Polypharmacy Increased in Adults NHANES Survey Reports
Commentary by Carrie A. Diulus, MD -- Orthopaedic Spine Surgeon
Commentary by Elizabeth D. Kantor, PhD and Carrie A. Diulus, MD
Overall prescription drug use increased 9% among U.S. adults between 1999 and 2012, according to data from the National Health and Nutrition Examination Survey (NHANES). Use of 5 or more prescriptions nearly doubled during this period, researchers reported in the November 3 issue of JAMA.
“When we look at these results, we might first think that this is attributable to the aging of the U.S. population. However, when we adjust for the changing age structure of the U.S. population we found that these trends persisted, suggesting that there are factors other than age that are driving the observed increase prescription drug use,” explained lead author Elizabeth D. Kantor, PhD, Assistant Attending Epidemiologist at Memorial Sloan Kettering Cancer Center, New York, NY.
Dr. Kantor and colleagues evaluated trends in prescription drug use among 37,959 adults (age ≥ 20 years) participating in NHANES. Seven NHANES cycles were included (1999-2000 to 2011-2012), and the sample size per cycle ranged from 4,861 to 6,212. Within each NHANES cycle, use of prescription drugs in the prior 30 days was assessed overall and by drug class.
The prevalence of prescription drug use increased from 51% in 1999-2000 to 59% in 2011-2012, while the prevalence of using of ≥5 prescription drugs increased from 8% to 15%.
Increases in Select Analgesics Found
Use of prescription analgesics remained stable during the study period (11%); however, different trends were found when individual analgesics were analyzed separately. For example, use of cyclooxygenase-2 (COX-2) inhibitors decreased from 1.9% to 0.6%, while use of narcotic analgesics increased from 3.8% to 5.7%. The increase in use of narcotic analgesics primarily occurred from 2003 to 2004, and stabilized thereafter.
Trends in analgesic use also differed by age group with a significant decrease found among participants age ≥65 years (from 18% to 14%), but no changes found among those ages 40 to 65 years (13% to 14%).
Use of muscle relaxants increased from (1.2%-2.5%), and was due to a significant increase in use among women (1.2% to 3.3%). In contrast, men did not show an increase in use of muscle relaxants (1.3%-1.7%).
Most Commonly Used Medications
Simvastatin was the most commonly used drug in 2011-2012 (7.9%), increasing from 2.0% in 1999-2000. The remaining top 10 drugs included lisinopril, levothyroxine, metoprolol, metformin, hydrochlorothiazide, omeprazole, amlodipine, atorvastatin, and albuterol. With the exception of atorvastatin, all of these medications increased in use over the study period except.
Notably, several of the top 10 most commonly used drugs in 2011-2012 were medications used to treat factors associated with the cardiometabolic syndrome—including hypertension, diabetes, and dyslipidemia—or obesity.
Nearly 40% of Elderly Use 5 or More Medications
The increase in use of 5 or more medications “was particularly notable among participants age 65 and older where we observed polypharmacy to increase from 24% to 39% in 2012,” said Dr. Kantor.
When examining whether trends for particular drug classes varied over the period, study authors found that the greatest increase in prescription drug use occurred early in 2000s, “which I think is interesting as we think of what factors may or may not be driving the observed increase in prescription drug use,” Dr. Kantor said.
Carrie A. Diulus, MD
Orthopaedic Spine Surgeon
Crystal Clinic Orthopaedic Center
As chronic diseases increase in this country at a logarithmic rate, the NHANES data on the increase in use of medications is not surprising. The use of these medications impacts diagnosis and treatment of spine patients. The study found that the most commonly used drug, not surprisingly, is a statin. With the newer cardiac recommendations, statin usage seems to have become almost ubiquitous.
Statins, however, are not without their side effects. Muscle pain resulting from the medication is not uncommon and can often be mistaken for having a spinal origin. While spine providers may have concern about temporarily taking patients off of statin therapy to see if their symptoms improve, this trial can make a substantial improvement in patients’ quality of life and potentially avoid unnecessary additional medication, advanced imaging studies, and surgery. For patients with a history of heart attack, I use caution prior to stopping the medication and discuss it with the patient’s cardiologist. With most other patients, a short trial off the statin is generally safe and patients often report improvement in a very short period of time.
It also is not surprising that the next most common drugs are those used to treat cardiometabolic syndrome and associated conditions. The number of patients with these conditions is even higher than data on medication use would indicate. Currently, more than 90 million adults—up to 50% of the U.S. population—have diabetes or prediabetes, and many of these patients don’t know it. We see both macrovascular and microvascular complications in patients often before they are diagnosed. Treating patients with lifestyle modification is often more effective than medication, and yet we are seeing this data indicating that medication management is the primary means of treatment. Motivated patients with type 2 diabetes often have the potential to reverse the condition with lifestyle changes without medications or with lower doses of medications. Studies have demonstrated that when physicians are strong supporters of these lifestyle changes, patients are more successful.
As spine providers, we often have the opportunity to be even stronger motivators of change than primary care physicians. Spine outcomes are not as good in diabetic patients, particularly poorly controlled diabetics, compared with those who do not have glucose intolerance/insulin resistance. Taking this into account, counseling our patients about expectations for outcome is important to consider, but better yet, helping to motivate them to make necessary changes can decrease their medication need, improve their outcomes from spinal procedures, and improve their quality of life.
Omeprazole is listed as one of the top 10 medications. Long-term use of proton pump inhibitors can impact mineral absorption and can lead to increased risk for bone insufficiency fractures. I have seen pelvic stress fractures with prolonged use even among men in their 30s who have no other risk factor. When we are contemplating doing repeated epidural steroid injections or fusion surgeries in our patients, we should consider screening DEXA scans in those who have as history of long-term proton pump inhibitors.
It is easy in medicine to develop tunnel vision and focus on treating “only” our patients spine-related conditions; however, the human body and all of these conditions and the medications used to treat them are a complex interconnected web. We better serve our patients when we take all of these factors into account.