South London GP James Le Fanu published his book, Too Many Pills: How Too Much Medicine is Endangering Our Health and What We Can Do About It, earlier this year. A regular writer on medicine and science for the Sunday and Daily Telegraph, here he explores how routine medical practice in the UK has become addicted to over-medicating patients…
Doctors nowadays prescribe too many pills – a regular topic of conversation round the dinner table, down the pub and on the golf course. Some are apprehensive lest they be prescribed yet more: ‘Quite a lot of people I know are fearful of visiting their doctors’ surgery because of this’. Dutiful children visiting parents or elderly relatives are rightly concerned at the plethora of drugs cluttering the bathroom cabinet.
The relevant statistics can only be described as awesome. In just fifteen years the number of prescriptions issued by family doctors has increased almost threefold, an additional 600 million a year – including a dizzying four fold rise for diabetes treatments, seven fold for anti-hypertensives and twenty fold for the cholesterol-lowering statins.
Meanwhile the number of people taking five or more different drugs has quadrupled to include almost half of those aged 65 or over.
These drugs are, of course, very effective but there is none with its chance of good that does not have adverse effects in some. The more taken, the greater that risk – a massive 75 per cent upswing in emergency l admissions for adverse drug reactions (an additional 30,000 a year), a twenty-fold rise in fall-induced major trauma in the elderly and almost certainly a contributory factor to the decline in life expectancy (an additional one thousand deaths a week, compared to five years ago).
My first intimation of this debacle came just over a decade ago in a letter from a reader of my Telegraph column who 18 months previously had undergone a successful repair of a large aortic aneurysm.
He recovered well but subsequently had gone progressively downhill, becoming increasingly decrepit, immiserated by muscular aches and pains his doctors were unable to explain. He was determined at least to make it to his son’s wedding in Hawaii – not an easy journey requiring a wheelchair at several transfer stop-overs.
Reaching his destination the patient realised he had forgotten to pack the statins prescribed after his operation but was so miraculously improved by three weeks of not taking them he was able on his return to walk unaided back through Heathrow Airport.
This account of his near miraculous recovery was corroborated by many others describing how their impaired mobility, lethargy, poor concentration or insomnia previously misattributed to anno domini (‘what can you expect at your age?) had similarly resolved after discontinuing, for one reason or another, their medicines.
And as time has passed so the toll of polypharmacy has become ever more apparent. For those who are otherwise fit and healthy the onset of side-effects soon after initiating treatment will indicate the cause.
The difficulty arises when these symptoms are more insidious with doctors obtusely refusing to acknowledge the drugs might be responsible – as with the following from a woman whose 71-year-old husband who was taking eight pills in the morning, five in the evening.
“He has lost all confidence”, she writes, “he gets up in the morning with no energy, unable to work in the house or garden. When our grandchildren visit it is all too much for him. His life stretches out with no hope of improvement. On enquiring about the necessity of taking so many medicines, his doctor said he would not be here if he stopped any of them”.
So how did this situation arise? The origins of polypharmacy can be traced to two very radical ideas. More than forty years ago, Henry Gadsden, the brilliant chairman of (at the time) the world’s largest and most innovative drug company Merck proposed the future prosperity of the pharmaceutical industry would require expanding the market for its products beyond treating the ill to include the healthy as well. Ideally, he would like to ‘sell to everyone’ just as Wrigley’s sell their chewing gum.
Ten years later the prominent British epidemiologist, Geoffrey Rose, provided, if unintentionally, the rationale with which Gadsden’s rather disturbing vision might be realised.
It is not just individuals who are ill argued Rose; rather ‘the population is sick’.
The blood pressure, cholesterol and glucose in the population are on average ‘too high’ and there is more to be gained by lowering these measurements in millions of people than focusing on the relative few in whom they are markedly elevated.
This ‘population approach’ remains a central tenet of medical thinking exploited by the pharmaceutical industry to its immensely profitable advantage.
Who would know, given the current enthusiasm for mass medication that the benefits of commonly prescribed drugs are systematically exaggerated fifty-fold or as in certain instances 98 per cent of those taking them gain no benefit from taking them?
The third crucial element, closing the circle as it were, of ‘too much medicine’ is more recent.
In 2004, the long-standing contractual arrangements by which family doctors are remunerated were overturned in favour of ‘payment by performance’ mediated via the notorious Quality and Outcomes Framework (QOF) – their income dependent on their success in hitting more than fifty targets for the number of patients diagnosed and treated for a given set of conditions.
The synergy of these three ‘players’ in promoting polypharmacy, albeit for very different reasons is now deeply entrenched, institutionalized within routine medical practice. Virtually everyone agrees this needs to be reversed (nine out of ten GP’s in a recent straw poll) but this is unlikely to happen any time soon.
This leaves little alternative for the public other than to take the initiative and after acquainting themselves with the merits (or otherwise) of the drugs they are taking, have a properly informed discussion on whether they really need to ‘keep taking the pills’.