The challenges of polypharmacy

This episode of “Good Health, Better World” is all about polypharmacy, or more than one medication at the same time. Tune in to understand some of the considerations for chronic medications as we age, and hear about how insurance plans and pharmacies work together to help members and patients manage their medications as prescribed.

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Episode transcript

Ellen

Stronger communities begin with good health—for everyone.

You’re listening to the “Good Health, Better World” podcast from UPMC Health Plan. This season, we’re exploring the joys, challenges, and opportunities associated with healthy aging. We’ll talk about what it means to age well; how to care for body, mind, and spirit as we get older; and the tools and programs available to ensure a good life, throughout life.

I’m your host, Dr. Ellen Beckjord. Let’s get started.

We're joined by Vanessa Campbell and Stephanie McGrath in this episode to learn about polypharmacy. We'll discuss medication use in older adults and how insurance plans and pharmacies can work together to help members and patients manage their medications as prescribed. 

Stephanie, welcome to “Good Health, Better World.” 

Stephanie 

Thank you. 

Ellen 

Vanessa, thanks for joining us on “Good Health, Better World.” 

Vanessa 

Thanks for having me. 

Ellen 

Vanessa, if I could start with you, but would love to hear from both of you, what is polypharmacy? 

Vanessa 

So it can be defined a lot of different ways depending on the context. Overall, it is the simultaneous use of multiple chronic medications. And why I say it kind of depends on the context is that, depending on the resource that you're looking at, whether it's the CDC defines it as like five or more medications that folks are taking per day, or other resources may say seven or nine or more medications, but ultimately it is the use of multiple chronic meds. And obviously this can lead to several issues with medication management and adherence. So definitely a pretty big hot topic in our world today. 

Ellen 

And just for our listeners, Vanessa, I think you use the phrase “chronic medications,” and I'm assuming that means medications that people take indefinitely as compared to, say, maybe an antibiotic where you're going to take it for 10 days. Is that right? 

Vanessa 

Yes. 

Stephanie 

So polypharmacy from a pharmacist perspective is very problematic because the more medications that a person takes, the more likely they are to have a side effect or that they could interact. So it's really important that we acknowledge that this could be a problem. And I'm excited today to talk about ways that we can help to prevent those issues. 

Ellen 

Stephanie, is it appropriate to say that sometimes those challenges arise by the fact that those medications may be prescribed by more than one provider, and sometimes providers don't have full visibility into all of the medications that a patient is taking? 

Stephanie 

Absolutely. So the more chronic health conditions an individual has, the more likely they are to visit multiple providers. 
 
Sometimes it's their primary care provider, sometimes it's a specialist, sometimes it's multiple specialists. Sometimes it's urgent care. Sometimes it's a hospitalist. And so when they're discharged from a hospital visit, there can accumulate to be a large number of medications that an individual would have in their home. So I think that is ultimately one of the greatest challenges with polypharmacy, is that there are multiple prescribers giving a patient medication. And it's the patient that has all of the medication. And if they're filled at the same pharmacy, that's where the pharmacist can really help the patient understand what medications they should be taking and shouldn't be taking and discontinue the ones that they should not. 

Ellen 
Both of you are pharmacists, but you're working in different contexts. Stephanie, you're a pharmacist who represents a network of community-based pharmacies and are doing program development with those community-based pharmacies, interacting with health plans. Vanessa, you're a pharmacist working within the context of an insurance company, where there are all kinds of ways that you and your team serve our members related to pharmacy. 

But we're having this discussion about polypharmacy in our season of “Good Health, Better World” devoted to aging. It sounds like, based on the definitions, that polypharmacy is not unique to older adults. But, Vanessa, could I start with you: Why is polypharmacy especially important to think about in the context of aging and older adults in particular? 

Vanessa 

Sure. So as we age, our bodies go through a lot of changes specifically with slower metabolism, how drugs move through the body. So drugs, or medications, stay in our system a lot longer as we age. So that's where polypharmacy really becomes even more of a huge issue because those drugs are sticking around longer in an older member’s body, where there could be significantly [more] drug interactions or adverse events, which to Stephanie's point is where programs and retail pharmacies and such really come into play with like helping a member navigate that. 

And in case you can't tell how passionate I am about the subject of polypharmacy, it's because I am board certified in geriatrics. So I've really found a love for studying the way our bodies change as we age and how that impacts medication metabolism and how long that medications stick around in our body as a result. 

And I think that one of the things that many people don't realize is, you know, medications can definitely cause a lot of different side effects or the way that it interacts with our body. And so, sometimes a patient might say, “I'm getting a lot of dry mouth” or maybe “I'm starting to have blurry vision” or an array of different things, but sometimes medications are then added on to combat those side effects that were originally caused by maybe that original offending medication.

So it's another important point, talking to your pharmacist about any side effects or how your medications are making you feel and telling your providers so that potentially those things can be addressed by maybe decreasing your dose, changing you to an alternative medication in place of, like, adding more and more medications, which even further contribute to polypharmacy. 

Ellen 
Stephanie, how about your perspective on polypharmacy in older adults? 

Stephanie 

Sure. Absolutely. So as we age, we're more likely to develop more chronic health conditions—high blood pressure, diabetes, in particular are some of the most common chronic health conditions that are managed by medication outside of just diet and exercise. And so the longer we live, the more likely we are to need medications to manage those health conditions. 

So if you start adding medications for some health conditions early in your life—again, as you age, you start to add more and more and more to help manage additional medications. And the more medications that you add onto that regimen, the more likely there will be for some things to interact. 

So the pharmacists are specially trained to look to see if each medication is appropriate and indicated at that point in time. So just because a patient started taking it 5, 10 years ago doesn't necessarily mean that it's still appropriate for them at this point in their life, based on the chronic medical conditions that they have, based on their age as well.  Over 65, some medications are just not recommended to be used for the reasons that Vanessa just described. So the pharmacists are looking to see is the medication indicated? Is it effective? So is the medication even working? It could have many side effects or drug interactions. And if it's not working, we need to think about a different strategy. Is the medication safe for that patient? Again, drug interaction side effects are common problems. And then is the patient able to take the medication? So we talk about adherence quite a bit. Adherence to medication is essentially a patient's ability to take that medication as prescribed by their physician. 

And so, for a variety of reasons, people may not be able to take a medication. And if they're not taking it, it could be problematic because if their primary care doctor has it on their list that they're taking it, but they're actually not taking it for some reason, that can cause some issues too. Really making sure that there is an up-to-date medication list that's accurate, that's reflective of what the patient is doing, what they can do, and making sure that all health care providers that are involved with that patient's care are on the same page with that medication list.  

Ellen 
I'm just really struck by listening to both of you about the complexity and the real burden, like the morbidity that can be associated. On the one hand, people are probably very grateful for medications that they can take to help them manage chronic conditions, to help, you know, reduce the impact of various health conditions or extend their life. 

But listening to both of you talk and thinking about older adults in particular where a whole constellation of things may be happening, including challenges related to cognitive function, social isolation, just even the processes of, the logistics of obtaining your medications. I mean, this is a heavy burden. 

As a behavioral scientist, I tend to think a lot about health behaviors that people engage in or don't that can be helpful or less helpful for their health or managing chronic conditions. And this, of course, is a whole set of health behaviors. But it's like a really complex set of health behaviors that I'm just noting how like overwhelming I'm thinking about how it might be.  

And Stephanie, you mentioned, you know, if you take medications early in life, then you really could be on the road to polypharmacy later in life as you need to bring more and more on board. But I'm also, I guess, thinking about people who maybe live most of their life without having to take any medications at all, and then maybe at some point like it just, you know, hyperlipidemia, hypertension, diabetes, suddenly you're crashing into needing to take a lot of medications. And that, again, I think it just speaks to the importance of the support that the fields that you represent provide to consumers because it seems like it's really, really needed. I'm grateful for the opportunity to hear from both of you as part of raising awareness of that support. If either of you care to just speak briefly about how what is going through my mind right now is reflected in your day-to-day experience? 

Stephanie 

Sure. So our pharmacists see many older adults quite often because they're filling their prescriptions, sometimes multiple times a month, you know, coming in for different prescriptions. 

And while those regular touch points are very helpful to answer questions, sometimes that becomes a lot for the patient or the caregiver to visit a pharmacy that often. And so one of the services that some of our pharmacies offer is medication synchronization. So syncing their medication fills to be filled on the same day every month. And then allowing that patient or caregiver, you know, this is your day, your pickup day, to come in and let's talk about your medications. And make sure that these are the right medications as well.  

Some of our pharmacies also offer services like medication reconciliation, where it's kind of like a med checkup. So let's go through all of your meds, all of your OTC supplements. Let's see what you're taking, what you should be taking, what you shouldn't be taking. Often, when you do that, either in a patient's home in some cases or the patient can bring their medications in and go through all of the pill bottles and everything, our pharmacists find two doses of the same medication, where, you know, the prescriber intended them to increase the dose and the patient just continued to take it, both doses. So that's just, you know, one very specific example, a simple example of polypharmacy, but happens time and time again. 

We talked a lot about prescription medications, but most people also take over-the-counter supplements and vitamins. And there can be an assumption or a perception that those are completely safe because they're available over-the-counter. And that's not always the case. Especially as you age or when you start thinking about how they may interact and combine with prescription medications or even other supplements. 

So I would just share this great caution to make sure that when you think about your up-to-date medication list, you also include those vitamins and supplements as well. And again, share those with your pharmacist, share those with all of the other providers and prescribers on your care team, because they all play a role together in your body. And again, especially as you age. So, just because it was safe for you when you were 50 doesn't necessarily mean it's safe for you when you're 70. So, important to continue having that conversation with your pharmacist and your health care providers. 

Vanessa 

And part of what you were saying, Ellen, struck me and I wanted to kind of add in about the social isolation and some of the behavioral factors in addition to medications and addressing polypharmacy. 

But some members might not realize that in addition to looking at your meds, providing education and counseling on those topics, pharmacists have also really evolved into becoming almost these, like, mini social workers in terms of surveying folks for social determinants of health. On every phone call that our pharmacists make here at the Health Plan, we screen for social determinants of health to really make sure that if we identify an issue with housing or transportation, that we're making the appropriate referrals to get members the help that they need. 

And I think that why that is so important in regards to adherence and polypharmacy is that if a patient doesn't have a place to live or, you know, is struggling to even afford like utilities or food, they obviously are going to put their medications on the back burner in terms of taking those and filling them on time. 

So I think that one of the great ways that our partnership has really evolved is that we also will screen Health Plan members at the point of sale at these community pharmacies for those same social determinant of health needs. And so our teams are really working together to make sure that we're really putting our arms around these members and making sure that they get the assistance that they need so they can take their medications and live healthier lives. 

Ellen  
Yeah. It sounds like you're both talking about really innovative ways that you're making the most of that engagement opportunity. You know, we're so often seeking to engage our members or engage patients, but people have such full and busy lives and trying to capture the right moment to facilitate that engagement is difficult. But when people are seeking to obtain the medication that's been prescribed, they're in need of something, they're showing up to have that need fulfilled. And then that creates an opportunity to do a whole lot of other things that provide deep support to that person. And that doesn't happen by accident, right? That happens because of your leadership and your vision for how to capture that. So thank you.  

Vanessa 

Absolutely. 

Ellen 
There seem to be more tools all the time that are intended to help people manage medication, achieve medication adherence. Seems like they would be relevant to polypharmacy, and I'm thinking specifically of digital tools. 

Stephanie, can you talk a little bit about how digital tools can be useful for people who are taking a lot of medications? And Vanessa, I'd love to hear your perspective, too.  

Stephanie 

Yeah, absolutely. I think that's one great benefit of technology is hopefully to help make our lives easier and help us remember the things that maybe sometimes we forget. 

So, I mean, just simple reminders on your cell phone—my mother-in-law uses a reminder on her cell phone to the point where my kids say, you know, “Mimi, it's time to take your medicine!” when the timer goes off—to sophisticated apps on your phone that can help you, or if you are a caregiver for another individual, to help manage those medications. 

Many of our pharmacies use medication refill apps so that the patient can communicate with the pharmacy through an app to request refills of their medication or send refill reminders. Looks like you should be due for this medication. Can we fill it for you? So some of those processes are automated based on prescription fill history, and that's how technology helps to support that. 

And some of our pharmacies also offer tools like adherence packaging. There's multiple varieties of different forms of adherence packaging, but essentially you can see, OK, I've got four days left of the week. What pills did I take or what pills didn't I take? Also very helpful for caregivers to utilize that type of tool. 

Vanessa 

And there can be several barriers related to adherence or why somebody might not be taking their medications on time. For some, like if it might be a side effect-related issue, sometimes members don't want to wait until they have a doctor's appointment like six months from then to have that discussion. So some, unfortunately, will abruptly stop the medication, which can be very harmful to their health.  

So we have virtual support tools at the Health Plan that link a pharmacist directly to the member when they need it. So members are able to go on there when they have a question, maybe about side effects or something that's going on with their medication, linking to a licensed pharmacist to have that discussion so that we can provide support—whether it be education and counseling, to connecting with their physician and making an alternative recommendation, if needed, based on, you know, what is happening with the member. 

Ellen 
That's a great segue to the next question I'd like to ask. But before I do, I just want to pause to note, like I'm maybe making an erroneous assumption, but I think it's worth noting for listeners that pharmacists and health plans have a lot of support available to consumers related to medication, medication adherence, managing polypharmacy. 

I don't know how well-known that is, but knowing, you know, a lot about the work that you do, Vanessa and your teams and Stephanie less directly about yours, but I just—I think this kind of support is so instrumental, it's so critical and it's so wonderful that it's available to people. And I hope that we can help raise awareness of that so more people can take advantage of it. 

Vanessa 
Thank you. Just to add, I think that to your point that several folks may not know is that even from a health plan perspective, all of the claims that are coming through in terms of when you're filling a medication at the pharmacy—and to Stephanie's point, there could be multiple physicians but there also could be multiple pharmacies involved—we are surveying all of those claims from all of the inputs to really run like drug utilization review checks on those. Those are things members might not even know that are happening just to keep them safe, to make sure if we're seeing a contraindication, a side effect, you know, something that could harm the member, that we're acting on that by working with our provider to make sure that we streamline their medication list. 

Stephanie 
I was just going to add that 90 percent of Americans live within five miles of a community pharmacy. And I think that is sometimes an underutilized resource. Pharmacists are the most accessible health care provider. They see their patients 10 times a year more than the primary care provider will see the patients in many cases, and so patients do have this really great resource at their fingertips. But they need to ask questions. 

One point I'd like to convey is to empower patients to do that—to ask questions of their pharmacists. For the caregivers as well to ask questions, because they see the whole picture, they know what they're taking or not taking or, what their parent or child is taking or not taking. And I think it's really important for the patient to be actively engaged and involved in that care as well.  

Ellen 

Could you share some ways that health plans and pharmacies work together to keep patients and members safe? To support patients and members who are taking multiple medications? Any examples you care to share about even how the two of your teams work directly together? 

Vanessa 
So my team reaches out to members and providers on a daily basis, whether it's transitions of care issues, chronic management with disease states, and every day we come across issues where a member may need to put their medications on automatic refill. Maybe they're having transportation issues where med packaging would really be helpful in having free delivery to their door each month with like, a box of their medications. 

And so we are outreaching to pharmacies like the ones that Stephanie works with on a daily basis to try to, you know, make those links, set those things up for members, really take the work off of the member just because a lot of what they're dealing with on a daily basis is like multiple appointments, how do I afford my medications, and even things outside of their house, like what's going on with, like, their utilities, their housing? So we really try to assess members with all of those things. 

And I think the really great thing about our partnership with Stephanie and all of the pharmacies in her network is having that bidirectional communication to where they could be seeing someone in their pharmacy that's our member, or we're on the phone with a member that's using their pharmacy. And really working together to make sure that the member has everything that they need and is taking care of. 

Stephanie 

Absolutely. And I would just add that, you know, the pharmacies typically see that person, right? So the person is walking into their door and acknowledging that there's a problem or they need help with something. Because of the partnership that we have, our pharmacists are in tune to the resources that the Health Plan offers. So they may not have the answer in that moment, but they can call the Health Plan and help the patient get transportation to their doctor appointment, for example.

And the technology aspect of the relationship, a lot of those things that happen on the back end that Vanessa described—pharmacists receive notifications when they're filling prescriptions about drug interactions and things that may be occurring with medications filled at a different pharmacy. So that's an interesting way, again, that I don't think most people, if you're outside of that world, appreciate the data sharing that can occur. And data is powerful and you can make better decisions if you have access to that information.  

Ellen 

Absolutely. This has been a really insightful discussion. I want to thank both of you for taking the time to talk about these things with me. Stephanie, thanks so much. 

Stephanie 

Thank you for the opportunity. 

Ellen 

Vanessa, thanks for joining us on “Good Health, Better World.”  

Vanessa 

Thanks so much. 

Ellen

We hope you enjoyed this episode of “Good Health, Better World.” Be sure to tune in next time and visit upmchealthplan.com/goodhealth for resources and show notes.

This podcast is for informational and educational purposes. It is not medical care or advice. Individuals in need of medical care should consult their care provider. Views and opinions expressed by the host and guests are solely their own and do not necessarily reflect those of UPMC Health Plan and its employees.

Guest speakers:

 

 

Vanessa Campbell 

Director, Clinical Pharmacy, UPMC Health Plan 

Vanessa Campbell is the Director of Clinical Pharmacy at UPMC Health Plan who oversees their clinical care management, pharmacy quality, and pharmacy provider incentive strategies. She leads a team of clinical pharmacists that outreach to members through a variety of modalities addressing disease state management, post-acute, quality (HEDIS and STARS), and value-based arrangements. She is also Board Certified in Geriatrics. 

 

 

 

Dr. Stephanie McGrath 

Executive Director, Pennsylvania Pharmacists Care Network 

Dr. McGrath is also Director of Community Partnerships and Adjunct Clinical Instructor with the University of Pittsburgh School of Pharmacy. She previously served as an Assistant Professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy from 2010-14 where she contributed to the community pharmacy curriculum. She was recognized in 2013 as the APhA-ASP Faculty Member of the Year and in 2015 as a Rising Star from the Alumni Society Board. She currently works with students and post-graduate trainees to advance community pharmacy practice in Pennsylvania.

Dr. McGrath is an active Pennsylvania Pharmacists Association member and was honored as the 2013 Distinguished Young Pharmacist, one of the 2017 “Ten Under Ten” awards for PPA, and the 2020 Pharmacist of the Year award recipient.