The Perils of Polypharmacy

by Theodore Dalrymple

The post-mortem examination of actor Matthew Perry shows that he died principally of ketamine poisoning, though the condition of his body suggested that he had not otherwise lived an altogether healthy life.

Traces of other psychoactive prescription drugs were also found in his body and may have played some supporting role in his death. A search of his house revealed a veritable pharmacopeia of prescription and over-the-counter drugs, few of which were of the kind likely to improve his health greatly or save him from ill health.

There are still unanswered questions about his death, which it was no part of the post-mortem examination to answer. How did he come by and take an anesthetic dose of ketamine? Were his drugs prescribed by one doctor alone, or by more than one? If the latter, did they know what the others were prescribing?

Polypharmacy, as the prescription of many different drugs or medicines at the same time is known, is very common, and among the elderly almost universal, but it’s hazardous and often harmful. However many warnings there are against it, the practice continues, as if by some invisible compulsion. I spent more of my career trying to persuade people to stop taking their medications than I did in prescribing them. In some circumstances, in prison, for example, there’s almost an inverse rule of compliance: those who take their medicine don’t need it, and those who need it don’t take it. Of course, this is only a very rough rule.

Despite the fact that it has been shown over and over again that the combination of opioid drugs with benzodiazepines, the latter safe in themselves, is extremely dangerous, patients are somehow still prescribed them simultaneously. Moreover, many patients—most, in fact—don’t take medications exactly as prescribed. They forget; they think they’re better and therefore stop; they feel worse and therefore take more than prescribed.

I learned this early in my career when I visited an old lady in heart failure, who was being visited by a neighbor who suffered from severe asthma. “Here,” said the old lady, “take some of these. I always take a few extra when I’m not feeling well.” The neighbor reciprocated the gift with her own medication.

Mr. Perry was prescribed opioids and benzodiazepines. Here’s how such polypharmacy occurs: a patient goes to his doctor and complains of something. The doctor prescribes a medication. The patient returns a little later. “Has the prescription helped?” asks the doctor. “I think so,” says the patient, so that the doctor is reluctant to stop it. Then the patient describes another problem, and the procedure is repeated until the patient is taking a veritable cocktail of drugs. If by chance the doctor does stop one of the drugs (he’s reluctant to do so just in case it is working, even if the patient doesn’t realize it) and prescribes something to replace it, the patient doesn’t throw the surplus pills away; he stores them in a cupboard, for future use. You never know when they might be needed again, even if they didn’t work the first time.

The plethora of medications found in Mr. Perry’s house suggests that he, and possibly one or more of his doctors, believed the modern superstition that for every human dissatisfaction, from that of aging skin to loneliness, there’s an equal and opposite pill or potion.

Of course, this is nothing new: If you look at magazines from a century and more ago, they’re full of advertisements for quack medicines. Doing some historical research into three murders committed in the 1840s, I discovered quite by chance that half of provincial newspaper owners or editors in Britain also actually sold the quack medicines that took up half the advertising space in their publications—a fine example of commercial synergy. Moreover, about half the quack medicines they advertised were supposedly either preventive or curative of syphilis, casting a lurid light on the fears, justified or not, of the Victorians.

However, we’re still inclined to believe that, with the advance of science and technology, we can live a life of permanent satisfaction and even happiness. Therefore, we medicalize their opposite, as if the natural state of Mankind were perpetual bliss, deviations from which were a pathology that called for medical intervention.

It’s 30 years since the best-selling book “Listening to Prozac” was published. The author, Peter D. Kramer, complained that the media had “missed the main story” about Prozac:

“The transformative powers of the medicine—how it went beyond treating illness to changing personality, how it entered into our struggle to understand the self—were nowhere mentioned.”

Dr. Kramer made a prediction, which turned out to be correct:

“I suspect we will come to discover that modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives.”

The phrase “climate of opinion” is taken, of course, from W.H. Auden’s poem, “In Memory of Sigmund Freud,” written shortly after Freud’s death:

“… to us he is no more a person now but a whole climate of opinion, under whom we conduct our different lives …”

But a whole climate of opinion isn’t the same as truth, and saying that we conduct our lives under that climate of opinion isn’t the same as saying that we conduct them better. I can’t help but recall a vainglorious post on the website of the National Institute of Drug Abuse claiming that it, the institute, had contributed greatly to new understandings of drug addiction—this at a time when unprecedented numbers of people in America were dying of overdoses of addictive drugs.

First published in Epoch Times.