Duelling Prescriptions

It’s not a “polypharmacy” issue, it’s a “polyprovider” issue

It’s been about ten years since I found a list of the Mother-Out-Law’s medications posted on her kitchen door, marked as the Father-Out-Law’s medications. The list was posted by one of the state-provided in-home caregivers in anticipation of a visit by the agency that was trying to get them additional assistance. (They were in their late 80s and early 90s, respectively, at the time, and in physical decline.) In the Blogabetes* post I wrote shortly after that visit “down home” (the Other Half’s family lives about 350 miles — 500 km — away), I mentioned my concerns over the mixup — which I recognized only because I was familiar with both of their medical conditions and some of the medications used to manage each. When the Very Significant Other and I went through his parents’ medications to sort out the lists for this visit, I also found a medication that was inconsistent with the FoL’s medical history as I had known it. We asked the FoL about it, learned that it was prescribed based on a single out-of-range reading, and dropped almost immediately after having been dispensed.

I still shudder to think what might have happened had we not intercepted that list before the agency rep, and if we hadn’t discussed the outlier medication with the FoL.

One observation I made at the time was,

Based on some of the things I’ve been reading on my health groups, it wouldn’t be the first time a pharmacist kept dispensing medications after a doctor ceased the medication (as long as there were refills remaining).

Right now, I have two “regular” doctors (my primary care doctor, whom I’ve been seeing since 2002, and my cardiologist, who has taken over certain aspects of my health care since 2022). As my cardiologist has taken over responsibility for regular EKGs and the rest of my cardiovascular care (hypertension and cholesterol management), she has also taken over prescribing most of my medications in those areas.

There have been a few times in which my cardiologist wrote my prescriptions with fewer refills than I needed to get to my next cardiologist appointment, and I had to ask my PCP to write a one-time fill. I have never had issues with that.

However, I have had issues with “overflows” of a couple of my medications, which it’s taken me a couple of years, and a copy of my PCP’s system’s list of my meds, to figure out.

While my PCP stopped writing one of my antihypertensives once my cardiologist changed the dose, she (both my main doctors are female) never stopped writing for another hypertensive for which the dose has changed, nor for the higher-than-required dose of the statin I’m taking. This, despite color-coding my meds list and mentioning specifically which medications I needed her to write refills for.

So, obviously, I have an issue with my PCP’s office — which I’ll have to address next time I’m there.

BUT — in this world of inequitable pharmaceutical dispensing, local shortages, and rising medical costs, shouldn’t my insurance company see this and flag it for the pharmacist the same way it does when (either) doctor submits a prescription a month or two early for the usual three-month dispensing? Or, shouldn’t the pharmacist’s dispensing software (the one that checks for adverse interactions every time a healthcare provider writes a new prescription for a patient) flag that too much of a medication might be dispensed?

The answer I got from the pharmacist was understandable, but less than ideal.

The big issue (or one of the big issues) with my duelling prescriptions is that each of these medications are written for different dosages by each of the two physicians. Every time the higher dosage came up for refill, the software saw that the dose had increased, assumed that I required the higher dose, and ignored that it recently dispensed at least half of that medication (same strength pill, more pills per day). Since neither medication is at the maximum prescribable dosage (per drugs.com), the apparent add-on dosage didn’t raise any flags.

The other major issue is that my pharmacy strongly encourages patients with ongoing medication needs to sign up for its automatic refill service, and that service tends to be very strident about guilting us into picking up these medications whether or not we need them. When they are medications whose costs are fully covered by our insurance (aka, $0.00 copay), it’s way too easy to say, “OK. This way, I have a stash just in case ‘something’ happens.” (“Something” can be loss of insurance, change of coverage/formulary, natural catastrophe, etc.) Earlier this year, my statin stash reached the point where it would expire out before I could use it.

By the way, if I am out of refills, the pharmacy will keep bugging me to allow them to contact my physician’s office for a new prescription — even if it was a short-term medication, such as an antibiotic or an antihistamine.

The pharmacist on duty at my pharmacy said that every time they filled a changed dosage in the prescription, they asked if the patient was aware of the dosage change. I’ve never encountered that, personally — and often it’s my Other Half who’s picking up the scripts. Also, the “your prescription is ready” texts and app information never note the prescribing doctor, the dose, or the number of pills dispensed without going deep into the details, so it’s very easy for the average patient to miss it.

Unfortunately, the issues surrounding the purity (avoiding tampering) and maintenance (within the required temperature and humidity ranges) of medications that have already been dispensed for home use means that they usually can’t be donated somewhere for the use of people who can’t afford them, even if it’s two years until it expires, and in a sealed bottle direct from the manufacturer. (A few communities and states have donation programs; mine don’t.) This means that over-dispensed medications — in addition to creating a potential overdose hazard for the patient for whom they were prescribed — also pose environmental hazards in the methods of their disposal. Pharmaceuticals dumped directly into the trash either stay intact for years in their plastic bottles, or, if released from those bottles, disintegrate and contaminate the soil and groundwater, requiring greater water purification and posing hazards to wildlife. On the other hand, pharmaceuticals disposed of “properly” via your local pharmacy or police department, are disposed of by incinerating them at extremely high temperatures (to denature their active ingredients), using a lot of fossil fuels and contributing to our carbon footprints.

For the moment, I’ve told the pharmacy to stop automatically refilling those duelling prescriptions. As it is, I’m going to have to spend a couple of hours over the next year pill-splitting some of them so I don’t end up contributing more to the medical waste issue than necessary. I still think there needs to be a better system in place to make sure people get all of the medication they need, but not so much extra that they end up either overmedicated or contributing to the tons of medical waste we create each year. I’m just not sure what it should look like.

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*Blogabetes was a metablog (a blog with multiple independent contributors — similar to Medium’s “publications”) on the dLife website/portal from some time after its original founding (around 2005) until a change in ownership in 2016, at which time the blog and its posts were removed from the website. I was one of the writers for Blogabetes from April 2009 until August 2016.