Oh Yeah… They Make a Pill For That

March 30, 2008

When I originally went to work at the psych hospital, I spent most of my time right out on the front lines of direct patient care. I spent more time with our patients than the nurses, doctors, therapists, or just about anyone else (save for the other technicians, of course). We did groups with them all day long, took their vital signs, did “checks” every 15 minutes, and manned the desk of the nurse’s station that the patients have direct access to.

One of the most common reasons a patient would approach the nurse’s station was to ask for medication. Most of their medications are scheduled for certain times of the day… and they don’t have to ask for those. The med nurse delivers all scheduled medications when they’re due. But every patient also has access to PRN or “as needed” medications. We admit all patients with a standard list of these PRNs: Tylenol, Mylanta, Milk of Mag, Carmex, and eye drops. In addition, they almost always come with a few PRN medications specific to their situation.

In my front lines position, I never really knew what medications a patient was on. It wasn’t my job to know and I basically acted like a relay between the patient and the nurse: “Such-and-such is asking for something for a headache” or “So-and-so is getting agitated and might need a PRN”. Now, however, I see every single medication that every one of our patients is on, be they scheduled or PRN.

And let me tell you: the number of medications some of these people are on would floor you.

When new patients come in, they’re generally already on some meds. Their outside psychiatrist, family doctor, specialist, etc has already created a medication regiment for them. Generally speaking, we don’t mess with those regiments unless it’s believed that some medication they’re either on or supposed to be on (and not taking) is the reason they’re in psychiatric crisis in the first place. I guess it’s a generally accepted faux pas for one doctor to mess with the treatment of another one. Who knows. But 9 times out of 10, the only changes made to an existing medication regiment are substitutions for things we don’t carry.

Let’s do a check here real quick. So far we have medications patients are on before they come into the hospital (for anything from allergies, to medical conditions, to psych drugs). We add on a list of PRN medications and anything we’ve had to substitute. That’s not too bad I suppose.

But it gets worse… just wait.

Within 24 hours of being admitted, all patients are required to be seen by a family practice doctor in addition to their psychiatrist. So the psychiatrist adds psych meds – sometimes multiple psych meds – to both the list of the scheduled medications the patient gets and their list of available PRN medications. Then, the family practice doctor comes in and usually adds a med or two here for some non-psych medical condition or out of whack lab result.

So now we’ve got the meds the patient comes in on, our standard PRNs, the psychiatrist’s scheduled meds, the psychiatrist’s PRN meds, the family practice doctor’s scheduled meds, and the family practice doctor’s PRN meds. Keep in mind, of course, most patients have multiple changes and adjustments made to our part of the medication regiment while they’re in the hospital. So the list can continue to change for as long as we admit the patient.

Exactly how many medications are we talking here?

It’s not uncommon for most people to have some medication that they take on a daily basis. Allergies… blood pressure… depression… cholesterol… almost all of us are on medication for something. And we take these meds, what… once… maybe twice a day? That’s not bad at all. Easy to remember… and generally easy on the body. A little foreign chemical here and there doesn’t normally do too many terrible things to our insides.

So how many medications would someone have to be taking to be considered over-medicated? Three? Five? Ten? Twenty? How about forty? Would forty medications be too many?

Well guess what, folks? I’ve seen patients in our hospital pushing that many available medications. Now maybe they only have 15 or so scheduled with an additional 15 – 20 PRNs available. But still… 15 medications to take every single day at various intervals throughout the day?

Some have two or three meds for depression or mood stabilization… a couple of anti-psychotics… an inhaler for respiratory problems… pain medications… allergy meds… anticoagulants… blood pressure meds… diabetic meds or insulin… ointments/creams… and any number of other pills to for a wide variety of health issues. On top of that, they may have additional PRNs for pain, agitation, psychosis, anxiety, constipation, migraines, etc.

Don’t tell me that all of these medications aren’t interacting and possibly making things worse.

I just don’t believe it. You can’t put that many foreign chemicals in the body and not have some sort of adverse reaction. The problem is, we normally just treat those adverse reactions with – you guessed it – another medication. Case in point, it’s not uncommon for our patients to have scheduled, PRN, or both scheduled and PRN doses of Cogentin… a drug used to treat reactions from other medications. Now what does that tell you?

Part of the problem lies with the doctors. And some doctors are worse about piling on the pills than others. Between not messing with other doctor’s orders and approaching every situation from a ‘what pill can I use to fix this’ mentality, it’s no wonder some of these folks are on a dozen medications. Is it just our hospital or just psychiatric hospitals that this pertains to? Of course not. I see it everyday with non-psych issues and within my own family. My parents are probably on ten different medications between the two of them and not one of them is psych-related.

Part of the problem lies with the patients themselves. As unfortunate as it may be, a lot of our patients want as many drugs for as many things as possible. They either enjoy the feeling of being doped up to the point of near unconsciousness or they don’t want to try to actually deal with their problems. They go to as many doctors and as many hospitals as they can complaining of the same issues over and over again so that they can get as many prescriptions as possible. I don’t know how many times I’ve talked to pharmacies calling because a patient we’ve discharged has come in with prescriptions from our doctors for the exact same medications another doctor is already prescribing. And the patient just “forgot” to mention that to us… of course.

But society as a whole is also part of the problem. We’re so quick to look for a pill to fix all of our problems. We want the quickest, easiest, least painful way to deal with anything life throws our way. Why work through an issue if we can just medicate depression away? Why change diets and eating habits if we can just medicate our cholesterol down? Why waste the time learning coping skills when there are pills out there that can make your anxiety disappear just like that?

If science can discover a way to alter our biology to compensate for an unhealthy lifestyle or a maladaptive way of living, you can bet your bottom dollar people will line up to get that chemical fix. For some medical conditions, a pill is the best option. Some people would die if it wasn’t for their medications.

But come on. When does it become too much? If it takes three medications to ease your depression, don’t you think there’s a bigger issue? If you have to take two different pills three times a day to keep your anxiety in check, isn’t there a message from your brain being missed? And is it possible that you wouldn’t feel so disoriented and drugged all the time if you weren’t taking ten medications a day for things that could be dealt with in a better way? You wouldn’t need that Cogentin to keep the shakes away if you didn’t have all those pills to take!

Where do we draw the line?

Posted in Questions, Rants, Society