How Many Meds Are Too Many Meds?

When looking at an injured worker’s entire medication regimen, there is no specific number of medications that is automatically considered “too many.” Our Optum clinical reviewers know that the “right” number depends on the individual’s medical profile, conditions, injuries, and comorbid diseases. The number of medications excessive for one person could be exactly appropriate for another.

However, there’s no question that as the number of medications increases, so do the risks of adverse events, medication interactions, and potential health impacts.

The challenge of polypharmacy

Polypharmacy is typically defined as the use of five or more medications to treat one or more disease states in an individual. It is common in aging populations and with workers’ compensation catastrophic injury claims.

The following medications are often seen in claims with polypharmacy:

• Anticoagulant medications
• Non-steroidal anti-inflammatory drugs
• Antidepressants and antianxiety medications
• Sleep aids
• Gastrointestinal agents
• Cardiovascular medications
• Over-the-counter medications
• Diabetic medications
• Antipsychotics
• Bone-density agents

When an injured person is taking multiple medications, the increase for potential negative implications and interactions increases. Polypharmacy complications may include decreased quality of life; increased mobility issues; and health risks (adverse drug events, disability, falls, frailty, long-term care placement, inappropriate medication use, and medication nonadherence); as well as increased use of the health care system.1

Factors contributing to polypharmacy

• An aging population
  People are living longer, and they are working longer. As individuals age, there is a gradual decline in normal bodily functions — from muscle strength and capacity to bone density, balance, and internal organ function. Older workers are at increased risk of disease and other conditions, including obesity, diabetes, heart disease, and cancer. They are also at higher risk for comorbid conditions, which raises the chances they will be prescribed multiple medications. With each new prescription comes increased risk — and newly added medications may initiate bodily changes that interact with existing medications, causing new medication challenges.
   
• More specific medications and treatments
  As advances in diagnosis progress, the pharmaceutical industry continues to develop new and improved medications targeted to specific diseases. The number of new drugs approved each year has grown significantly over the past 15 years. This increase in new medications includes many specialty drugs, which generally treat chronic, complex, or rare conditions, and may also require special handling or monitoring of patients.2
   
• Increasing patient awareness of medications
  Through the internet, digital marketing campaigns, television, and word of mouth, people can become familiar with medications on the market. It’s not uncommon for an injured worker to request a specific medication from a provider because they believe it will help them. This increase in awareness may put pressure on providers to write another prescription, thereby adding to the total count of medications the patient is taking.
   
• Medication regimen complexity
  Clinical practice guidelines increasingly advocate the use of multiple medications to achieve therapeutic targets.3 While this can have distinct health advantages, it can also result in complex medication regimens for injured workers. And as the complexity of a medication regimen increases, it can become more difficult to understand and follow, which may lead to non-adherence. Errors in administration and dosing can have serious consequences, especially for injured workers who are taking high-risk medications.
   
• Transitions of care
  Moving an injured worker between care settings — for example, from the hospital to a rehabilitation facility — can cause medication issues. Patients may be prescribed medications by health professionals who are not aware of other providers and the medications they are prescribing. Or there may be a lack of communication and coordination between the physician, nurse, and pharmacist at different facilities. Poor medication reconciliation poses a significant risk for medication discrepancies, errors, and adverse drug events.
   
• More specific diagnoses
  There are nearly five times as many diagnosis codes in ICD-10-CM than in ICD-9-CM. The greater level of detail in the new code sets enables more precise identification and tracking of specific conditions. It also enables providers to record more accurate and specific diagnoses. A decade ago, a physician might prescribe a more general drug to address an injury or medical condition. Now, a physician might prescribe two drugs, each of which is targeted to a more specific diagnosis.

Medication misuse prevention

The consequences of medication misuse include extended illness, escalating health conditions, and increased expenses. And medication misuse may be a consequence of polypharmacy, but polypharmacy is not the only reason for misuse.

Prevention education is a key component of any comprehensive prevention plan to address substance misuse. To help claims professionals and providers, Optum provides information and educational tools that are easy to find and access. Our Ask-A-Pharmacist resource is available 24 hours a day, 7 days a week for questions. In addition, our pharmacy platform, VitalPoint®, presents a color-coded single Risk Score on the injured worker’s profile to alert the adjuster to medication and claim related escalating risks that may indicate potential medication concerns.

Other educational resources include those that teach core medication safety principles, such as Generation Rx, a program led by the College of Pharmacy at The Ohio State University. The mission of the program is to educate people of all ages about the potential dangers of misusing prescription medications. Generation Rx provides open-source educational materials that anyone can use to help prevent the misuse of prescription drugs.

As always, the goal is to keep each injured worker as safe and healthy as possible. Through essential communication, education, support tools, and careful monitoring, we can make sure that injured workers are receiving the medications and dosages that are appropriate — and will enable them to experience the best possible recovery and quality of life.

References
1.  Polypharmacy: Evaluating Risks and Deprescribing | AAFP
2.  Research and Development in the Pharmaceutical Industry | Congressional Budget Office
3.  Medication Regimen Complexity and Polypharmacy as Factors Associated with All-Cause Mortality in Older People – PMC (nih.gov)