The polypharmacy crisis was probably inevitable. The U.S. population is among the world’s most medicated, served by a healthcare system that is among the least integrated. An aging patient-nation is treated by an array of mostly unconnected specialists – following single-disease-based guidelines, writing disease-specific scripts, measuring outcomes through disease-specific bio-markers. According to the NIH, 65% of U.S. seniors take five or more meds. 36% take more than nine.

Overwhelming… and Under-Reported
By any measure polypharmacy is a crisis, responsible for 30% of hospitalizations for seniors and other at-risk groups. If it were a disease, polypharmacy would rank in the top 10 for mortality. In multiple longitudinal studies, patients taking five or more meds were found to have significantly higher incidence of both hospitalizations and mortality across age, sex, and comorbidity burden.

Moreover, these data are almost certainly under-reported, since many ADRs – sleepiness, confusion, depression, falls, incontinence, loss of appetite – are easily confused with conditions of normal aging. Even more alarming is that ADRs are often misinterpreted as new medical conditions, leading to additional scripts, a vicious cycle benignly referred to in the literature as a “prescribing cascade.”

94-Page Action-Plans & Other Fantasies
Who’s keeping track of all these medications? Who’s monitoring patients holistically? Who’s double-checking drug-drug contraindications? The patients themselves? Not realistic. Pharmacists? Also not realistic.

No, it is PCPs who are best positioned to monitor and manage patients’ regimens – according to an unending stream of PCP-focused comprehensive “action-plans” from the NIH, the American Academy of Family Physicians, and medical centers throughout the country, as well as think tanks like The Lown Institute with its 94-page contribution.

The result? Effectively zero progress, likely because few of these action-plans seem to have any regard for the actual challenges and real-world limitations of time-crunched frontline physicians. As reported in medical journals and the mainstream media, researchers at U Chicago et al. determined that it would take PCPs a shocking-but-not 27 hours a day to adhere to all national guidelines. Said another way, PCPs already have 17-18 hours of daily recommendations that they don’t have the capacity to follow. 

So tempting as it may be to insist that PCPs incorporate a wide range of action-steps into their already maxed-out practices, instead let’s try a radically realistic approach. Let’s ask for just one.

“Throw It All in a Bag”
The most important step in addressing the polypharmacy crisis is the first one, but “even getting an accurate list can be extremely challenging,” says Dr. Milta Little of Duke University School of Medicine. Studies have found that fewer than 25% of EHRs contained complete information about prescription meds. Patient intake forms were (surprisingly?) slightly better, but still just 36% were accurate. Which OTC meds is a patient actually taking? How many dietary supplements? It’s anyone’s guess.

What some PCPs do – and arguably all should – is ask patients to bring all their meds to each appointment. “Throw it all in a bag and bring it in,” says Mariana B. Dangiolo, M.D., a family physician and professor at the University of Central Florida School of Medicine. The physical presence of all those orange vials, bottles, jars, tubes, drops, injectors, and inhalers puts the issue of polypharmacy front-and-center for both PCP and patient, likely making a medication reconciliation something close to a routine part of every visit. Has a 94-page action-plan ever done that?