POLYPHARMACY: REAL DRUGS FOR REAL DISEASES VS PSYCH DRUGS FOR PSYCH
"DISEASES"
ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)
http://www.ahrp.org
Vera Hassner Sharav:
FYI
The escalating cost of healthcare is in large measure due to
the spiraling expenditure on drugs--many of which are misprescribed.
The Boston Globe reports about one Medicaid patient who is prescribed
18 medications at a cost of roughly $16,000 a year--
"all at the expense of the financially struggling Massachusetts
Medicaid program."
[Fred A. Baughman Jr., MD:
The woman (who was alcoholic) is a pharmaceutical company's
dream consumer. Thanks to psychiatrists' poly-pharmacy prescribing
practices she is taking multiple costly drugs of the same class.
Such prescribing practices are more likely to generate drug-induced
new pathologies
[Fred A. Baughman Jr., MD:
than to cure the condition for which they are prescribed.
What some would call malpractice, is an incredibly lucrative marketing
strategy.
According to Massachusetts Medicaid
[Fred A. Baughman Jr., MD:
, the 10 most prescribed drugs under
the Medicaid program are:
1. Zyprexa (antipsychotic) costs Massachusetts taxpayers $4.2 million,
2. Protonix (heartburn) costs $3.6 million
3. Risperdal (antipsychotic) costs $3.1 million
4. Lipitor (anti-cholesterol) costs $2.8 million
5. Seroquel (antipsychotic) costs $2.8 million
6. Neurontin (neuropathic pain...) $2 mill
7. Depakote (antidepressant) $1.7 million
8. OxyContin (narcotic) $1.6 million
9. Zoloft (antidepressant)$1.5 million
10. Paxil (antidepressant) $1.2 million
7 of the 10 drugs are expensive psychiatric drugs that are eating up
the Medicaid budget. The Boston Globe reports that about 40,000 patients
in the Massachusetts Medicaid program take eight or more medications.
"Thousands of other patients take five or more psychiatric drugs,
more than one newer antidepressant, or more than one newer antipsychotic."
Furthermore, "For patients on eight or more drugs or five or more
psychiatric drugs, Medicaid officials will try to
educate doctors about why this could be a health problem."
One must wonder about the professional competence of State licensed
psychiatrists who prescribe powerful, mind altering drugs, yet
are ignorant about these drugs' potential to cause patients harm.
[Fred A. Baughman Jr., MD:
~~~~~~~~~~~~~~~~~~~~~~
http://www.boston.com/dailyglobe2/173/business/Cost_and_consequence+.shtml
Cost and consequence
Medicaid aims to curb 'poly-pharmacy' approach, but drug limits may
undermine patients' health
By Liz Kowalczyk, Globe Staff, 6/22/2003
Seven years ago, Cheryl Desio was homeless and addicted to alcohol,
sometimes sleeping on a gym mat in a friend's basement, other times staying
briefly in a shelter or with one of her children. One night, drunk and
angry, she remembers showing up at Massachusetts General Hospital looking
for psychiatric help and began a long climb up, to treatment programs at the
Salvation Army in Brockton, Father Bill's Place in Quincy, Boston's Lemuel
Shattuck Hospital, and the Edwina Martin House in Brockton. Finally she
moved into a low-income apartment in Dorchester, which she shares with a
roommate, and onto Medicaid, the government's health insurance program for
the poor.
"Cheryl is a real survivor," said Dr. Michael Folino, her primary care
physician. "It's amazing to me she's still living and doing well."
Desio, 50, is amazed, too, especially at her children's generosity and
respect since she became sober. One daughter pays her monthly phone bill
while a son bought her reading glasses. "We're so proud of her," said her
daughter Stacy Konopka, 27. "Growing up with her drinking was really hard.
Her life was spiraling down. This year she called me on Mother's Day,
because I have a new daughter. To have her do that, was amazing."
But keeping her fragile life and health together is not easy. Desio takes 18
medications, for diabetes
[Fred A. Baughman Jr., MD:
, depression [Fred A. Baughman Jr., MD:
, anxiety, [Fred A. Baughman Jr., MD:
pain [Fred A. Baughman Jr., MD:
, and emphysema
[Fred A. Baughman Jr., MD:
, all at
the expense of the financially struggling Massachusetts Medicaid program.
The cost for her medicines alone: roughly $16,000 a year.
On July 1, Medicaid officials will start reviewing Desio and other
"poly-pharmacy" patients -- those using many medications or several
medications in the same class -- for its newest cost-cutting initiative
aimed at controlling the state's skyrocketing prescription drug costs.
Medicaid officials believe that pushing doctors to reduce the number of
medications individuals take will not only save the state as much as $20
million annually
[Fred A. Baughman Jr., MD:
but will reduce dangerous side
effects and drug interactions for patients
[Fred A. Baughman Jr., MD:
.
Many doctors fear the initiative will have unintended consequences for
seriously ill Medicaid recipients like Desio, whose complex conditions often
require an equally complicated drug cocktail. "The question is what happens
when you take one brick out of the foundation?" said Folino, medical
director of Harbor Health Services Inc., a group of three community health
centers in Boston.
Desio's doctors don't know whether Medicaid officials will push them to
reduce or change her medications, or whether the reviewers who monitor drugs
for the agency will find them all medically necessary. But Desio is anxious.
"I am scared of this," she said
[Fred A. Baughman Jr., MD:
. "I'm doing the best I can to keep myself well."
Medicaid officials have been struggling to control the program's growing
$1.1 billion pharmacy budget by switching many patients from expensive brand
name drugs to cheaper generics
[Fred A. Baughman Jr., MD:
. When generics don't exist, most patients now
can take only the cheapest brand name drug for a particular condition.
When Desio tried to renew her prescriptions for the antidepressant Lexapro
[Fred A. Baughman Jr., MD:
and the migraine
[Fred A. Baughman Jr., MD:
medication Maxalt two weeks ago, her pharmacist said
Medicaid would no longer pay for these expensive drugs -- unless her doctors
get special permission
[Fred A. Baughman Jr., MD:
.
But these measures, Medicaid officials say, have done nothing to address a
pressing cost problem that also may be hurting patients' health. About
40,000 patients take eight or more medications. Thousands of other patients
take five or more psychiatric drugs, more than one newer antidepressant, or
more than one newer antipsychotic. Officials don't know precisely how much
these members' medicines cost the program, which insures 950,000 poor and
disabled residents, but still think some of it is wasteful spending.
Starting July 1, Medicaid officials will use a computer program to identify
these patients and call their physicians to ask them to reduce their
medications. Patients will not be allowed to take more than one newer
antidepressant
[Fred A. Baughman Jr., MD:
or more
than one newer antipsychotic
[Fred A. Baughman Jr., MD:
--unless a doctor
proves with medical records that the combination works better for the
patient than a single drug.
For patients on eight or more drugs or five or more psychiatric drugs
[Fred A. Baughman Jr., MD:
, Medicaid officials will try to educate doctors about why this could be a
health problem. Massachusetts is one of the first states to target
poly-pharmacy
[Fred A. Baughman Jr., MD:
, said Mike Fitzpatrick, director of policy
research for the
National Alliance for the Mentally Ill, a nonprofit advocacy group based
near Washington, D.C. But he said many states now are following suit. Texas
plans to limit patients to four brand name drugs per month, and Eli Lilly &
Co., maker of a number of psychiatric drugs, gave Missouri several hundred
thousand dollars in part to educate doctors who are prescribing patients too
many psychiatric drugs.
"There is increasing evidence that members are getting many drugs that
aren't appropriate or are excessive," said Douglas Brown, Massachusetts
acting Medicaid director. "If we focus on the relatively small number of
people on high numbers of drugs, we can improve their health care and save
money."
But Dr. George Sigel, Desio's psychiatrist
[Fred A. Baughman Jr., MD:
, objects to government
interference in his medical judgments, and worries these initiatives will
shake patients' confidence in their doctors. "They won't know if the doctor
is thinking about what's best for them, or about how time-consuming it's
going to be for him to get permission from Medicaid," he said. The state's
"prior approval" forms are two-pages long and require a detailed
description of the patient's medical history. "There's no way deleting any
of Cheryl's medications on the basis of cost is going to be good for her,"
he said.
Other physicians are not so sure. Medicaid officials -- and some doctors --
say that for various reasons, including health insurers' reluctance to pay
for long hospital stays and intensive outpatient psychotherapy since the
advent of managed care, poly-prescribing or poly-pharmacy has gotten out of
hand. Dr. Marie Hobart, a Worcester psychiatrist who serves on the Medicaid
committee that developed the new poly-pharmacy rules, said the agency
primarily wants to cut costs but deserves credit for taking a clinical
approach. The committee reviewed studies on poly-prescribing and interviewed
experts.
Widespread poly-pharmacy came about, she said, partly because doctors in
clinics are struggling to see huge numbers of complicated patients.
"Sometimes these multiple medicines have been arrived at in a painstaking
way," she said. "Other times we have patients who are very difficult to
treat and very little time to spend with them, and it becomes more difficult
to make changes in their medicines."
Dr. James Ellison, a psychiatrist on the committee and president of the
Massachusetts Psychiatric Society, said patients tapering off one medication
and starting another sometimes feel better and believe it's the combination
rather than the new drug taking effect. And sometimes, he said, doctors
resort to poly-pharmacy in desperation on difficult patients for whom no
drug seems to work. Out of 200 patients he's treating for depression, one
man takes two newer antidepressants known as Selective Serotonin Re-uptake
Inhibitors -- even though no proof exists for this combination.
"I don't think that's why the patient is doing well, but he strongly
believes this is useful," Ellison said. "My worry is that we're exposing
him to increased side effects, and for society, we're drawing resources away
from other problems."
Folino, Desio's doctor, said he is not a fan of poly-pharmacy but that it
will be difficult to comply with the state's directive in complicated cases
like hers. Desio has hepatitis C, diabetes, and chronic obstructive
pulmonary disease from years of smoking and not taking care of herself. She
also has cervical stenosis, a narrowing of the spinal canal that pinches the
nerves, and migraines that cause her severe pain.
Desio, who has huge light blue eyes and a worn look, takes medicines four
times daily. The regimen is so complicated a nurse has written it on a big
sheet of paper. A good day is when she can walk around the Harborpoint
housing development in Dorchester or sit on a bench near the ocean. Less
often recently is a bad day -- or two or three together -- when she can't
get out of bed.
Folino said Desio's drugs interact in such a way that she needs more than
one medication for each problem. For example, she requires a steroid,
Advair, to help her breathe. But that elevates her blood sugar, so Folino
has had to put her on three diabetes medications. Steroids also can
destabilize her anxiety and depression
[Fred A. Baughman Jr., MD:
; she's on
four medications to control
those conditions. But she has to be careful about which antidepressants she
takes because they can cause weight gain, and in turn aggravate her diabetes.
Even so, Desio is having symptoms Folino said could be the result of
multiple drug interactions. Her roommate has called an ambulance many times
because Desio has gotten dizzy, fallen, and been unable to stand up. Folino
referred her to yet another doctor, a neurologist
[Fred A. Baughman Jr., MD:
.
"Obviously it's a delicate balance," Folino said. "This could have to do
with poly-pharmacy. But on the other hand, with the combination she's on
she's functioning as well as she ever has."
Liz Kowalczyk can be reached at kowalczyk@globe.com.
This story ran on page E1 of the Boston Globe on 6/22/2003.
© Copyright 2003 Globe Newspaper Company.
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