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Overmedication

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Overmedication describes the excessive use of over-the-counter or precription medicines for a person. Overmedication can have harmful effects, such as non-adherence or interactions with multiple prescription drugs.

Over-the-counter medication overuse

Over-the-counter (OTC) medications are generally first-line therapies that people may choose to treat common acute illnesses, such as fevers, colds, allergies, headaches, or other pain. Many of these medications can be bought in retail pharmacies or grocery stores without a prescription. OTC medication overuse is most prevalent in adolescents and young adults.[1] This overuse is common due to the relatively low cost, widespread availability, low perceived dangers, and internet culture associated with OTC medications.[2] It is also important to note that many OTC medications come in combination formulations that contain multiple drugs. These combination formulations are often used with other substances, which complicates treatment for these types of overdoses. Furthermore, the easy access to information online can sometimes lead to self-diagnosis and self-medication, contributing to the potential for misuse and overuse.

Acetaminophen

Overuse of acetaminophen is the leading cause of liver failure in the Western world.[3] The maximum daily limit of acetaminophen is 4 grams per day for someone with a healthy liver. It is also highly recommended to go over the maximum daily limit. Exceeding the maximum daily limit could involve severe liver toxicity, liver failure, kidney failure, or even death.[4] People who have poor liver function or with chronic alcohol use disorder should either limit or not ingest acetaminophen to prevent morbidities.[5] Additionally, it is crucial to be aware that acetaminophen is an ingredient in many combination medications, increasing the risk of unintentional overdose. Patients should read labels carefully and consult healthcare providers to ensure they are not consuming excessive doses. In cases of suspected overdose, immediate medical attention is essential to mitigate potential life-threatening consequences.

Codeine

Main article: Opioid use disorder

Codeine is an opioid and shares similarities to other opioid overuse. Many OTC medications for cough have formulations that contain codeine, which people may seek to overuse. The common effects of codeine include miosis, respiratory depression, CNS depression, and decreased bowel motility. Opioid deaths are more related to super potent opioids such as fentanyl or for naive opioid users.[6] Despite the risk of death, dependence is another significant issue related to codeine overuse. Tolerance can build up, causing users to seek out more of the opioid, leading to dependence, especially with chronic daily use of codeine.[1] Additionally, the misuse of codeine-containing cough syrups has become a public health concern, as it can serve as a gateway to stronger opioids. It's important to monitor use and seek professional help if dependence is suspected. Moreover, education about the risks and signs of opioid addiction can play a crucial role in prevention and early intervention.

Dextromethorphan

Dextromethorphan, also shortened to DXM, affects the NMDA receptor and serotonin receptors which is believed to give its psychoactive effects at high doses. Similarly to codeine, DXM comes primarily in formulations that contain other OTC medications and is not common to find DXM on its own. Moreso, people who use DXM tend to use it concomitantly with other substances such as alcohol, hallucinogens, sedative drugs, and opioids.[1] DXM has dose dependent psychoactive effects with lower dose leading to more restlessness and euphoria and higher doses causing hallucinations, delusional beliefs, paranoia, perceptual distortions, ataxia, and out of body experiences.[1]

Diphenhydramine

Diphenhydramine is typically used for allergy relief, however, there are people who use it recreationally to help alleviate their sleeping problems, anxiety, and overall restlessness.[7] This is how overuse can occur. Acute effects are both psychiatric and physiological. For psychiatric effects a user may experience euphoria, hallucinations, or psychosis.[8] The physiological effects originate from the anticholinergic activity which may lead to tachycardia, dry mouth, blurred vision, mydriasis, CNS depression, and urinary retention.[8] While fatalities are not common it is primarily seen in individuals who have suicidal ideation who overuse the drug as a suicide attempt.[9]

Pseudoephedrine

Pseudoephedrine overuse is not common in the US due to the amount of the medication that can be purchased. The total amount of pseudoephedrine a customer can purchase in a day is 3.6 grams while a max of 9 grams of pseudoephedrine could be purchased in a 30 day cycle.[10] This is mainly due that ephedrine, pseudoephedrine, or phenylpropanolamine can all be used as a precursor for methamphetamine production. Prior to the limiting supply of pseudoephedrine, it was used as a weight loss and improve athletic performance.[1] The habitual use of the medication has led to dependance for many user using for weight loss leading to symptoms of insomnia, diminished sense of fatigue, euphoria, and psychotic behavior. Withdrawal symptoms include restlessness, dysphoria, and distorted perceptions.

Special populations

Elderly

Seniors (65 years old and up) are commonly victims of overmedication/overprescribing. It may make sense that with older age comes more chronic conditions, however, taking that into account does not change the higher incidence of adverse drug events in people over 65 years of age[11]. Seniors are disproportionately affected by not only adverse drug events but also drug-drug interactions and more hospital admissions. Having the risk of adverse drug reactions impacts the want to take certain medications. The best medication a provider can prescribe is a medication that the patient will take.

The term often used for individuals taking 5 or more medications is polypharmacy. Polypharmacy is commonly seen in elderly people, which increases their risk of overmedication/reactions from overmedication.[12] Medical providers are generally hesitant to take on cases of polypharmacy in the elderly due to the risk of harmful drug interactions. Concerns with polypharmacy and elderly groups are reduced medication adherence, increased fall risk, cognitive function impairment and adverse drug reaction. [13] As elderly individuals face various chronic diseases compared to other populations, they face polypharmacy from both over the counter (OTC) medications as well as various physicians prescribing without correlating together to optimize treatment plan. This can be seen from both specialty providers and primary care providers. A study was conducted stated it is easier for prescribers to write a prescription than to take time with the person and discussion patient education. Another study stated that most individuals are ready to obtain a prescription after their visit. Almost 75% of visits will result in people obtaining a written prescription.[14] As this targets more elderly populations, more studies and time need to be conducted to ensure that elderly people are optimizing their treatment plans. However, avoiding polypharmacy is not the objective of medical practice and it is important to practice safe drug therapy with our senior citizens.[15]

Some improvements that could increase medication adherence, along with lessening the risk of adverse drug events, include decreasing medication load. It has been shown that individuals greater than 95 years of age have less medications than their geriatric counterparts. This has been hypothesized to occur due to more careful prescribing practices.[16] It is important to be carefully prescribing medication to anyone, especially with our senior citizens as they are more likely to have more medications. Utilizing single-pill combination therapy is also a method to reduce the medication burden. It has been proven that combination therapy, specifically with antihypertensives, has shown greater blood pressure control.[17] Single-pill combination formulations make it easier for the patient to keep track of their medications, instead of taking two different tablets for the same condition. Single-pill formulations have also been shown to possibly provide added benefits otherwise not seen, such as further reduction in macro and microvascular complications. [17] Overall, it decreases the medication burden on the patient, making them more likely to take the tablet, increasing adherence.

Children

Children are another vulnerable population that can experience overmedication and overprescription. The overmedication of children has dramatically risen with those between the ages of 2-5 years old who are being prescribed atypical antipsychotics for bipolar disorders, developmental disabilities, ADHD, and behavior disorders.[18] In regards to prescription of psychotropic medications, there is an uneven distribution of the amount of children in the foster care system within the United States being prescribed these drugs. Being within the system also means that these children do not receive adequate drug monitoring and therapy.[19] This can lead to dangerous consequences, including adverse drug events.

Drug companies have benefited considerably with profits made in sales for drugs such as stimulants for children with attention deficit disorders, with half a million children in the United States receiving medication.[20][obsolete source] Children have become more involved with technology resulting in less play time outside and less time spent with parents. The long hours children spend with technology has impacted their attachment development, sensory and motor development, along with socialization skills, in return causing behavioral and psychological disorders and learning disabilities being diagnosed by psychotropic medication.[21]

Non-medication treatments to children with attention deficit disorders can vary per child. It is difficult to analyze what is happening to a child and how to aid in making it better. It was found that familial relationships can be largely affecting the mental health of the child, maybe leading to signs of depression and mood disorders.[22] If parents monitor their child's behavior and regulate their environment, it can help to prevent any future affective disorders. Medication is often prescribed to these children; however, it alone will not teach a child to create more valuable relationships at home or in the community. Other forms of intervention can be applied to supplement the effects of medication therapy and teach the child self-regulatory behaviors and healthy coping skills.[22] The increase of psychiatric medication of children may be a result of the declining support for caregiving, leading to psychopathology in which drugs are oftentimes the go-to method of treatment.[18] This is because some families do not always have knowledge regarding or the means to pursue other methods of intervention such as one-on-one therapy with the child, family therapy, and parenting counseling that can teach effective parenting strategies to meet their child's specific needs.

Overprescription

Overprescription can lead to medication misuse or abuse. Antibiotics[23] and Narcotic painkillers[24] are both common examples seen in both inpatient and outpatient settings.

Opioids

Opioids are used for pain management acutely or prescribed after a surgical procedure. A large issue with opioid prescription is the oversupply for pain management leading to opioid misuse. While opioids aid in short and long term pain management, overprescription or constant opioid-exposure allows people to be at risk for addiction or even sharing of medications for relief.[25] There is a rise within healthcare systems or departments to manage prescription day supply of opioids to avoid opioid misuse and abuse.

Opioids act as an analgesic (pain relief), this means it can help people of all ages; children and adults. Children being affected by opioid overuse can lead to more harm, additional treatment and can not provide the individual the most optimized treatment.[26]Pediatric populations also face increased opioid use at discharge from inpatient hospital. This was observed through studies that focused on medication reconciliation and the discrepancies of medications from admission to discharge. It was found that more medications were being prescribed at discharge than stated at inpatient admission. A great deal would provide relief for symptoms but not for the underlying cause. Opioids were one of the more common medications seen more at discharge than admission for postoperative patients. However, opioid prescriptions were also given to patients at discharge for people who did not undergo surgery during their specific hospitalization. This brings awareness for the interventions that can be done at discharge and medication reconciliation. It also calls for more information and treatment options to be given to adolescents that are nonopioid alternatives and to ensure proper communication with primary care providers and outpatient clinics. Focusing on factors like this will aid with decreasing adolescent exposure to opioids and its misuse. [27]

There are various instances where studies look at deprescribing opioids in certain groups. For example, individuals with chronic non-cancerous pain were studied to look at either dose-reduction or stopping opioid prescriptions as a whole. [28]

Antibiotics

See also: Antimicrobial resistance

Antibiotics are a group of drugs that fight against or prevent bacterial infections. Antibiotics are one of the most commonly prescribed medications. Because of this the misuse and overuse of these medications over the years have led them to lose their affinity for fighting certain bacteria due to bacteria developing resistance.[29]Antibiotic over-prescription is one of the most significant contributing factors to the global antimicrobial resistance crisis.[30]Antibiotic overprescription is a problem in all areas of healthcare settings, whether in acute, primary hospitals, or dental offices.

Half of all written antibiotic prescriptions are inappropriate, and as a result, antibiotic-resistant bacterial infections are increasing.[29] In the recent years of the COVID-19 pandemic, inappropriate antibiotic prescriptions have increased. A systemic review of admitted COVID-19 patients who were prescribed antibiotics showed that 80% of the admitted patients were given antibiotics upon admission without confirmed bacterial co-infections.[31]

Another study showed that outpatient doctors are prescribing antibiotics for non-indicated diagnoses such as viral infections to gain patient satisfaction; the consequence of this is the occurrence of more antibiotic-resistant infections, greater adverse drug events, more drug-drug interactions, and 15,000 deaths a year in the US alone. [32]Dentists also play a significant role in this issue; like medical doctors, they also fall under the pressure/expectations of patients and inappropriately prescribe antibiotics for non-indicated conditions that could otherwise be treated with other interventions against current guidelines.[33]

Undiagnosing to prevent overprescribing

Some diagnoses do not hold important clinical implications and do not require treatment. When they are treated, there is the potential for harm but little potential for benefit. The ERASE algorithm can help clinicians to Evaluate diagnoses through the consideration of Resolved conditions, Aging normally and selecting appropriate targets to eliminate unnecessary diagnoses and associated medicines.[34] Undiagnosing relies on accurate and comprehensive medical records to inform a thorough review of diagnoses.[35]

Medication overuse headaches

Main article: Medication overuse headache

Medication overuse headaches (MOH), also known as rebound headaches, are a consequence of the long-term overuse of pain-relieving drugs for headaches, affecting patients with chronic headache disorders such as migraine headaches. It impacts 1-2% of the population, occurring with the use of acute over-the-counter or prescription analgesics over 15 days or more. Though MOH can be treated with the discontinuation of analgesics, it can be pretty difficult with challenges such as withdrawal symptoms, lack of patient adherence, and education. [36]

References

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