Medication minefield

LITTLE ROCK — Not too many years ago, if you got sick, you went to see your family doctor, who maybe prescribed some medicine to make you well.

You took your prescription to the corner drugstore, where you knew the guy behind the counter and he knew you.

These days, health care has become an industry, your family doctor is now your “primary care physician,” patient privacy is paramount, every ailment comes with its own specialist attached and everything, if you’re fortunate enough to have health insurance, goes through the eye of your insurance company’s needle.

The older you get, the more likely you’re seeing multiple doctors, including a dentist, an eye doctor, an oncologist (if you have cancer), a cardiologist (if you have heart disease), an endocrinologist (if you have diabetes) and a doctor to look after your respective “plumbing.”

Four out of five people 75 and older are taking at least one medicine, and 36 percent are taking four or more, according to CareLink, a central Arkansas nonprofit agency that provides information and resources for more than 18,000 older residents of Faulkner, Lonoke, Monroe, Prairie, Pulaski and Saline countiestoward helping them stay active and in their own homes.

The proliferation of medications comes with the risk that pills may have unpleasant interactions. They might enhance or cancel out the effects of one another; in the worst case, complications could potentially be fatal.

Health-care experts agree that the pharmacist is the best gatekeeper in keeping track of what might interfere with something else, and to keep the patient and physician fully informed about the options.

“The best advice would be to pick one pharmacy and stick with [it] for all your prescriptions, regardless of how many physicians you see or how many prescribers you have,” says Stephanie Gardner, dean of the College of Pharmacy at the University of Arkansas for Medical Sciences.

That way, “The pharmacist will have a profile that will have all your medications listed.

Part of [his] responsibility is to look for drug interactions, for duplications of therapy [and] for medications that should have been discontinued, perhaps, before new ones started.

“In my experience, [it’s better] if a patient goes to one pharmacy or to a chain of pharmacies,” agrees Dr. Jeannette Shorey, professor of medicine and associate dean for continuingmedical education and faculty affairs in the UAMS College of Medicine.

“The brand doesn’t matter, but if they have electronic systems so that they can tell which branch of their pharmacy the patient has gone to, that’s the safety net.”

Gardner and Shorey concur that the real key is maintaining a complete, up-to-date list of all the medications you take, prescription and over-the-counter, and making sure every health-care provider you visit gets a copy.

It’s particularly helpful, Gardner says, “if you have a new prescription and have concerns about whether there’s an interaction, or you’re out of town, or you’re at a pharmacy that you don’t normally go to - maybe it’s the middle of the night and you’re at a 24-hour [pharmacy].

“If you take a list of your medications with you, they can look at it and make that same judgment as they would if they had your profile. Or if you don’t have it written down, if you can throw your bottles into a brown paper bag and take that with you, they can look through all of those and try to make sure the new prescription won’t interact with anything you’re already taking.”

The buzzword in the healthcare business, Shorey says, is “medicine reconciliation.”

“It’s tremendously important,” she adds. “Ideally, that should happen every time a patient interacts with any potential provider, and that the physician or the nurse or the physician’s assistant actually reviews the list and compares that with what the physician’s records indicate he believes the patient is taking.”

Shorey knows firsthand: She trained as an internist and practiced primary care internal medicine for many years before she moved into medical education.

“It astounded me on a regular basis,” she says, when the prescription records she had on file “didn’t match what the patient was bringing me on the next visit. The usual reason for that was that the patient was seeing other physicians who prescribed additional medication.

“I think it’s common for patients to think in a compartmentalized way: ‘This doctor takes care of this part of me and this doctor takes care of that part of me.’ There can be a trust and expectation that those doctors are communicating. I would certainly wish that it were true, but it doesn’t always happen.”

INFORMATION SHARING

Gardner adds: “Unfortunately, there’s not [yet] electronic health records that allow us to share information [among]pharmacies, except within a chain drugstore.”

“If you always go to Walgreens, regardless of which Walgreens you’re at, they’ll be able to access your records. But if you go to Walgreens oneday and the next day you go to Wal-Mart or to an independent drugstore, they won’t have a way to talk to each other.

“Eventually, in the next three to five years ... health information exchange will be much simpler, because anywhere you get your prescription filled can access your specific record.” And, she says, it should also help coordinate communication among doctors.

As it is, modern technology can help the pharmacist keep your medications in balance, Gardner adds. Most drugstores - not just the chains - have software that raises a red flag when there’s a known interaction between two prescribed medications.

“Most independent pharmacies have that, too; it flags interactions, doses that are outside the normal limits and duplications,” she says. “Then it’s up to the pharmacist to decide which ones are truly issues.”

INPATIENT PILLS

“One time to be particularly careful is if there’s a hospital discharge, because patients come into the hospital on some medications and they’re discharged on others,” Gardner warns.

“That’s the risky time, where sometimes there will be duplications of therapy: Patients get home and start taking the new one in addition to the one they already have.

“We recently had a member of our family discharged from the hospital; we made a very complete list and it ended up with 20 medications on it. So it’s not a simple thing for patients to keep track of.”

Having a complete medication list should cut down on another risk, says Debbie Gillespie, outreach manager for CareLink: “A lot of times we find people getting prescribed the same medicine [they’re already taking], then they go home andoverdose on it.”

COMFORT LEVEL

It’s important that the patient or caregiver always feels comfortable enough to ask questions.

“It ought to be simple and it’s sometimes awfully difficult,” Shorey says, “if patients have multiple people writing prescriptions for them, and for patients to feel comfortable speaking up to any health-care provider that there are multiple people on the scene.

“Health-care providers and patients have to partner in that. It is important that the providers ask, ‘What are the meds you are taking?’ - and ask in many ways: ‘Are there any others? Is anyone else writing prescriptions for you?’”

Sometimes patients believe they’re answering the question honestly the first time but may not fully understand it, Shorey says. “They’re not intentionally [being untruthful]; it’s justa matter of mindset.”

And sometimes they don’t understand that the doctor needs to know about not only the prescriptions but what the patient is taking over the counter, including aspirin and herbal preparations, “therapies that they may not think of in the way I would think of as a drug,” she says.

For example, she notes, some oral contraceptives won’t be effective if they’re taken close in time to certain antibiotics. And certain antibiotics react negatively to minerals such as calcium and iron, and so should not be taken in conjunction with multivitamins.

It’s also incumbent on physician and pharmacist to tell patients about possible interactions among their medications and certain foods.

“I think my colleagues at the pharmacy are the very best at that, and they have labels thatget stuck on pill bottles,” Gardner says. But she acknowledges that patients don’t always read, understand or comply with those labels.

“The best case is that when the pills are handed over there’s a conversation between the pharmacist and the patient about food interaction,” she says. “It would be ideal as well if the physician would have a conversation at the time the prescription is handed over. I daresay that doesn’t happen as often as it should.

“The key is having the whole list, bringing the same list to all one’s providers and editing it if [any] medication has changed.”

KEEPING THE LIST

“Communicating well takes some time; it doesn’t take forever, but it takes some time tomake sure doctor and nurse and patient are actually understanding each other,” Shorey says.

She says she’s a big fan of being able now to keep things like medication lists on smart phones, where they can be edited with a few keystrokes.

And at most pharmacies with online ordering systems, especially the chains, it’s possible to print out a complete list of prescription medicines from the page where patients can place orders. (That’s another argument in favor of getting all your meds from the same drugstore.)

Meanwhile, CareLink has come up with an easy, decidedly low-tech device: A wallet-size, paper, write-it-in-longhand list.

“It’s the size of your Social Security card or your Medicare card,” Gillespie explains. “And it fits in your wallet where you have your identification.” That way, “if ever an emergency happened, they’d have all their drugs and doctors; that’s just so helpful when they’re in an emergency room or going to a differentdoctor.” You can get free copies by calling CareLink at (501) 372-5300 or (800) 482-6359; the website is carelink.org.

In the end, it’s the patient and/or caregiver who has to keep that list of medications complete and up to date.

“The patient’s responsibility is to provide as much information as they can to the prescriber and the pharmacist, and if they’re going to multiple physicians for multiple problems, to share as much information as they can,” Gardner says.

Shorey adds that it’s important for patients and caregivers to take an active or proactive role.

“The person ultimately responsible is not the pharmacist or the physician, but you the patient - be aware of what you’re being prescribed, how you take it and what’s in the bottle,” she says.

“We’re all on a team, either in the same institution or a virtual team; every single one of us plays a role.

“Patients do need to be strong advocates for themselves, and if they can’t be, they need a partner who helps, a mate or a caregiver. We’ve all got some skin in the game. The patient has the most, because if medications have conflicting side effects, it’s that person that’s going to be in trouble.”