Should doctors reconsider prescribing these drugs?

More Americans are taking prescription medications than ever before. Authors of a nationally representative study published in JAMA found that prescription drug use among adult Americans increased from 51% in 1999-2000 to 59% in 2011-2012. 

Furthermore, polypharmacy (defined as taking five or more prescription drugs) increased from 8.2% to 15% in this same period. Among the 18 most popular drug classes, prescription drug use increased significantly in 11 of them, including antihyperlipidemic agents, prescription proton-pump inhibitors, antidepressants, and muscle relaxants.

Many prescribed drugs, such as statins and blood-pressure medications, do yield considerable benefits for millions of people. But certain drugs of limited benefit are likely overprescribed, an issue decried by experts.

“Hopefully, as a result of analyzing the overprescribing of specific highly prescribed drugs, by their major indication,” wrote the author of a literature review published in the Journal of Clinical Medicine Research, “pathways can be identified to better understand the dimensions of polypharmacy and thereby curtail its excesses.”

Here are five classes of overprescribed drugs that warrant further consideration:

Muscle relaxants

Due to the opioid epidemic, physicians and patients seek out opioid alternatives to treat musculoskeletal ailments. Consequently, the prescription of skeletal muscle relaxants—including baclofen, carisoprodol, cyclobenzaprine, chlorzoxazone, methocarbamol, metaxalone, orphenadrine, and tizanidine—has skyrocketed in recent years. 

Per the results of a population-based cross-sectional study published in JAMA, outpatient visits involving prescribed skeletal muscle relaxants nearly doubled from 15.5 million in 2005 to 30.7 million in 2016. Although visits for new skeletal-muscle relaxant therapy held stable during these years, office visits for continued therapy tripled from 8.5 million to 24.7 million in this same time period. Notably, 67.2% of patients with a continuing prescription of skeletal muscle relaxants were concurrently using opioids in 2016. Disconcertingly, older adult patients accounted for 22.2% of office visits for skeletal muscle relaxants.

Skeletal muscle relaxants are indicated for muscle spasms and lower back pain, and prescribed off-label for neuropathic pain, chronic non-cancer pain, temporomandibular disorder pain, and non-pain conditions. However, little evidence exists to support the long-term efficacy and safety of these drugs, and concerns about misuse, dependence, and overdose fester. 

Experts recommend that these drugs be used between 2 and 3 weeks at most, but 44.5% of people taking these drugs are continuously treated for more than 1 year, according to research cited by the authors. Moreover, carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol, metaxalone, and orphenadrine can be dangerous in the elderly and lead to cognitive impairment, sedation, and fracture, as well as drug-drug interactions (ie, opioid interactions).

“Given their prominent adverse effects and the limited evidence for their long-term efficacy, growth in the continued use of SMRs [skeletal muscle relaxants], particularly in older adults and concomitantly with opioids, is concerning,” the authors concluded. “Given the findings of this cross-sectional study, efforts to limit the long-term use of SMRs may be needed, especially for older adults, similar to efforts used to limit the long-term use of opioids and benzodiazepines.”

Proton-pump inhibitors

Use of prescription proton-pump inhibitors (PPIs) doubled from 3.9% in 1999-2000 to 7.8% in 2011-2012. The FDA approved PPIs to be used for 10 days in the case of Helicobacter pylori infection, up to 2 weeks for heartburn, and up to 8 weeks for gastroesophageal reflux disuse. Treatment of ulcers, on the other hand, can extend between 2 and 6 months. Regardless, these drugs should not be taken indefinitely, as long-term use can lead to fractures, hypomagnesemia, anemia, Clostridium difficile infections, and gastric polyps.

Nevertheless, these drugs are the most popular prescription by primary-care physicians for the treatment of indigestion, and long-term use of PPIs is incredibly common, with 60% of patients in the community remaining on the drugs for more than a year, and 31% of patients continuing for more than 3 years, according to the aforementioned literature review. To boot, 44% to 59% of people taking the drugs experience symptomatic withdrawal after discontinuance. And this withdrawal can last for weeks.

Perhaps lifestyle changes should be more strongly emphasized than taking a PPI. “GI disorders such as GERD of course increase with age, but they are also increased in association with smoking, alcohol use, obesity, spicy food, and late meals. So, life pattern changes to reduce GI symptoms can be very useful for treatment,” wrote the author of the review.

Levothyroxine

Prescription rates for levothyroxine jumped from 4.6% in 1999-2000 to 6.0% in 2011-2012—a phenomenon that could be fueled by unjustified prescription for subclinical hypothyroidism, per the experts.

Although levothyroxine is indicated for the treatment of hypothyroidism, it is often prescribed inappropriately for the treatment of subclinical hypothyroidism based on serum levels of thyroid-stimulating hormone (TSH) that are only moderately outside the normal limits.

Normal reference values for TSH represent a population average that can be misleading in older adults, who naturally develop higher TSH levels over time. Other factors that skew normal TSH values include geographic location, living in an iodine-rich area, race, morbid obesity, exercise, sleep deprivation, prescription drug use, pregnancy, winter season, and kidney/liver disorders. As a result of these variables, the frequency of subclinical hypothyroidism ranges between 3% and 15% in different communities.

As recommended in the literature review, monitoring patients with elevated TSH levels is necessary. But rushing to treatment is imprudent, as outcomes data show that levothyroxine treatment for subclinical hypothyroidism does not affect rates of depression or death, quality-of-life measures, and cognitive function.

Selective serotonin reuptake inhibitors

Use of selective serotonin reuptake inhibitors (SSRIs) increased from 4.3% in 1999-2000 to 8.5% in 2011-2012. Although these psychotropics relieve symptoms of major depression and anxiety in the short term, their use as maintenance therapy is not as well backed by the research, with 1-year relapse rates of 34% to 50% in adults taking the drugs following remission of major depressive disorder. Notably, many adults taking antidepressants do not meet the threshold count for diagnostic symptoms recommended for prescription of these drugs.

Importantly, antidepressants carry the risk of unwanted adverse effects, including impaired sexual function, weight gain, agitation, hypertension, type 2 diabetes, and low-bone density. Withdrawal can also be an issue when the drugs are terminated abruptly following 6 or more weeks of therapy.

Opioids

When used appropriately, prescription opioids can be an irreplaceable treatment for chronic and acute pain. However, their use carries serious risks that need to be weighed carefully with their benefits. 

Prescription rates for opioid analgesics went up from 3.8% in 1999-2000 to 5.7% in 2011-2012. Although the opioid prescribing rate has been declining after hitting its peak in 2010-2012, there were still almost 58 opioid prescriptions written for every 100 Americans in 2017, according to the CDC.

“Since the 1990s, when the amount of opioids prescribed to patients began to grow, the number of overdoses and deaths from prescription opioids has also increased. Even as the amount of opioids prescribed and sold for pain has increased, the amount of pain that Americans report has not similarly changed,” the CDC noted.

“From 1999 to 2018, more than 232,000 people died in the United States from overdoses involving prescription opioids. Overdose deaths involving prescription opioids were more than four times higher in 2018 than in 1999,” the agency reported.