The University of Nottingham

Policy, medical training and clinical practice have failed to adapt to a significant increase in the number of patients taking multiple prescription drugs, according to a new report published by The King’s Fund and co-authored by Tony Avery, Professor of Primary Health Care in the School of Medicine at The University of Nottingham.

Professor Avery said: “We are finding that increasing numbers of people are taking large amounts of medicines each day. This is not necessarily a bad thing, but sometimes it can result in harm, and sometimes patients cannot cope with the pill burden. Our report highlights the ways in which we can try and tackle the issues around ‘polypharmacy’ so that patients don’t have to take more medicines than they really need.”

Estimates suggest that from 1995 to 2010 the number of patients taking 10 or more medicines trebled2, reflecting a large increase in the number of people with complex, or several, long-term conditions —  largely driven by an ageing and increasingly frail population but also by increasing use of multiple interventions. While taking numerous prescription drugs (polypharmacy) has often been seen as something to be avoided in the past, the report shows that taking an evidence-based approach to polypharmacy should improve outcomes for many people.

However, with most research and health systems based on single disease frameworks, policy, medical training and clinical practice have often not adapted to provide ‘appropriate polypharmacy’ — optimising the use of multiple medicines and prescribing them according to best evidence. Our report suggests that for polypharmacy to be used more effectively there needs to be:

• better training for doctors in managing complex multi-morbidity and in polypharmacy

• more research set in the context of using treatments where people have several diseases, rather than selecting subjects who have single conditions

• national guidelines for multi-morbidity to match those for single conditions

• improved systems, particularly for GPs, to flag problematic polypharmacy

• regular reviews of patients’ medication and a willingness to consider stopping medication, particularly in cases of limited life expectancy

• changes in systems of medical care to move away from increased specialisation towards a focus on multi-morbidity

Helping patients to feel confident

The report argues that polypharmacy needs to be better understood and defined, and accompanied by more engagement with patients to ensure that medicines are taken in the way that prescribers intend. This may require compromise between prescribers and patients to ensure that patients feel confident in what they are taking and situations where medicines go unused or are wasted are avoided.

Integrated care is now widely accepted as the way forward in caring for people living with multiple, complex, long-term conditions. Appropriate polypharmacy, or medicines optimisation, now needs to be similarly accepted as one of the ways in which we can deliver more coordinated care.

Better understanding of the patient’s medicine in-take

Martin Duerden, the report’s lead author, said: “Currently patients may still be treated in silos where one specialist doctor will look after their care for diabetes, another for their heart condition and a third for their asthma. They will then be prescribed medicines for each condition but these are often not considered in the whole. We need more generalist doctors able to understand a patient’s medicine in-take in its entirety and how they are managing, especially if they have to take numerous medicines at different times in the day.

“A sensible way forward might be to identify those taking ten or more medicines and focus on them first. Their medicine intake should be regularly reviewed so that as well as adding a medicine as a condition worsens you can also scale back or even stop treatment — particularly recognising that end-of-life quality applies to chronic as well as cancer conditions.”

1. Polypharmacy and medicines optimisation: safe and sound by Martin Duerden, Tony Avery and Rupert Payne is available free to download or to purchase for £5 at:

www.kingsfund.org.uk/polypharmacy

2. Between 1995 and 2010 the proportion of people taking 10 or more drugs in a study of 300,000 patients in Scotland increased from 1.9 per cent to 5.8 per cent. This was a study by Guthrie and Makubate (2012),  ‘The rising tide of polypharmacy and potentially serious drug interactions 1995–2010: repeated cross sectional analysis of dispensed prescribing in one region’. Primary Health Care Research & Development, vol 13, supp S1: 45 2E.2