Drug Cocktails Out of Hand
Source:
Boston Globe
Massachusetts to Warn Doctors against Prescribing Multiple Psychiatric
Drugs
The Boston Globe - July 12, 2002
Massachusetts, grappling with soaring Medicaid prescription drug costs, will
warn doctors about a practice officials say costs millions and may harm some
patients: physicians prescribing multiple psychiatric drugs -- sometimes as many
as seven -- to individual patients.
Medicaid officials, who are seeking new ways to control drug spending, recently
turned their attention to psychiatric medications, which gobble up half the
state's $890 million drug budget. They said they were surprised by what they
discovered: Nearly 5,000 patients on two or more antidepressants. More than
1,100 on five, six or seven different psychiatric medications. And even one
mentally ill man for whom doctors simultaneously prescribed 15 mood stabilizers,
antipsychotics, and anti-anxiety drugs.
Dr. Annette Hanson, the state's Medicaid medical director, said that sometimes
psychiatric patients are so ill with numerous overlapping problems that their
treatment requires some sort of drug cocktail, just as for AIDS patients. But
she said that for various reasons, including the movement toward shorter
hospital stays, "poly-prescribing" or "poly-pharmacy" has gotten out of hand.
Dr. Ken Duckworth, deputy commissioner at the state Department of Mental Health,
said little scientific evidence exists that multiple drug regimens help
patients, and that, in some cases, they may worsen side effects such as weight
gain, agitation, and diabetes.
On Aug. 1, the agencies will warn hundreds of doctors to cut back on
unnecessarily prescribing medications for the state's Medicaid psychiatric
patients. If doctors don't voluntarily restrict the practice, Hanson said, the
state will consider requiring prior approval for psychiatric drugs -- a measure
patients' groups strongly oppose.
The Medicaid program is tracking the prescribing habits of psychiatrists and
physicians who treat the mentally ill and will send out two pharmacists to
educate the most frequent poly-prescribing offenders. This approach, known as
"counter-detailing," is intended to give physicians more objective information
than drug company sales people do during "detailing" visits, Hanson said.
"We are very concerned about this," she said. Medicaid spent $45 million last
year on the schizophrenia drug Zyprexa alone -- the most money spent on any drug
for Medicaid recipients. Officials don't know how much money they will save by
reducing multiple prescriptions for individuals but say the figure may be at
least $20 million.
Medicaid is wading into a mysterious but well-established practice in
psychiatric medicine. Many psychiatrists see poly-prescribing as part of the art
of treating the mentally ill, a sort of improvisational medicine; they know that
many expensive new psychiatric drugs -- or combinations of them -- work for some
patients, but they don't know exactly how. And they often can't predict which
drugs will help which patients.
"Sometimes psychiatrists are like mad scientists, and for some reason these wild
combinations work," said Toby Fisher, executive director of the Massachusetts
Alliance for the Mentally Ill. "We can't always say why, but we know the person
hasn't been in the hospital for a long time."
In academic medical centers in particular, physicians increasingly believe that
even similar drugs in the same class -- the schizophrenia drugs Clozaril and
Risperdal, for example -- work on different neurotransmitters in the brain and
may be more effective when combined. That's given doctors license to overlap
different medications, a practice growing more common, said Dr. Donald Goff,
head of the schizophrenia program at Massachusetts General Hospital.
Medicaid, the state health insurance program for 900,000 needy residents, tends
to cover the state's most mentally ill residents; people with severe depression,
anxiety, and schizophrenia often lose their jobs and their private health
insurance.
"With a lot of patients, doctors have tried these drug combinations out of
desperation because patients are so ill," Goff said. "Everyone is trying to
figure out the best way to proceed. Most studies say these medications end up
saving money over the long haul by reducing hospital stays. Everyone looks at
escalating pharmacy costs but not always at the big picture."
Dr. Juan Avila, a psychiatrist at the South End Community Health Center, said
one problem is that clinical trials on psychiatric medications are unrealistic.
They often study "a very clean population" of patients on a single drug for one
specific problem like severe anxiety.But in "reality we deal with individuals
with multiple problems and diagnoses, and we have to cope with all of these
variables," he said.
For example, Avila treats a woman who was admitted to the hospital twice for
psychosis but who wants to take only herbal remedies. He persuaded her after
several months to take low doses of two antipsychotics -- Risperdal and Zyprexa
-- but she won't take a higher dose of one.
"Someone may look at her prescriptions and say, 'Why is he giving her two drugs
and why low doses? This psychiatrist doesn't know what he's doing.' But you have
to look at the individual patient," Avila said.
Goff said Mass. General and other medical centers now are more aggressively
evaluating drug combinations. About one-third of schizophrenic patients are on
more than one antipsychotic medication, he said, and he believes half are
benefiting and half are not.
Many psychiatrists agree that poly-prescribing has gotten too common. Since
managed care took off during the 1990s, insurance companies have enforced
shorter hospital stays for psychiatric patients. This is true of patients with
all types of health insurance, not just Medicaid. When stays were longer,
doctors had time to "wash" old drugs out of patients' bodies while they were
still in the hospital before trying new medications. Now, with most patients in
the hospital a week or less, doctors don't have time to wean patients off old
drugs first. And when patients are discharged on new medications, their regular
physicians don't want to upset the delicate balance by taking them off of their
old drugs.
"In order to get patients out of the hospital, they snow them with medication so
they aren't doing whatever they were doing to get into the hospital," Hanson
said. "And then when they get out and go back to see their regular psychiatrist,
he says, 'Dr. So-and-So, a world-famous physician, put him on this. So who I am
to take him off?' The communication between inpatient and outpatient isn't
great."
Psychiatrists often use medications to control symptoms -- not treat causes of
illnesses. And the number of drugs for various symptoms from insomnia to anxiety
to hallucinations have exploded in the last decade, said Dr. David Osser, past
president of the Massachusetts Psychiatric Society and a psychiatrist at the
Brockton and Taunton Veterans Administration hospitals.
"If a patient can't sleep, the path of least resistance is to add a sleep
medication -- even if they're on four other drugs," said Osser, who advised
Medicaid on its plan to curb multiple prescribing. "This is improvisational
fly-by-the-seat-of-the-pants medicine. The real question is why are all these
people on all these medications?"
Osser recently treated a man with post-traumatic stress disorder who was taking
five medications -- an antidepressant, a mood stabilizer, two anti-epileptics,
and an antipsychotic. He came in asking for a sixth drug, a tranquilizer.
Instead, Osser said he signed up the man for cognitive therapy and eventually
weaned him off all his medications.
Medicaid will phase in a program beginning Aug. 1 to limit the state's drug list
to the most effective and lowest-priced drugs for certain diseases. But for
Medicaid programs across the country, controlling the cost of psychiatric drugs
has been extremely difficult because patients' groups have fought prior approval
and other limits. Hanson said she understands patients' concerns, which is why
the program is trying an educational approach first.
