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Who Is Popping All Those Pills?

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Ritalin (Photo credit: Wikipedia)

There is some debate about whether American doctors overprescribe and we are a culture too fast to look for pharmaceutical fixes.  On the one side, critics point to drug epidemics in various age groups as signs of a pill popping culture: for example, the overprescribing of ADHD and antipsychotic drugs to children, the painkiller and sleeping pill abuse epidemics, and the largely unchecked polypharmacy among the elderly, who many doctors see as cash cows.

However, others argue that while there are some problems, America is not needlessly taking too many drugs.  Our wealth and access to healthcare provides us with leading medicines that improve health and the proof of this is a steadily increasing well being.  They correctly point to the amazing progress in the medical field in just the past two decades, much of which have had a direct impact on longevity.

This is a case where both sides are right.  Drugs are our most effective and cost effective treatment (and prevention) of many leading diseases, however, this is not to say that these same weapons are not at times and in large numbers being abused.

We decided to try to better understand who is taking all these drugs by surveying people about their prescription drug use.  According to our national survey released today:

  • 34% of American adults take at least one prescription drug
  • 11.5% of American adults take three or more prescription drugs.
  • 6.5% of American adults take 4 or more prescription drugs.

Digging deeper, more interesting facts appear -  those at the highest income levels and those at the lowest, are more likely to be taking prescription drugs than the middle class.  However, it is the lowest income Americans who are most likely to be on 4 or more drugs.

The Older You Get, The More Drugs You Take

If you had guessed that as one ages, there is a big uptick in prescription drug use - you'd be right.

  • Nearly half of all Americans aged 55 and above are on a prescription drug, vs. just 23% of those 18 - 24 years old.  If we look at those on 4 or more drugs - only 2.6% of 18 - 34 year olds are on 4 or more drugs vs. 12.6% of those 65+ years old.

It is estimated that while the elderly represent approximately 12.9% of the U.S. population, they represent approximately 25% to 30% of all prescribed medications and 40% of the OTC drugs.

By Income Level, Big Differences In Drug Use

Most interesting is what the data show by income level.  It appears that those in the upper income levels are more likely to be taking one or more prescription drugs than any other income group.  However this does not follow a straight line relationship - the more money one has does not appear to perfectly relate to prescription drug use.

If we first look at those taking one or two prescription drugs, the data show that higher income does translate into a higher percentage of prescription drug use: 20.4% of those earning $100,000 - $149,000 state they take one prescription drug vs. approximately 14% of those in the other lower income groups. It is possible the higher response rate among upper income respondents with one or two prescriptions and the high rate of respondents in the lower income range indicating they take 4 or more prescriptions is reflective of insurance and income.  That is, the upper income respondents have insurance, the lower income respondents have aid and more health problems, and the middle income level respondents might face more out of pocket costs, so they take fewer drugs.

The Lower Income Levels Take Far More Prescription Drugs

The lower income levels respondents have dramatically higher use of 4 or more prescriptions.

  • In our survey, 10.5% of those earning $0 - $24,999 said they were taking 4 or more prescription drugs.   This compares to no respondents in the highest upper income group ($100,000 - $149,000 income category) indicating they were taking 4 or more prescription drugs, and only 3 - 5% those in the $50,000 - $100,000 ranges.

In other words, the lower income respondents are much more likely to be taking four or more prescription drugs than the middle- and upper-income respondents.

However, how does this differ from those taking 1, 2 or 3 drugs?  

When we look at those taking one, two, or three prescription drugs - we don't see a similar trend of the poor being bigger users of drugs than the higher income levels. Among the many possible explanations, perhaps lower income respondents wait a long time to get medical care and when the patient eventually seeks care, he or she is in worse shape, requiring greater drug intervention.  While we know lack of access to care leads to poorer care and more drastic measures needed when care is eventually used, I am not sure that is what we are really seeing in the data (mostly because there is no linear relationship of income and prescription use for the smaller number of prescriptions).

The second possibility is that what we are seeing is the by product of poorly coordinated Federal care  - a system that allows and in face encourages poor patients to be on as many drugs as possible to ensure repeat visits for doctors.

My own research to better understand Federal healthcare brought me to Appalachia where the combination of low income and aged population make Federal healthcare programs (Medicare and Medicaid) prevalent.

The problems of drug abuse and polypharmacy in Appalachia are staggering.  I visited with one elderly woman who looked older than her years, her legs swollen with edema making walking nearly impossible.  I noticed her shoes did not fit on her feet.  When I asked how many drugs she was currently taking she held up a freezer bag full of medicines.  She told me she takes more than a dozen medications.  I explored it further – she indicated that she was on an antidepressant prescribed by her doctor because he indicated “many people get depressed after surgery” so he prescribed an antidepressant ahead of her knee surgery.  Yes, she was given an antidepressant not to treat, but to prevent, depression - and she was still on it more than a year later.

I do not know exactly how and why this occurred, and it is possible this one instance, it was appropriate for her situation, although I highly doubt it based on her responses to my questions.  I do believe that part of this is due to uncoordinated care and poor incentives.  Doctors get paid to see Medicare and Medicaid patients, and the more regular follow-up appointments, the better it is for them.  True, many doctors are increasingly starting to not see Medicare patients - trying to weed out a lower profit patient population.  However some of those who do sometimes try to make up for the low payments with volume.  Her case, like so many others, points to the problem of polypharmacy - or people on multiple drugs.

Adverse drug reactions among multiple drugs and even Over-the-Counter (OTC) drugs are a serious problem.  It has been estimated that perhaps approximately 16% of hospital admissions were related to adverse reactions to medicines and approximately 100,000 deaths occur yearly due to adverse drug reactions - making it the 4th leading cause of death and ahead of pulmonary disease, diabetes, AIDS and automobile deaths, according to Polypharmacy and the Elderly.

I came away from this trip concerned that the aging of the babyboomers and the implementation of government healthcare for a broader group will make the problems of overspending and uncoordinated care - including deaths related to drug interactions  - worse, not better.  Those that fear that government sponsored healthcare will lead to fewer prescription drugs are simply wrong.  It will lead to the opposite – an explosion of people seeking drug treatments and already squeezed doctors to feel even greater pressure.  This conclusion seems to be supported by the data from our survey, although it is admittingly not conclusive.

My takeaway's:

1) Federal healthcare will initially lead to a large increase in Federal spending on drugs.

2) Adverse events, including deaths, from polypharmacy is a serious problem already and will get worse as babyboomers age and government healthcare programs expand.

3) It appears the poor are much more likely to be on a high level of prescription drugs - more should be done to understand why this is.

I am truly interested in your opinion of what might be causing the disparity in the use of prescription drugs by income level, especially at the ends of the barbell - the higher income groups being large users of one or two prescription drugs and the low income being such large users of 4 or more prescriptions.

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The survey was commissioned by my firm, Phalanx Investment Partners and conducted by Google Consumer Surveys.  Nothing in this article is meant to imply or suggest investment advice.