumer Ads
Direct to Consumer Advertising Under Fire http://www.who.int/bulletin/volumes/87/8/09-040809/en/
Antibiotic Overuse & Resistance
The Centers for Disease Control in the United States : Antibiotic Resistance website http://www.cdc.gov/drugresistance/
Antibiotic Resistance Still Widely Misunderstood ( By The Public) http://blog.wellcome.ac.uk/2015/07/29/antimicrobial-resistance-still-widely-misunderstood/
When Antibiotics Stop Working http://www.forbes.com/sites/realspin/2015/10/27/rise-of-the-superbugs-when-antibiotics-stop-working/?utm_source=&utm_medium=&utm_campaign=
American Academy of Pain Medication http://www.painmed.org/patientcenter/facts_on_pain.aspx
A World of Pain http://www.cbsnews.com/news/a-world-of-pain/
Painkiller Abuse Survey http://www.huffingtonpost.com/entry/painkiller-abuse-survey_565380c0e4b0258edb32985d
Sleeping Pill Addiction and Abuse https://www.addictioncenter.com/sleeping-pills/
Nearly 9 million Americans Use Prescription Sleep Aids http://www.cbsnews.com/news/cdc-nearly-9-millon-americans-use-prescription-sleep-aids/
Mental Health: The Over/ Under Problem-Dementia, Anxiety, Depression, ADHD,
The Use and Abuse of Benzos http://www.abc.net.au/radionational/programs/allinthemind/the-use-and-abuse-of-benzos/6945200
Death Rates Rising for Middle Aged White Americans http://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americans-study-finds.html?_r=0
The Science & History of Treating Depression http://www.nytimes.com/2012/04/22/magazine/the-science-and-history-of-treating-depression.html
Is ADHD Being Over-diagnosed and Over-treated in Children http://www.empowher.com/adhd/content/adhd-being-overdiagnosed-and-overtreated-children
A.D.H.D. is in the American DNA http://www.nytimes.com/roomfordebate/2011/10/12/are-americans-more-prone-to-adhd/adhd-is-in-the-american-dna
Near death and overmedicated http://newoldage.blogs.nytimes.com/2014/09/09/near-death-and-overmedicated/?_r=0
The Drug from Limitless is Available On Your College Campus http://www.huffingtonpost.com/eliza-sankargorton/the-drug-from-limitless-is-available-on-your-college-campus_b_4704689.html
The smart drug modafinil is the new Adderall only better https://news.vice.com/article/users-say-the-smart-drug-modafinil-is-the-new-adderall-only-better
Antibiotic Resistance Awareness Campaigns – see Storify https://storify.com/nxtstop1/world-antibiotic-awareness-week
FDA Moves Quickly to Approve Easy To Use Nasal Spray to Treat Opioid Overdose http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm
Are you self medicating? http://www.futuresofpalmbeach.com/blog/are-you-self-medicating/
5 Must Ask Questions When Your Doctor Prescribes Painkillers https://www.psychologytoday.com/blog/where-science-meets-the-steps/201503/5-must-ask-questions-when-your-doctor-prescribes
Closing the Pain Divide http://www.huffingtonpost.com/felicia-m-knaul/closing-the-global-pain-divide_b_3963838.html
Thinking About Addiction: New Approaches for Chronic Pain http://treatmentandrecoverysystems.com/blogs/thinking-about-addiction/new-approaches-for-chronic-pain/
Expanding access for addiction treatment in primary care http://www.fiercepracticemanagement.com/story/expanding-access-addiction-treatment-primary-care/2015-11-09
5 Ways To Ease Dementia Without Drugs http://www.futurity.org/5-ways-ease-dementia-without-drugs-868592/
Taking pills for unhappiness reinforces the idea that being sad is not human http://www.theguardian.com/commentisfree/belief/2013/aug/09/pills-unhappiness-reinforces-sad-human
Saving Normal: An Insider’s Revolt Against Out of Control Psychiatric Diagnoses, DSM-V, Big Pharma and the Medicalization of Ordinary Life by M.D. Francis Allen 2013