Johanna Trimble on tackling over-medication as a CADeN public partner
Johanna Trimble is a founding member of CADeN and a past co-chair and current member of our Public Awareness Committee. Here, she writes about her experience engaging as a public partner with our network to raise awareness of medication overload and how to prevent harm.
The theme of World Patient Safety Day 2023 is engaging patients for patient safety. In celebration of the amazing contributions of our patient and public partners, we asked a few of them two questions about their experience engaging with our network.
Johanna Trimble (pictured above) is a founding member of the Canadian Medication Appropriateness and Deprescribing Network (CADeN), and a past co-chair and current member of our Public Awareness Committee. Read her responses below!
Why is it important for you to contribute as a public partner with CADeN, and what are the most rewarding aspects you've experienced so far?
When I began advocacy work on over-medication over 12 years ago, nobody quite knew what I was talking about. I would say—“many older people are on too many drugs and it can seriously harm them! I know because it’s happened in my family more than once.” But often friends with older parents did understand. I would hear this repeatedly: “they keep giving my Mom more drugs but she just gets worse not better.” These families were seeing the consequences of over-medication but had no solutions or were afraid to bring it up to medical staff. I began to see this problem as a public health issue on the scale of the harms of smoking. I still do. I felt we would need to make this a national priority to begin to make a change. As with smoking, the evidence of the harms of over-medication and the need for change is becoming more and more clear.
CADeN has been working towards this change since it started and I’ve been involved as a public partner from the beginning. Working with like-minded doctors, pharmacists and public partners has legitimized and reinforced what I saw happening in my own family. I had hoped, but had difficulty imagining, that this issue would be taken up at a national level. CADeN is doing that. An emphasis on effectiveness, safety and education is of equal importance to access to pharmaceuticals for any National Pharmacare strategy. I saw the consequences of over-medication in my own family and experienced the difficulty of addressing it alone. Tackling this issue will have the best chance of success if we can work together: politicians, citizens and medical professionals.
How has your involvement with CADeN as a public partner impacted you and your community?
CADeN has reinforced and legitimized my personal experience with over-medication issues. It’s no longer just my own opinion and experience that I bring to my community work but the backing of the doctors and pharmacists that I work with in CADeN. We’re working towards the same goal of patient health and safety. We’ve been able to write information in plain, not medical, language for public handouts on pharmaceuticals. I am confident using them as they have been checked for accuracy by our CADeN pharmacist. I can use these freely at community events, meetings and workshops for both the public and for medical professionals. Personally, I now have a feeling of camaraderie with professionals that I value highly. Some of our public informational handouts have been taken up internationally and it has been tremendously gratifying that our work is known and used beyond Canada.
Summer heat waves and the medications that increase your risk
Click here to download a printable version of this article.
By Camille Gagnon, Pharmacist, Assistant Director of the Canadian Medication Appropriateness and Deprescribing Network
For many Canadians, summer is synonymous with having fun in the sun. Unfortunately, over the past several years, extreme heat waves have become increasingly common. This not only makes summer less enjoyable but can affect your health. Heat and humidity can cause heat stroke, dehydration, dizziness and fainting, hospitalizations, and even death.
As you get older, it becomes harder for the body to adjust to changes in temperature. That’s why older adults are at greater risk during periods of extreme heat. Certain medical conditions more common in older adults, such as diabetes or Parkinson’s disease, can also make it harder for the body to adapt to heat.
Did you know? Some medications can increase your risk of heat stroke
Certain commonly used medications can make you more sensitive to the effects of heat. These medications can increase your risk of heat stroke and other heat illnesses. The more medications you take, the greater your risk.
Medications that can increase your risk
Below are several examples of medications that can impair your body’s ability to adapt to heat. Many of them are commonly used medications. Some are available with a prescription and others are available off the shelf in your pharmacy. Are you taking any of these medications?
Some medications impair the body’s ability to produce sweat, which is essential for cooling off when it’s hot out. For example:
Beta blockers (e.g. metoprolol or bisoprolol), which are medications used for certain heart conditions and for treating high blood pressure.
Decongestants such as pseudoephedrine, an active ingredient in cold medications that are available off the shelf.
Anticholinergic medications, which include some off-the-shelf allergy medications (e.g. diphenhydramine or Benadryl®), off-the-shelf sleeping pills (e.g. Nytol®), medications used to treat urinary incontinence (e.g. oxybutynine), and some antidepressants (e.g. amitriptyline or nortriptyline).
Click here to learn more about anticholinergic medications.
Some medications can make you dehydrated. For example:
Diuretics (e.g. hydrochlorothiazide or furosemide), laxatives (e.g. Senokot®) or some diabetes medications (e.g. Invokana® or Jardiance®), which increase the elimination of bodily fluids through urine or stool.
Some antidepressants (e.g. fluoxetine or venlafaxine) cause excessive sweating, which can lead to dehydration.
Some medications can increase your body temperature. For example:
Antipsychotic medications, such as olanzapine or quetiapine.
Stimulant medications for attention disorders, such as Ritalin® or Adderall®.
Some medications can make you drowsy, reduce your ability to concentrate, and slow your reaction time. This can impair your ability to adopt safe behaviours in period of extreme heat, such as drinking water or staying cool. For example:
Some medications can become toxic to the body and kidneys if you become dehydrated from the heat:
Anti-inflammatory medications (e.g. ibuprofen or Advil®, naproxen or Aleve®).
Blood thinners, which are used to prevent blood clots.
Medications for high blood pressure.
Various medications used to treat diabetes, including metformin.
Lithium, for bipolar disorder.
What can you do to prevent heat stroke and protect your health this summer?
If you take medications, especially any of those identified in this article, it’s particularly important to take action and prepare for the heat this summer. Here are 3 things you can do:
Protect yourself from extreme heat and stay hydrated, as per your health care professional’s recommendations. Visit this Government of Canada webpage to find out how to stay cool and hydrated during periods of extreme heat, and what to do in case of heat stroke.
Complete a thorough review of all your medications with your doctor, pharmacist or nurse. Make an appointment specifically for a medication review. Together with your health care professional, you can identify the medications that increase your risk of heat illnesses, including heat stroke and dehydration. You may then decide to put in place an action plan to reduce your risk. Don’t forget that medications that you can buy off the shelf can cause harmful effects too.
Do not hesitate to ask your health care professional the following question: “Do I still need this medication?” — The answer might surprise you! Even if it is not possible to stop a given medication, reducing the dose could decrease your risk of harm. For example, gradually reducing the dose of your sleeping pill could help you stay more alert, for a safer and healthier summer. If a medication is stopped or reduced, ensure that a follow-up plan is put in place with your health care provider.
The author
Camille Gagnon is the Assistant Director of the Canadian Medication Appropriateness and Deprescribing Network. Camille is a clinical pharmacist with experience in clinical program management, community pharmacy, teaching and pharmacogeriatrics.
The views expressed herein do not necessarily represent the views of Health Canada.
Doctor, do I really need an antibiotic?
What is antimicrobial resistance and why is it important?
When antibiotics no longer work to kill bacteria, this is called antibiotic or antimicrobial resistance. This means that infections caused by certain types of bacteria can become difficult or impossible to treat with the antibiotics we have now. Read more…
By Janet Currie and Johanna Trimble
Click here to download a printable version of this article
What is antimicrobial resistance and why is it important?
When antibiotics no longer work to kill bacteria, this is called antibiotic or antimicrobial resistance. This means that infections caused by certain types of bacteria can become difficult or impossible to treat with the antibiotics we have now. For example, there is growing evidence that urinary tract infections are becoming increasingly resistant to the antibiotics that, for generations, easily and quickly cured them. As another example, some types of tuberculosis have become resistant to antibiotics and are becoming deadlier, just like they were before antibiotics were discovered.
In Canada, over a quarter of bacterial infections are now resistant to antibiotics that once cured them (1). In 2018, experts estimated that 15 Canadians died every day as a direct result of antimicrobial resistance (1). According to the World Health Organization, antimicrobial resistance is one of the ten most serious public health problems of our time (2). Antimicrobial resistance has been made worse because of a decline in the development of new antibiotics over the past decades, especially those that target the most resistant bacteria.
Why should older Canadians be concerned about antibiotic resistance?
Canadians aged 60 and over are prescribed antibiotics 1.5 times more often than any other age group (3). Older people may have weaker immune systems, making them more vulnerable to bacterial infections. Furthermore, older Canadians living in long-term care or assisted living facilities or who are admitted to hospitals may be more at risk of being exposed to “superbugs” like C. difficile. C. difficile can cause a life threatening diarrheal illness, especially among those who have compromised immune systems or who have recently used antibiotics. C. difficile is now resistant to most antibiotics.
What causes antibiotic resistance?
Using antibiotics when they are not needed or don’t work.
Antibiotics are often prescribed to treat illnesses not caused by bacteria. Colds and flu are caused by viruses and cannot be cured by antibiotics. Another example is when a lab test shows bacteria in the urine but there are no physical symptoms of a urinary tract infection, which is common in older adults. Giving antibiotics in this case can lead to overuse and antibiotic resistance.
Overusing broad spectrum antibiotics.
Broad-spectrum antibiotics are a type of antibiotic that kill many types of bacteria as opposed to only the specific bacteria causing the illness. For example, the overuse of broad-spectrum fluroquinolone antibiotics (drugs whose names end in “floxacin”, such as ciprofloxacin or Cipro®) contributes to antimicrobial resistance. Not to mention, fluroquinolones have a history of harmful side effects (4). Narrow-spectrum antibiotics, which focus on the specific bacteria causing the infection, should be used where possible. Sometimes, tests are needed to determine the type of bacteria involved.
Not using antibiotics as prescribed.
It is important to only use antibiotics that are prescribed for you and to take the dose as prescribed, even if the infection seems to be gone before the treatment is finished.
Global, poorly regulated antibiotic use.
Antibiotics are overused in agriculture as well as seafood and meat production. In some countries, they are available without a prescription, leading to overuse and contributing to resistance. Residue from human and animal antibiotic use contaminates our soil and water, another cause of antibiotic resistance.
What can you do to help reduce antibiotic resistance?
DON’T
Do not share or use leftover antibiotics.
Do not demand an antibiotic if your doctor, nurse, dentist or pharmacist says you don’t need one.
DO
Ask your doctor, nurse, dentist or pharmacist, “Do I really need an antibiotic?”
Follow your doctor, nurse, dentist or pharmacist’s advice if you are prescribed antibiotics.
Take all of the antibiotics as prescribed, even if you feel better before you are finished.
Avoid infections from bacteria:
Wash your hands regularly, especially after you use the bathroom and before eating.
Avoid close contact with sick people.
Keep your vaccines up to date.
Spread the word about the dangers of antibiotic resistance and how we must use antibiotics more wisely.
Always talk to your doctor, pharmacist or nurse before stopping or changing any medication.
References
1. Council of Canadian Academies. (2019). When Antibiotics Fail. The Expert Panel on the Potential Socio-Economic Impacts of Antimicrobial Resistance in Canada, Council of Canadian Academies. https://cca-reports.ca/wp-content/uploads/2018/10/When-Antibiotics-Fail-1.pdf
2. World Health Organization. (2021, November 17). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
3. Public Health Agency of Canada. (2018, April 3). Prescribe antibiotics wisely (Clinical points). Government of Canada. https://www.canada.ca/en/public-health/services/publications/drugs-health-products/prescribe-antibiotics-wisely.html
4. Health Canada. (2017, January 23). Summary Safety Review - Fluoroquinolones - Assessing the potential risk of persistent and disabling side effects. Government of Canada. https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/safety-reviews/summary-safety-review-fluoroquinolones-assessing-potential-risk-persistent-disabling-effects.html
The authors
Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She is a member of the core Executive of the Canadian Deprescribing Network, the past co-chair of the Canadian Women’s Health Network and was a two-term member of Health Canada’s Expert Advisory Committee on the Vigilance of Health Products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian Senate and the Parliamentary Standing Committee on Health on prescription drug surveillance and adverse drug effects. She is completing a Ph.D. on medication safety and off-label prescribing at UBC. Janet is Chair of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the Geriatrics and Palliative Care Subcommittee of the Council on Health Promotion for Doctors of BC. As an honourary lecturer, she co-teaches first-year medical students at UBC in Community Geriatrics as well as pharmacy students on medication issues in Long Term Care. Johanna is an active member of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Are you the victim of a prescribing cascade?
What is a prescribing cascade?
A prescribing cascade can happen when you and/or your health providers do not realize new symptoms are actually the side effects of one of your medications. Read more…
By Camille Gagnon, Janet Currie and Johanna Trimble
Click here to download a printable version of this article
What is a prescribing cascade?
A prescribing cascade can happen when you and/or your health providers do not realize new symptoms are actually the side effects of one of your medications. When this happens, you may be diagnosed with a new medical condition. As a result, often your health provider will prescribe a new medication to treat the side effects of the first medication.
Your new medication may also have side effects. When you and/or your health provider interpret these side effects as yet another new health condition, this can lead to more prescriptions. What happens next? Too often, you can end up taking a cascade of new medications which are not needed and which can cause harm.
Whenever you take a medication, there is a risk you will experience a side effect. The more medications you take, the greater your risk of side effects. Whenever you experience new symptoms, you and your health providers should always first consider whether they could be caused by medications you are currently taking. This will help avoid a common preventable problem called a “prescribing cascade”.
Mrs. Reynolds’ story
At 75, Mrs. Reynolds started having trouble falling asleep. She felt like she was spending hours tossing and turning. Her daily routine hadn’t changed: she visited with friends, went for her daily walk, and made sure to keep her coffee consumption low. Her medications hadn’t changed either. She’d been taking medications regularly for depression, high cholesterol and high blood pressure for years.
Hoping it would help her get a good night’s sleep, Mrs. Reynolds bought a box of sleeping pills (Sleep-Eze®) at the pharmacy and took one that evening. Although it didn’t help, she thought it would be worth trying them a little longer. But over the next few days, Mrs. Reynolds noticed her mouth started feeling dry, which forced her to keep a glass of water on her bedside table. In the mornings, she woke up feeling groggy and constipated. Meanwhile, her sleep hadn’t improved. Feeling frustrated, she decided to go see her pharmacist Nadia about these new symptoms as well as about her sleep problem.
Nadia listened carefully to Mrs. Reynolds’ story. Then, she explained that the most likely cause of her dry mouth, constipation and daytime grogginess was the sleeping pill she’d been taking. Nadia then took a close look at Mrs. Reynolds’ file. She told Mrs. Reynolds her antidepressant (bupropion) could be causing her insomnia in the first place.
“Your sleep problem is likely a side effect of the antidepressant medication you are taking. When you took another medication for your sleep problem, this created what we call a prescribing cascade.” Mrs. Reynolds was puzzled. She had been taking bupropion for over two years. Was it possible new side effects could appear after so much time had passed? The pharmacist’s response was clear: “Yes. You can get a new side effect at any time.”
A few other examples of common prescribing cascades:
Identifying side effects to prevent prescribing cascades
The more medications we take, the greater our risk of harmful effects. When Mrs. Reynolds tried to treat her insomnia with a sleeping pill, she ended up with new side effects (dry mouth, constipation and foggy brain). And if she had tried to treat these new side effects with medications, these new medications may have caused even more side effects. Luckily, Mrs. Reynolds consulted with her pharmacist, who recognized that her new symptoms were side effects. The key to avoiding prescribing cascades is identifying when new symptoms are really side effects.
When a new symptom may be a medication side effect, you and your health provider should consider deprescribing. Deprescribing means reducing or stopping medications that may not be beneficial or that may be causing harm.
Deprescribing should always be done in a planned and supervised manner, in partnership with your health provider. The goal of deprescribing is to improve your quality of life without compromising your health.
How can you help prevent prescribing cascades?
It is not always easy to identify prescribing cascades, as they may go on for years, and involve many medical conditions, symptoms and medications. Many symptoms, such as fatigue, confusion, dizziness and falls, may actually be side effects of medications, not old age or a new medical condition. These side effects can lead to hospitalizations and changes to your life and well-being. Here are five things you can do to help prevent prescribing cascades:
Ask questions. Have you noticed a new symptom? Ask a health provider this question: “Could this symptom be a side effect of one of my medications?” Do not assume your doctor, pharmacist or nurse is always looking out for side effects of the medications you are taking. If you have a doubt about a medication, ask about it.
Don’t forget your non-prescription medications. Non-prescription medications (also known as over-the-counter or OTC medications) and natural health products can also cause side effects and prescribing cascades. The sleeping pill Mrs. Reynolds started taking is just one example. Be sure to include all non-prescription medications on your list, and share this information with your health provider(s).
Stay informed. Educate yourself about the possible side effects of your medications. New side effects can appear months or even years after taking the same medication, even at the same dose. Remember that even if your medications or dosage hasn’t changed, over time your body, life situation and health change. This can affect the way your body processes medications. Be sure to review all your medications with a health provider at least once a year. This will help ensure you are taking only medications you still need. Each time you add a new prescription, ask for a full review of your medications to ensure it won’t interact with those you already take.
Consider deprescribing. When you and your health provider identify a prescribing cascade, it’s important to discuss whether stopping a medication or reducing the dose would be a good option for you. You may decide to put a tapering plan in place to stop a medication gradually.
Are there alternatives? Could other, safer treatments (medication or non-medication) help with this health condition?
Back to Mrs. Reynolds
Following their discussion, Nadia offered to contact Mrs. Reynolds’ family doctor to recommend they reduce the dose of her antidepressant (bupropion). Mrs. Reynolds’ family doctor agreed to the change and asked her to follow up with him in a few weeks to check on her mood. Mrs. Reynolds was relieved that the side effects from the sleeping pill disappeared a few days after she stopped taking them.
About two weeks after reducing the dose of her antidepressant, Mrs. Reynolds noticed a definite improvement in her sleep. She also found several of the techniques explained in a brochure her pharmacist gave her on how to get a good night’s sleep to be helpful. Waking up at the same time every day and limiting naps helped improve her sleep at night. Mrs. Reynolds was satisfied. Her conclusion? To avoid taking medications unnecessarily, when new symptoms appeared in future she would make sure to always ask her doctor or pharmacist this question first: “Could this symptom be a medication side effect?”.
Always talk to your doctor, pharmacist or nurse before stopping or changing any medication.
The authors
Camille Gagnon is the Assistant Director of the Canadian Deprescribing Network. Camille is a clinical pharmacist and works in a primary care clinic. She has experience in clinical program management, community pharmacy, teaching and pharmacogeriatry. She is a passionate medication safety advocate.
Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She is a member of the core Executive of the Canadian Deprescribing Network, the past co-chair of the Canadian Women’s Health Network and was a two-term member of Health Canada’s Expert Advisory Committee on the Vigilance of Health Products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian Senate and the Parliamentary Standing Committee on Health on prescription drug surveillance and adverse drug effects. She is completing a Ph.D. on medication safety and off-label prescribing at UBC. Janet is Chair of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the Geriatrics and Palliative Care Subcommittee of the Council on Health Promotion for Doctors of BC. As an honourary lecturer, she co-teaches first-year medical students at UBC in Community Geriatrics as well as pharmacy students on medication issues in Long Term Care. Johanna is an active member of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
What you need to know about anticholinergic medications
By Johanna Trimble and Janet Currie
Some medications you take for allergies, sleep, nausea, depression or incontinence belong to a group of medications called anticholinergic medications. Read more…
By Johanna Trimble and Janet Currie
Click here to download a printable version of this article
What are anticholinergic medications?
Some medications you take for allergies, sleep, nausea, depression or incontinence belong to a group of medications called anticholinergic medications. They work by blocking a chemical in your body called acetylcholine. Acetylcholine is used in many parts of your body and helps you stay alert, keep a steady heart rate, breathe, digest food, sweat and empty your bladder. When you take an anticholinergic medication, it acts on many parts of your body at the same time.
How do I know if I’m taking an anticholinergic medication?
Anticholinergic medications can be prescribed to you by your healthcare professional or bought over the counter (also called OTC) at a store without a prescription. Here are some of the most common types of anticholinergic medications.*
Allergy medications (for example, Benadryl® - diphenhydramine)
Anti-nausea medications (for example, Gravol® - dimenhydrinate)
Antidepressants (for example, Paxil® - paroxetine)
Antipsychotics (for example, Seroquel® - quetiapine)
Bladder control medications (for example, Ditropan® - oxybutynin)
Sleeping pills (for example, trazodone or OTC medications like Nytol® or Sominex®)
Muscle relaxants (for example, Robaxin® - methocarbamol)
All opioids
Combination medications (for example, Tylenol PM® or other medications with “PM” in their name which include the ingredient diphenhydramine)
*This list does not include all anticholinergic medications.
Did you know?
Strong anticholinergic ingredients can be found in many of the over-the-counter medications you buy. Always read the ingredient list on the package of any medications you buy over-the-counter. If there are two or more ingredients it is called a combination medication. A combination medication may have an anticholinergic medication in the ingredients list. For example, diphenhydramine or dimenhydrinate are strong anticholinergic medications found in many over-the-counter products.
Ask your doctor, pharmacist or nurse if the medications you are taking have anticholinergic effects.
Older adults are most at risk from anticholinergic medications. Why is that?
As we get older, our liver and kidneys aren’t able to process medications as well so we become more sensitive to them. Also, many older adults have more than one health condition and may take many medications including one or more anticholinergics. The more medications a person takes, the more likely it is that he or she will have unwanted side effects.
What are the side effects from anticholinergic medications?
When you take an anticholinergic medication, it can act on many different parts of your body at the same time. This can cause unwanted side effects. Your risk of side effects is higher if:
you are taking higher doses;
you take the medication for a long time;
you are taking more than one anticholinergic medication.
Anticholinergic medications have many different side effects. Side effects can appear at any time, even many years after starting a medication. As time passes, you may think new symptoms are a new illness, when in fact they are side effects from your medications. Below are a few common side effects of anticholinergic medications:
Does taking anticholinergic medications increase my risk of dementia?
A few studies have suggested that older adults who use anticholinergic medications for a long time or at higher doses may have a higher risk of dementia. Research has not proven this, but it does suggest that older adults should limit the number of anticholinergic medications they take and use the lowest dose for the shortest length of time.
How do I lower my risk of side effects from anticholinergic medications?
*The Anticholinergic Burden Calculator was developed to help health providers review a patient’s medication list to see if there are changes that could be safer for the patient. Visit the site at http://www.acbcalc.com/.
Always talk to your doctor, pharmacist or nurse before stopping or changing any medication.
References
1. Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2736353
2. King R, Rabino S. ACB Calculator. http://www.acbcalc.com
Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She is a member of the core Executive of the Canadian Deprescribing Network, the past co-chair of the Canadian Women’s Health Network and was a two-term member of Health Canada’s Expert Advisory Committee on the Vigilance of Health Products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian Senate and the Parliamentary Standing Committee on Health on prescription drug surveillance and adverse drug effects. She is completing a Ph.D. on medication safety and off-label prescribing at UBC. Janet is Chair of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the Geriatrics and Palliative Care Subcommittee of the Council on Health Promotion for Doctors of BC. As an honourary lecturer, she co-teaches first-year medical students at UBC in Community Geriatrics as well as pharmacy students on medication issues in Long Term Care. Johanna is an active member of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
A pill for every ill? Make sure your medication is really helping you.
By Dr. Cara Tannenbaum, Geriatrician and Director, Canadian Deprescribing Network
Nowadays, it seems there is a choice of pills you can take for every symptom, big or small. Most people only have 10 minutes in their doctor’s office to discuss health issues. Read more…
By Dr. Cara Tannenbaum, Geriatrician and Director, Canadian Deprescribing Network
Click here to download a printable version of this article
Nowadays, it seems there is a choice of pills you can take for every symptom, big or small. Most people only have 10 minutes in their doctor’s office to discuss health issues. A quick fix often comes in the form of a pill – and the number of pills can add up quickly if you count over-the-counter medication.
Two thirds of Canadians over the age of 65 take at least 5 different prescription medications; almost one third take 10 or more. What is important to know is that as we grow older, our bodies become more sensitive to medications, increasing the risk of harmful effects. These risks include drug interactions, falls and fractures, memory problems and even drug-related hospitalizations and death.
Not only are seniors at risk of harm from taking too many medications, but 40% of Canadians over the age of 65 take a medication considered unnecessary or potentially risky for seniors. Common medications such as sleeping pills, long-term prescriptions of proton-pump inhibitors for acid reflux, and antipsychotics for insomnia and dementia are no longer recommended. Opioids are another dangerous medication used to treat chronic non-cancer pain. As a geriatrician, I now advise patients to try non-drug therapy to treat their symptoms whenever possible. It may take more time and effort, but the benefits pay off down the road in terms of safety and effectiveness.
What can you do?
Check out the brochures and the information on the Canadian Deprescribing Network website (www.deprescribingnetwork.ca) to find out if your medications are safe, and whether you can substitute with safer alternatives. If your doctor suggests you take a new drug, you have the right to ask what the drug is for, what its benefits are and the risks of harm. Ask if there are equally effective lifestyle changes, exercise habits or other therapies you can try instead. Taking medication is, and always has to be, an informed choice.
Book a special appointment with your doctor, nurse or pharmacist to review your complete medication list on a regular basis. What was good for you then, may not be good for you now.
Do you ever wonder if you still have to take all your medications? Ask about the possibility of “deprescribing”. Deprescribing is stopping or reducing the dose of a drug that may no longer be necessary or may be causing harm. Never stop a medication before speaking to your doctor, nurse or pharmacist.
For more information about medication safety, visit this website: www.deprescribingnetwork.ca.
Why are you taking a PPI?
By Dr. Cara Tannenbaum, Geriatrician and Director, Canadian Deprescribing Network
Mr. Turner considers himself to be a typical healthy 67-year-old, but late last year he started to get sharp burning sensations in his stomach and throat, especially after meals. Read more…
By Dr. Cara Tannenbaum, Geriatrician and Director, Canadian Medication Appropriateness and Deprescribing Network
Mr. Turner considers himself to be a typical healthy 67-year-old, but late last year he started to get sharp burning sensations in his stomach and throat, especially after meals. His heartburn caused such discomfort that on occasion it interfered with his sleep. Growing increasingly concerned, he went to see his family doctor to seek a solution.
His family doctor, Dr. Kensington, diagnosed him with acid reflux. Mr. Turner received a prescription for the proton-pump inhibitor (PPI) omeprazole to alleviate his symptoms. Dr. Kensington explained that PPIs are commonly used to ease the discomfort of heartburn and acid reflux by reducing the amount of acid in the stomach. Mr. Turner immediately felt better after taking his new medication and was back to normal within a week.
A few months later, Mr. Turner was at his local pharmacy renewing his prescription. His pharmacist, Jill, noticed that he had been taking omeprazole for a few months. “Do you know why you have been taking omeprazole for 3 months?” she asked. “I had really bad heartburn and my doctor prescribed it. It really helps,” Mr. Turner replied, “Why, is there a problem?”
“When used to treat acid reflux, this medication should only be taken for 4 to 8 weeks. However, there are some cases where patients need to continue these medications. For example, some people have to take anti-inflammatories for a long period of time and need a PPI to protect their stomach from side effects. Others have been diagnosed with Barrett’s esophagitis and cannot discontinue them,” Jill explained. “However in the majority of cases, PPIs are often overprescribed and used for longer than necessary in patients like you with acid reflux.”
Mr. Turner was confused. “Why would this be such a big deal? These medications don’t seem to be causing any side effects,” he said. Jill explained the need to consider the balance between benefit and harm with all medications.
“When taken long-term, PPIs have been linked to serious harms,” Jill advised. “There is a higher risk of hip fractures, pneumonia, intestinal infections, higher risk of kidney problems as well as B12 and magnesium deficiencies.” Mr. Turner nodded. “I agree it makes sense to stop a medication if you don’t really need it, especially when it can cause side effects. Plus, I don’t like the idea of spending money on something I don’t need.”
Mr. Turner then had second thoughts. He was alarmed about these risks, but at the same time he was concerned. “What if I get heartburn again? It was so bad I couldn’t sleep!” Jill calmed his worries. “There are a few ways you can reduce the chance of having rebound symptoms. You can reduce the dose of your medication or you could take it every other day. Another option that many people find works well is to use them only when needed.” She gave him this brochure, to help him decide which option was best.
“When you have acid reflux or heartburn, it’s safer to try taking ranitidine (Zantac®) or antacids including Tums®, Rolaids® or Maalox® to control your symptoms. Use them only when needed,” she advised. “Most people who have heartburn don’t need drugs at all. There are many lifestyle changes that can help. You can eat smaller meals and avoid eating before bedtime. If you have discomfort at night, keep your head raised with extra pillows when you sleep. You may also want to avoid foods known to trigger heartburn, such as spicy foods, caffeinated beverages and alcohol. Losing weight and avoiding smoking also reduces your risk of developing heartburn symptoms.”
Mr. Turner was perplexed by all this but glad he had been given the information sooner rather than later. He agreed with having Jill contact Dr. Kensington to suggest reducing his PPI dose for 4 weeks before stopping it completely. His doctor agreed to deprescribe his medication. Deprescribing means reducing or stopping medications that may no longer be beneficial or may be causing harm.
Mr. Turner gradually stopped his PPI with the help of his doctor and pharmacist. Now, when he has heartburn, he takes Tums® or Rolaids®, which safely and effectively relieve his symptoms. He tried to lose some weight, exercises more often and avoids foods that can cause heartburn, like coffee and alcohol.
Through this experience, Mr. Turner realized that there is a lot to learn about better managing his health and medications. He experimented to figure out what makes his acid reflux worse, as well as how to prevent and manage it safely when it occurs. He appreciates the health care professionals like pharmacists or physicians, who took the time to take him off medications he didn’t need. He even told his story to friends and family to make sure they also discuss this with their nurse, doctor or pharmacist.
If you need to take a PPI, make sure you are prescribed the lowest dose possible for as short a time as possible. Not sure if you are on a PPI? Here is a list:
List of PPIs:
Brand name
Losec
Nexium
Dexilant
Prevacid
Pariet
Pantoloc
Tecta
Generic name
Omeprazole
Esomeprazole
Dexlansoprazole
Lansoprazole
Rabeprazole
Pantoprazole sodium
Pantoprazole magnesium
Do not stop a medication without first speaking to your doctor or pharmacist.
For more information on PPIs and safer alternatives, see this brochure.
Community champion in the spotlight: Herb John convinced we can make a difference
By Jennie Herbin, Community Engagement Coordinator, Canadian Deprescribing Network
Herb John was waiting to board a plane to Ottawa for a Canadian Transportation Agency meeting when I caught him on the phone this weekend. Read more…
National Pensioners’ Federation Past President and longstanding CaDeN member on why deprescribing speaks to Canadian seniors, and what needs doing next.
By Jennie Herbin, Community Engagement Coordinator, Canadian Deprescribing Network (CaDeN)
This interview has been edited and condensed.
Herb John was waiting to board a plane to Ottawa for a Canadian Transportation Agency meeting when I caught him on the phone this weekend. He’d only just returned from Regina, where he’d attended the 2018 National Pensioners’ Federation (NPF) Convention, and was now off again. This type of schedule is not unusual for the busy volunteers I am lucky to work with.
Quickly, our conversation turned to civic engagement, and how he’d met two young people in Regina who were surprised to learn that the NPF is fighting so that younger generations would have a pension. “They’d just assumed they [younger generations] wouldn’t be able to count on having a pension. People need to believe they can make a difference. Imagine if 50 people called their local MP about an issue. They’d start listening.”
Among the many hats he wears, Herb John is a member of the Canadian Deprescribing Network’s (CaDeN) Public Awareness Committee and a committed deprescribing advocate. His initiatives to raise deprescribing awareness over the years reflect this conviction that everyone has a role to play, and that together we can make change happen.
You’ve been working with CaDeN to get the word out about deprescribing for a few years now. Why did you first get involved?
I got an email from Cara Tannenbaum [CaDeN Co-Director] a few years ago, asking if I would participate in a panel discussion at one of CaDeN’s early meetings. I’d never heard of deprescribing at that point. But I immediately thought of a situation I’d had with my grandmother a few years earlier. I had to bring her to emergency, and I had to go gather up her medications and bring them to the hospital too. I couldn’t believe all the medications she was on. The emergency doctors cut half of them out. I thought, if I’m having this problem, I’m probably not the only one. There must be a lot of other people who are having this happen to them too.
So when Cara emailed me, I immediately understood what deprescribing was and recognized the relevance. Even then, I called her back and said, are you sure I’m the one you want? Cara responded saying that what they needed to do was get the word out to seniors, and she’d been told that a seniors’ advocacy group would be the best way to do that. Well then, I got it. That’s how I could help. I was on board, and our executive board endorsed the campaign.
What shape has your collaboration taken over the years?
Pretty soon, we were in communications about how to get the word out. We [NPF] started posting material about deprescribing on our website. Every month, we post CaDeN’s newsletter on the site. We [NPF] invited Cara Tannenbaum to give a presentation to our members at our 2016 annual convention in Richmond, B.C. Now, several of our affiliate organizations are involved with CaDeN as well.
What kind of response do you get when you talk to people about deprescribing?
This spring I gave two presentations to retired automobile union member groups in Windsor, Ontario. One of them was my own retired workers chapter. I’d approached the chair and asked if I could do a presentation. He said sure, but make sure you keep it brief because the members don’t want a long presentation. Well I spoke for 30 minutes! And no one was nodding off, everyone was paying attention. I got lots of compliments about the relevance and importance and timeliness of the topic. People seemed to appreciate the information—they “got” it.
After the presentation, I told everyone that at the next meeting in September, I’d be asking how many went to their pharmacist or doctor and asked those five key questions. Which I did. Well, 10% of people said they did have that conversation.
Why do you think this topic speaks to people so much?
Most people haven’t heard about the concepts before. But it makes sense. I still run into lots of people who don’t question what their doctor tells or gives them. They have no idea about those three major deprescribing messages: first, that some people are taking too many medications; two, that some mixtures aren’t good; and third, that medications affect us differently when we age. It’s a major awareness issue people need to understand.
What do you feel are the next steps?
Pauline Worsfold, Chair of the Canadian Health Coalition (CHC), gave a presentation on the Pharmacare file at the NPF convention last week. The CHC and NPF have been pushing hard for a Pharmacare program. People are starting to become aware that across the provinces, there’s a real mishmash of coverage. In New Zealand, when they implemented Pharmacare a few years ago, they saved $7 billion in the first year alone. But I haven’t heard anyone talk about deprescribing as part of the Pharmacare discussions. It should be part of a national Pharmacare program. The public would quickly understand the added benefit of ensuring the medications we’re taking are helping rather than harming.
We need to take advantage of this opportunity to talk about deprescribing, in the context of Pharmacare. We need people to start talking in their own jurisdictions about including deprescribing in the national Pharmacare conversation. If implemented properly, it could be a huge cost savings.
9 Quick Safety Tips to Manage Your Medications
By Johanna Trimble and Janet Currie
Track your meds. It’s up to you or your family to keep track of the drugs you are taking. Your medication list is unlikely to be available to all health professionals online! Electronic medical records systems often don’t “talk” to one another. Read more…
By Johanna Trimble and Janet Currie
Click here to download a printable version of this article
Always consult your doctor before stopping, changing or starting a drug.
1. Track your meds. It’s up to you or your family to keep track of the drugs you are taking. Your medication list is unlikely to be available to all health professionals online! Electronic medical records systems often don’t “talk” to one another.
2. Keep a list. For your safety, carry your own UPDATED list and keep one on your fridge. Make sure to include over-the-counter (OTC) drugs. Make sure drugs prescribed by specialists that you see are listed.
3. Stick to one pharmacy. Try to fill prescriptions from one pharmacy so drug interactions are easily checked. Any pharmacy’s list will only show what their pharmacy has dispensed to you and won’t include everything you take.
4. Don’t start a new drug when you’re alone. It’s rare, but if you have a severe allergic reaction you’ll need immediate help. Never take a prescription drug that was prescribed to someone else.
5. Check your prescription. When you pick up your prescription order, check both your name and the drug name on the bottle. At times, people who have the same name have received the other person’s drug.
6. Be aware of side effects and adverse effects. If you have a new symptom after taking a new drug, don’t assume it’s a “new condition” or “old age”. Tell your doctor or pharmacist right away. It could be adverse effects from the drug itself or an interaction with another drug you already take.
7. Beware of the prescription cascade. Sometimes new drugs might be prescribed to deal with symptoms caused by a drug you are already taking. This is called the “prescription cascade” – a common example is being prescribed a new drug for stomach upset, which may be caused by a drug you are already taking. Ask your doctor to consider whether new symptoms could be the result of the drugs and whether you should consider stopping a medication or reducing the dose, also known as deprescribing.
8. Look out for changes. Tell your doctor how new drugs affect you and whether there’s been a change for better or worse. Doctors may be depending on you to report and may not be actively monitoring the effects. If you SEE something (or feel something), SAY something (just like at the airport!). You do not have to be “right” in order to bring forward concerns about adverse reactions from a drug.
9. Seniors are more sensitive to medications. Older people are more sensitive to medications because of changes in their liver and kidney function as they age. In many cases, drugs for seniors should be prescribed at a reduced dose. The more medications used, the greater the chance of drug interactions. Drugs commonly prescribed to older adults can cause dizziness and loss of balance, leading to falls or factures and hospitalization, as well as cognitive and memory problems. Adverse drug reactions can start even if you have been taking a drug for a long time. Your doctor depends on you to raise issues of concern and to begin to talk about deprescribing some drugs: www.deprescribingnetwork.ca/starting-a-conversation
Read part 2 of this series here: 5 (More) Quick Safety Tips to Manage your Medications
Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the Geriatrics and Palliative Care Subcommittee of the Council on Health Promotion for Doctors of BC. As an honourary lecturer, she co-teaches first-year medical students at UBC in Community Geriatrics as well as pharmacy students on medication issues in Long Term Care. Johanna is an active member of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She is a member of the core Executive of the Canadian Deprescribing Network, the past co-chair of the Canadian Women’s Health Network and was a two-term member of Health Canada’s Expert Advisory Committee on the Vigilance of Health Products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian Senate and the Parliamentary Standing Committee on Health on prescription drug surveillance and adverse drug effects. She is completing a Ph.D. on medication safety and off-label prescribing at UBC. Janet is Chair of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
5 (More) Quick Safety Tips To Manage Your Medications
By Johanna Trimble and Janet Currie
Ask for a medication review. Ask your doctor or pharmacist to review all your medications, especially if you are taking several or if different doctors prescribed them. Read more…
By Johanna Trimble and Janet Currie
Click here to download a printable version of this article
Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life. Always consult your doctor before stopping, changing or starting a drug.
1. Ask for a medication review. Ask your doctor or pharmacist to review all your medications, especially if you are taking several or if different doctors prescribed them. This means reviewing your complete medication list to make sure all are needed and not causing problems as you grow older. List drugs prescribed by specialists and over the counter drugs too. Often, doctors are able to give you an appointment that is longer than the usual 10 minutes to have a consultation about your medications. It is up to you to ask for a review of your medication: don’t assume that your drugs will be reviewed on an annual basis. Remember to ask your doctor if you can either stop taking some medications or lower the doses of others as a result of the medication review.
2. Medication issues in nursing home settings need to be addressed quickly. In a nursing home setting, get answers quickly if you have concerns about your medications or a family member’s. Patients can lose function and mobility if bedridden from a drug interaction. Delirium (a reversible state of disorientation, agitation or drowsiness) or unusual behaviour can be caused by medications and it may be mistaken for a serious chronic illness such as dementia. Alert your family members and be prepared to go, with your family, to management, if you have serious concerns or can’t get an answer. If you feel anxious bringing up medication issues, ask a family member to make an appointment with nursing home staff and have them accompany you.
3. Avoid anticholinergic drugs. Older adults are often prescribed anticholinergic medications (medicines that affect acetylcholine, a neurotransmitter) for common conditions such as overactive bladder, allergies, gastrointestinal problems, Parkinson’s and depression. Seniors are highly sensitive to the harmful effects of anticholinergic drugs. These drugs can have a negative impact on the brain by causing delirium, confusion and memory problems as well as physical effects such as dry mouth, constipation and blurred vision. Recent research is exploring whether these drugs have a role in dementia. While this link is still being explored, seniors should avoid these drugs whenever possible or ask for a safer alternative.
4. Ask questions and be wary. When your doctor suggests a new drug, you have the right to ask what the drug is for, what its benefits are and the risks of harm. Is the drug being prescribed for prevention? How likely is it that you would become ill in the future if you didn’t take it? Could the side effects outweigh any benefit the drug may have? It may not be worthwhile feeling unwell every day because of a drug to gain a small chance of having a little less risk of future illness.
5. Ask if deprescribing is appropriate for you. If a drug is bothering you, ask your doctor or pharmacist about the possibility of a “drug holiday” or a trial of stopping or tapering the drug and carefully monitoring the results. It is reasonable to see if a drug is causing problems if it is not a life-saving drug. You may find more information here.
See part one of this two part series: 9 Quick Safety Tips to Manage Your Medications
Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the Geriatrics and Palliative Care Subcommittee of the Council on Health Promotion for Doctors of BC. As an honourary lecturer, she co-teaches first-year medical students at UBC in Community Geriatrics as well as pharmacy students on medication issues in Long Term Care. Johanna is an active member of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.
Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She is a member of the core Executive of the Canadian Deprescribing Network, the past co-chair of the Canadian Women’s Health Network and was a two-term member of Health Canada’s Expert Advisory Committee on the Vigilance of Health Products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian Senate and the Parliamentary Standing Committee on Health on prescription drug surveillance and adverse drug effects. She is completing a Ph.D. on medication safety and off-label prescribing at UBC. Janet is Chair of the Patient Awareness Committee of the Canadian Medication Appropriateness and Deprescribing Network.