Orchestrating drug management (American College of Physicians annual scientific meeting)

Managing medications is becoming more complicated due to the aging population, use of opioids for chronic pain and increased FDA drug safety messages.

By Christine S. Moyer — Posted May 14, 2012

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Before starting each office visit, geriatrician Holly M. Holmes, MD, reviews the medications documented in her patients’ medical records. The list often includes more than a dozen prescription drugs, over-the-counter medications and herbal supplements.

Many of the substances interact. Most have potentially negative side effects.

Managing medications, particularly among older patients, “is becoming more complex, but yet we don’t have more time to do it,” said Dr. Holmes, an assistant professor in the Dept. of General Internal Medicine at the University of Texas MD Anderson Cancer Center.

Among the challenges is caring for an aging population that is living longer due to medical advancements, health professionals say. As those patients develop chronic diseases, they are prescribed an assortment of drugs to manage the conditions.

Also complicating drug management is the movement to treat chronic pain with prescription opioids, physicians say. Doctors who prescribe those drugs must regularly monitor patients to ensure there is no substance abuse.

The frequent drug safety messages from the Food and Drug Administration add additional stress on some physicians who already feel overwhelmed by the complexity of their patients’ medication regiments, health professionals say.

As a result, it is critical that physicians regularly evaluate patients’ medication lists and determine which drugs can be stopped safely, Dr. Holmes told colleagues during a session of the American College of Physicians annual scientific meeting in New Orleans in April.

Discontinuing unnecessary medications can improve patients’ health, decrease their risk of an adverse drug event and save them money, she said. But doctors do not take this step often enough, Dr. Holmes said. Part of the problem is that conversations with patients about stopping medications are complicated and time-consuming. Some physicians also might worry about liability risks if a patient has a health complication after discontinuing a drug.

At the ACP meeting, medical experts offered physicians guidance on how to manage the challenges of polypharmacy and identify medications that can be stopped. Many of the meeting sessions focused on older patients, who the experts said are among the most complicated to treat.

“It’s so easy to give your older patients a lot of drugs, because they have so many problems,” but that’s not always the right thing to do, said Seattle internist Douglas Paauw, MD, who led a session on dangerous drugs.

If a patient is tired of taking all of his or her medications or cannot afford them, identify the essential drugs and take the person off the others, said Dr. Paauw, professor of medicine and director of the Medicine Student Program at the University of Washington School of Medicine. “This is patient-centered care,” he said.

Identifying which drugs to stop

More Americans are using prescription drugs than ever, due, in part, to the aging population and increased access to health care, medical experts say. In 2007-08, 48% of people took at least one prescription drug in the past month, up from 44% in 1999-2000, according to the Centers for Disease Control and Prevention.

The use of multiple drugs is most common among people 60 and older, the CDC said. Thirty-seven percent of this population took at least five prescription medications during the past month in 2007-08. The figure was 8% among people 20 to 59.

With the nation’s elderly population expected to more than double within 40 years, the challenges of managing medications are expected to rise.

To help lessen drug complications, “it’s important that physicians regularly look at the medications patients take and ask themselves, ‘What do they really need?’ ” Dr. Paauw said. In making that decision, he recommends that physicians consider patients’ life expectancy and treatment preferences. Doctors also can use several tools to help identify medication that can be stopped.

Dr. Holmes suggests using the medication appropriateness index, which helps determine whether a drug is appropriate for a patient based on the way the physician rates 10 criteria. Those criteria include the drug’s dosage and cost.

For older patients, Dr. Holmes recommends using the Good Palliative-Geriatric Practice algorithm, which identifies drugs to stop in elderly patients based on the physician’s response to several questions.

Talking to patients about discontinuing medications can be challenging, because they often feel strongly that they need the drug, Dr. Holmes said.

In cases where medication is negatively affecting a patient’s health, she educates the individual about the problem and says, “I think there’s harm in using this drug. We need to reduce something that is harmful.”

For less-urgent situations, Dr. Holmes talks to the patient about the benefits of continuing the medication and the benefits of stopping it. She also explains in clear terminology why she favors discontinuing the drug.

“The responses of patients vary,” she said. “A lot of times they challenge me and disagree. When it’s not harmful to stay on the medication, I’m more willing to let them continue taking it.”

Managing patients with chronic pain

That type of strong patient-physician communication is essential when prescribing opioids to people with chronic pain, said Seattle internist Barak Gaster, MD, who led a session on pain management in the outpatient setting.

He said chronic pain is one of the few areas of medicine in which patients sometimes misrepresent their symptoms to get medication. To ensure that physicians provide the most effective care and prevent substance abuse, they should talk openly to patients about the practice’s opioid prescribing policy and what types of behavior will not be tolerated, Dr. Gaster said.

“Repeating the rules of prescribing in your clinic several times is really important so you feel confident the patient got the message,” he said.

Those rules should be detailed in a concise care agreement that the patient should read and sign before starting treatment, Dr. Gaster said. He recommends that the agreement include a statement about how opioid prescriptions will be filled only after an office visit and cannot be refilled early.

“These are such high-risk drugs, the idea that we can refill them the same way we do blood pressure medications is not right. All refills should by done by clinical appointment,” Dr. Gaster told colleagues during an ACP session.

In 2008, opioid prescription painkillers were involved in 14,800 drug overdose deaths in the U.S., according to the CDC. That was up from 4,000 such deaths in 1999.

To help identify opioid abuse, Dr. Gaster encourages physicians to give random urine toxicology screens to patients they are treating for chronic pain. When doctors notice red flags, such as positive screens or patients who demand a higher dose, they should stop prescribing the drug. But they should not fire such patients, Dr. Gaster said.

“Ethically and legally, it’s not right to abandon a patient in that situation,” he said.

He recommends telling the individual, “In my medical opinion, this type of pain medicine is not safe for you, and I’m not willing to prescribe it anymore. Here’s my plan for treating your chronic pain.”

If the patient becomes upset, Dr. Gaster encourages physicians to be empathetic. He often tells them, “I’m really sorry. It sounds like this is terrible for you, but in my medical opinion, opiates just are not a safe option for you.”

Oceanside, N.Y., family physician Samuel A. Sandowski, MD, and his colleagues encountered so many red flags that they recently stopped prescribing opioids altogether for chronic pain. Dr. Sandowski now encourages patients who ask for the drugs to find a pain management specialist, and he tells them, “It’s the custom of this practice not to prescribe these medications on a regular basis.”

Information overload

Some physicians are becoming burned out by the challenges of managing medications and frequent drug safety alerts from the FDA, health professionals say.

In 2011, the FDA’s Center for Drug Evaluation and Research issued 68 drug safety communications, up from 39 in 2010. As of April 27, 12 such messages had been released this year. The 2012 notices include safety-label changes to statins and information on blood clot risks for women taking birth control pills that contain drospirenone.

The uptick in messages is due, in part, to the FDA’s improved monitoring of drug safety and an emphasis on communicating that information to the public, health professionals say. But too often, the alerts give information physicians already know, said Dr. Paauw, of the University of Washington.

“There’s a fine line between educating doctors in a timely fashion and giving so much information that people just become immune to it,” he said.

Dr. Paauw recommends that physicians look at safety notices to see what drugs they involve. He encourages doctors to read the entire message if it concerns a medication they prescribe or might use.

“I worry sometimes that we’re losing the judgment that is key to being a good doctor,” he said, because of pressure from the health care industry to put even the oldest patients on an assortment of drugs to control their medical conditions.

“Just treat the patient,” he advises colleagues.

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Adult ADHD often difficult to diagnose

Although attention-deficit/hyperactivity disorder long has been considered a childhood developmental problem, it is becoming an increasingly routine adult diagnosis in internal medicine, said internist and pediatrician Steven M. Scofield, MD.

“ADHD is common enough that the average internist has 20 to 80 patients” with the disorder, Dr. Scofield told colleagues during a session on adult ADHD that he led at the American College of Physicians’ annual meeting in New Orleans in April.

A sizable percentage of such patients probably are undiagnosed and receiving treatment for conditions such as depression and generalized anxiety disorder, said Dr. Scofield, an assistant professor in internal medicine and pediatrics at the University of Rochester Medical Center in New York.

In 2007, more than 5 million children 4 to 17 (9.5%) had been diagnosed with ADHD, says the Centers for Disease Control and Prevention.

It was once thought that children eventually outgrow the condition. But up to 60% of youths with ADHD continue to show significant symptoms of the disorder in adulthood, according to a 2005 Archives of Disease in Childhood report.

A key challenge for internists is diagnosing the disorder, because some of the symptoms have to be present in childhood, he said. Proposed changes to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders suggest raising the age at which some ADHD symptoms have to be present from 7 to 12.

But it still will be difficult for internists to confirm that an adult patient’s symptoms, such as frequent fidgeting and excessive talking, began in early adolescence, Dr. Scofield said.

When trying to determine if a patient has ADHD, he recommends that physicians tell the patient, “This will require at least two to three visits, and I need your help to make the diagnosis, because I need information from other people such as your employers, friends and family members.”

That information includes details about the patient’s performance in school and on the job.

Physicians should ask whether the patient graduated from high school or college, got suspended or expelled from school, and changes jobs frequently, Dr. Scofield said. Doctors also should inquire about relatives who were diagnosed with ADHD, because there are genetic predispositions to the condition.

Dr. Scofield suggests screening the patient for psychiatric conditions to rule out other possible causes of symptoms. He also recommends giving patients a questionnaire that can help identify people with ADHD. One such tool is the Wender Utah Rating Scale for the Attention Deficit Hyperactivity Disorder. The 61-item scale is free and tailored to adults. It includes a subset of 25 questions that are associated with ADHD.

Dr. Scofield said he never makes an ADHD diagnosis on the first visit. “Any patient who gets mad that you’re not prescribing a stimulant after one visit should be a red flag” that the individual could be abusing prescription drugs, he said.

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Meeting notes

Here are meeting notes from the American College of Physicians annual scientific meeting.

Ask open-ended questions to deal with sensory complaints. When seeing patients who have dizziness or headaches, physicians should take an open-ended history, said Martin A. Samuels, MD, chair of the Dept. of Neurology at Brigham and Women’s Hospital in Boston and professor of neurology at Harvard Medical School.

Asking specific questions about whether the room spins or if a person sees double can lead patients to believe they have those symptoms, said Dr. Samuels, who led a session on neurology for the non-neurologist.

When caring for such patients, he often repeats the last three words of a patient’s complaint and turns it into a question. He then waits for the individual to respond. The technique shows patients that the physician is listening. It also allows patients to hear what they are saying and make a clarification if needed.

If patients come in and say they need treatment for a condition such as vertigo, Dr. Samuels often repeats the name of the condition. He then says, “Please don’t tell me what other doctors told you or what you read. Tell me only what you’re experiencing, and say it in simple English.”

Lung cancer screening encouraged for high-risk patients. More Americans die from lung cancer than any other type of cancer, said James R. Jett, MD, professor of medicine at National Jewish Health, a hospital in Denver. To help reduce such deaths, physicians should use low-dose spiral computed tomographic scans to screen for lung cancer in patients 55 to 75 who smoke or those who quit in the past 15 years, said Dr. Jett, a lung cancer specialist, in a session on the disease.

He knows his suggestion conflicts with the 2004 U.S. Preventive Services Task Force finding that there is insufficient evidence to recommend for or against screening asymptomatic people for lung cancer with a CT scan, chest x-ray, sputum cytology or combination of those tests.

Medical organizations differ on the benefits of lung cancer screening. The American Cancer Society has issued interim guidance that says physicians should consider screening patients age 55 to 74 who were current or former smokers with at least a 30 pack-year history of smoking and who are concerned about their risk of developing lung cancer. Former smokers must have quit within the past 15 years.

Dr. Jett recommends that before screening a patient, doctors tell the person there is a chance a nodule will be found on the lungs and will require follow-up care. He suggests patients with nodules 0.5 mm or smaller be screened again in a year. People with larger nodules should receive follow-up screens at varying intervals, depending on the size of the mass.

Teach patients how to care for chronic skin problems. Physicians should educate patients with chronic dermatologic conditions such as eczema about how to manage the problem and avoid flare-ups, said Julia R. Nunley, MD, professor in the Dept. of Dermatology at Virginia Commonwealth University School of Medicine.

Dr. Nunley, who led a session on common dermatologic conditions in primary care, recommends that doctors discuss with patients how long it will take for them to begin seeing an improvement. She also encourages physicians to schedule follow-up visits to monitor patients’ progress and offer moral support when an improvement in skin is not yet apparent.

Help patients kick the habit. Tobacco use is the leading preventable cause of death in the U.S., with an estimated 443,000 people dying from smoking or exposure to secondhand smoke each year, said Michael K. Ong, MD, PhD, assistant professor of medicine in the division of general internal medicine and health services research at the University of California, Los Angeles, David Geffen School of Medicine.

Dr. Ong, who led a session on smoking cessation, said Centers for Disease Control and Prevention data show that 69% of smokers want to quit. He said doctors need to boost their efforts to help this group kick the habit.

Dr. Ong encourages physicians to ask all patients if they use tobacco products, advise those who use such substances to quit and refer them to a “quitline” (1-800-QUIT-NOW) or another internal resource that can help patients give up tobacco.

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External links

American College of Physicians 2012 annual scientific meeting (link)

Drug safety communications, Food and Drug Administration (link)

“Prescription Drug Use Continues to Increase: U.S. Prescription Drug Data for 2007-2008,” National Center for Health Statistics Data Brief No. 42, September 2010 (link)

“Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999-2008,” Morbidity and Mortality Weekly Report, Nov. 4, 2011 (link)

Centers for Disease Control and Prevention on prescription painkiller overdoses (link)

“The effect of ADHD on the life of an individual, their family, and community from preschool to adult life,” Archives of Disease in Childhood, February 2005 (link)

Centers for Disease Control and Prevention on attention-deficit/hyperactivity disorder (link)

Wender Utah Rating Scale for the Attention Deficit Hyperactivity Disorder (link)

“Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults: Addressing Polypharmacy,” Archives of Internal Medicine, Oct. 11, 2010 (link)

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