Thank God for noncompliance—this time, at least

The elderly patient had been hoarding medications from various sources. What if he had taken them all?

By Kerri M. Peterson, MD
Family Practitioner/Carmel Valley, CA

During internship, I worked in a clinic where I'd often see patients who came in only to refill medications. One memorable encounter involved a 70-year-old retired Navy officer I'll call Daniel Turner. He was dealing with heart failure, hypertension, emphysema, diabetes, osteoarthritis, and, at the time, toenail fungus. He was on lots of medications.

"Which of your pills are we refilling today?" I asked him.

"Oh, it's that little white one," he replied, confident I knew what he was talking about.

"Which little white one?" I asked. Although just an intern, I'd had variations on this conversation with many other patients.

"The round one. It's scored down the center."

"Do you think it's the Lasix?" I inquired.

"Could be. What's that for?"

"It's a water pill," I said. "You take it in the morning."

"Could be . . . could be. Which one is for my blood pressure?"

I flipped to the lengthy medication list on the front of his chart. You're on three different pressure medicines," I explained. "Hydrochlorothiazide, lisinopril. and Hytrin."

"Which one is for my diabetes, then?" he asked, a quizzical look on his face.

"The metformin—and the Zestril helps, too," I replied.

"And for my heart?"

"That would be the digoxin, the Zestril, and the Lasix," I explained.

"I thought you said Zestril was for my diabetes," he stated, becoming exasperated.

"It works for both, Dan, and for your blood pressure, too."

"You didn't say that one was for my blood pressure."

"Yes, I did, Dan. But I might've said lisinopril instead of Zestril. They're the same, though. I'm sorry. All the drugs have a generic name as well as a brand name, and it can be confusing."

He looked at me skeptically.

"I'm afraid to ask you which of these medicines are for my lungs," he said.

"Oh, that's a whole different set of medications," I assured him. "Nothing to mix you up with there. They're all the inhalers."

"What about the prebbacin? I thought that was for my lungs."

"The what?" I asked. Now I was becoming confused.

"The prebbacin, or prebbadone, or prebbasone, or something like that," he responded.

"Do you mean the prednisone?" I asked.

"Yeah, that's it," he replied, clearly pleased we'd solved the mystery.

"You're not supposed to be taking that all the time," I said. "Yes, it's for your lungs, but it's only for when they're really feeling bad. Besides, you shouldn't have any of that medication left, not if you took it correctly the last time you were on it. I only give you enough to get you over one episode."

"Well, the last episode went away quicker than you thought it would," he explained. "So I stopped the medication early. Then, a few days ago, I was feeling kind of wheezy, and I started on it again, and I've been on it ever since. That along with the rest of sepera."

"The Septra, you mean?" I inquired apprehensively. Besides the prednisone, Mr. Turner, I realized, had also saved some of his antibiotic medication for acute episodes. I was feeling frustrated: How many times had I explained to him the importance of taking the full course of his antibiotic treatment?

"Yeah, the Septra," he affirmed. I repeated my usual speech, knowing full well it was once again falling on deaf ears.

"Dan, I think it would be helpful if you brought in every medicine you have in your house," I said. "Include the over-the-counter stuff as well, along with herbal treatments and whatever home remedies you might use. We can sort through it all, and see what you're really taking."

"Okay," Dan agreed. "But could you at least write me a prescription today for that little white pill?"

"And what's that yogurt maker for, Mr. Turner?"

A week later, Mr. Turner came back, toting a large paper bag. As he laid it on my exam table, he said: "Here you go, this is everything! You asked for it!"

I couldn't believe the array of stuff before me—Baggies, pill bottles, plastic containers of all kinds. Rooting around the bottom of the bag, I noticed what looked like a yogurt maker—a plug-in, plastic contraption that held six or eight little cups.

"What's this?" I asked, genuinely curious.

"Oh, that's a system I used to have. My old doctor had me on so many pills that I couldn't keep 'em straight to save my life, so I just put all the yellow ones in one container, the white ones in another, the green in another, and so on. I'd take one of each in the morning, one of each at night. Made everything real simple. But my doctor didn't like that system much. Chewed me out real good when I told him. I gotta say, though, I never saw the inside of a hospital while I was doing it that way!"

"Good advice your doctor gave you," I said, shaking my head in disbelief. "Why the yogurt maker, though?"

"On account of the basement," he replied. "That's where I was staying at the time, back when Maggie was still alive. She had me sleeping in the basement for a spell, because she was mad at me about something—don't remember what. So damn cold down there, I figured I needed to plug this thing in just to keep my pills at room temperature, like the pharmacist told me."

"Wouldn't want you to eat frozen pills," I agreed, as I opened one of the yogurt cups and dumped the assorted orange pills on the exam table.

"Oh, you might as well toss those, Doc," Mr. Turner said. "They're real old. Never could figure how to put them back in their original bottles. Guess I didn't miss 'em much."

I continued rummaging in the box. I counted out fourteen Baggies of what looked like marijuana, all fastened tightly with tiny rubber bands. With some difficulty, I opened a bag. Mr. Turner saw the look of curiosity on my face, and explained.

"Those were Maggie's idea—some health kick she was on. Everything had to be home grown and herbal. I got oregano, parsley, tarragon, rosemary—you name it, an herb for every ailment. Maggie thought they needed to be sealed tight to keep 'em fresh. But I found it all too much to bother with."

I took a whiff of the contents of the Baggie I'd opened. Basil, I thought to myself.

There were 42 containers in all, some more than 20 years old. There were also no fewer than seven bottles containing hydrochlorothiazide in various combinations, and five other bottles labeled "Lasix," although two of them looked like they contained something else. I held up three small Ziploc bags filled with white pills.

"Rounds, ovals, and irregulars," Mr. Turner offered by way of explanation.

"I'm a little afraid to ask," I said hesitantly, "but which of all these are you actually taking?"

"Here, let me show you my new system," Mr. Turner replied, pulling out a prefabricated plastic box labeled with the days of the week.

Oh, good, I thought to myself. Some semblance of a real system. At least he's not as daffy as I'd thought.

Mr. Turner showed me how he filled the container from his pill bottles every Sunday night.

"There's one space for Monday's once-a-day drugs, another space for the twice-a-days, and this here three-times-a-day space I don't use very much," he said. "And it's the same for every day of the week."

"And where are the pill bottles you use to refill this?" I asked. He began pulling bottles from the paper bag, seemingly at random, and I must have look worried because Mr. Turner immediately tried to reassure me.

"All the bottles I'm using now have this little black 'x' at the bottom," he explained.

I lined the x-marked bottles along my desk. As I feared, there was a bottle marked "Lasix," and another labeled "furosemide." There was a bottle marked "Zestril," and one "lisinopril." The two bottles marked "captopril" and "enalapril" each had a different doctor's name on it. Yet another bottle, this one labeled "digoxin," contained pills in three different colors, which I was able to match to pictures in the Physicians' Desk Reference. The dosages were 0.125, 0.25, and 0.5 milligram, respectively. If Mr. Turner was really taking all these, he ought to be dead. Thank God for noncompliance, I thought.

Patients on multiple meds? Follow these simple steps

I carefully sorted through the various bottles, discarding everything except those pills on Mr. Turner's updated medications list.

Not including the inhalers, I managed to pare down his regimen to seven prescriptions: furosemide, lisinopril, digoxin, hydrochlorothiazide, metformin, celecoxib, and terazosin. I might have consolidated further, but I didn't want to make too many changes in one visit.

I then made sure the med list in his chart was accurate. I wrote down all the medications, including both generic and brand names, the prescribed dosages and frequencies, and the condition each one treated. I gave a copy of the list to Mr. Turner, and had him read it back to me to ensure that my handwriting was legible and that he understood my directions. When he finished, he folded the sheet into quarters and stuck it into the chest pocket of his shirt.

"Make sure you keep that with you," I said. "I want you to try taking all of these exactly as prescribed for a week, and then come back and see me."

I made a note to myself to discuss prescription refills with his cardiologist. I thanked Mr. Turner for bringing in his medications, and wished him a good day.

That was seven years ago. But the lessons learned in my encounter with Mr. Turner serve me well to this day. True, I haven't seen many patients quite as confused about their prescription regimens as he was. But I've seen many patients who've labored under similar misconceptions.

That's why I keep in mind a few critical steps for dealing with patients on multiple medications. First, maintain an updated med list, and share it with patients.

Second, at least once a year, encourage patients to bring in all their medicines, vitamins, nutritional supplements, and herbs for a physical inspection. I've done this repeatedly over the years, but it never ceases to amaze me what patients keep in their medicine cabinets.

And third, keep in mind that our patients may not really need all the medications we give them. As physicians, there's a balance we should strive for—between prolonging life and needlessly compromising its quality through piling on the pills.

 

Kerri Peterson-Tapson. Thank God for noncompliance—this time, at least. Medical Economics 2001;10:111.