Are You Taking PIMs?

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Getting Off The Overmedication Train

The older we get, the more likely we are to be on more medications. It’s easy to assume that this is because, much like the ailments they treat, we accumulate them over time. And superficially at least, that’s what happens.

And yet, almost half of people over 65 in Canada are taking “potentially inappropriate medications”, or PIMs—in other words, medications that are not needed and perhaps harmful. This categorization includes medications where the iatrogenic harms (side effects, risks) outweigh the benefits, and/or there’s a safer more effective medication available to do the job.

See: The cost of potentially inappropriate medications for older adults in Canada: A comparative cross-sectional study

You may be wondering: what does this mean for the US?

Well, we don’t have the figures for the US because we’re working from Canadian research today, but given the differences between the two country’s healthcare systems (mostly socialized in Canada and mostly private in the US), it seems a fair hypothesis that if it’s almost half in Canada, it’s probably more than half in the US. Socialized healthcare systems are generally quite thrifty and seek to spend less on healthcare, while private healthcare systems are generally keen to upsell to new products/services.

The three top categories of PIMs according to the above study:

  1. Gabapentinoids (anticonvulsants also used to treat neuropathic pain)
  2. Proton pump inhibitors (PPIs)
  3. Antipsychotics (especially, to people without psychosis)

…but those are just the top of the list; there are many many more.

The list continues: opioids, anticholinergics, sulfonlyurea, NSAIDs, benzodiazepines and related rugs, and cholinesterase inhibitors. That’s where the Canadian study cuts off (although it also includes “others” just before NSAIDs), but still, you guessed it, there are more (we’re willing to bet statins weigh heavily in the “others” section, for a start).

There are two likely main causes of overmedication:

The side effect train

This is where a patient has a condition and is prescribed drug A, which has some undesired side effects, so the patient is prescribed drug B to treat those. However, that drug also has some unwanted side effects of its own, so the patient is prescribed drug C to treat those. And so on.

For a real-life rundown of how this can play out, check out the case study in:

The Hidden Complexities of Statins and Cardiovascular Disease (CVD)

The convenience factor

No, not convenient for you. Convenient for others. Convenient for the doctor if it gets you out of their office (socialized healthcare) or because it was easy to sell (private healthcare). Convenient for the staff in a hospital or other care facility.

This latter is what happens when, for example, a patient is being too much trouble, so the staff give them promazine “to help them settle down”, notwithstanding that promazine is, besides being a sedative, also an antipsychotic whose common side effects include amenorrhea, arrhythmias, constipation, drowsiness and dizziness, dry mouth, impotence, tiredness, galactorrhoea, gynecomastia, hyperglycemia, insomnia, hypotension, seizures, tremor, vomiting and weight gain.

This kind of thing (and worse) happens more often towards the end of a patient’s life; indeed, sometimes precipitating that end, whether you want it or not:

Mortality, Palliative Care, & Euthanasia

How to avoid it

Good practice is to be “open-mindedly skeptical” about any medication. By this we mean, don’t reject it out of hand, but do ask questions about it.

Ask your prescriber not only what it’s for and what it’ll do, but also what the side effects and risks are, and an important question that many people don’t think to ask, and for which doctors thus don’t often have a well-prepared smooth-selling reply, “what will happen if I don’t take this?”

And look up unbiased neutral information about it, from reliable sources (Drugs.com and The BNF are good reference guides for this—and if it’s important to you, check both, in case of any disagreement, as they function under completely different regulatory bodies, the former being American and the latter being British. So if they both agree, it’s surely accurate, according to best current science).

Also: when you are on a medication, keep a journal of your symptoms, as well as a log of your vitals (heart rate, blood pressure, weight, sleep etc) so you know what the medication seems to be helping or harming, and be sure to have a regular meds review with your doctor to check everything’s still right for you. And don’t be afraid to seek a second opinion if you still have doubts.

Want to know more?

For a more in-depth exploration than we have room for here, check out this book that we reviewed not long back:

To Medicate or Not? That is the Question! – by Dr. Asha Bohannon

Take care!

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  • Insights into Osteoporosis

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    It’s Q&A Day at 10almonds!

    Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!

    In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

    As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!

    So, no question/request too big or small

    ❝I would like to see some articles on osteoporosis❞

    You might enjoy this mythbusting main feature we did a few weeks ago!

    The Bare-Bones Truth About Osteoporosis

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  • Fatty Acids For The Eyes & Brain: The Good And The Bad

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Good For The Eyes; Good For The Brain

    We’ve written before about omega-3 fatty acids, covering the basics and some lesser-known things:

    What Omega-3 Fatty Acids Really Do For Us

    …and while we discussed its well-established benefits against cognitive decline (which is to be expected, because omega-3 is good against inflammation, and a large part of age-related neurodegeneration is heavily related to neuroinflammation), there’s a part of the brain we didn’t talk about in that article: the eyes.

    We did, however, talk in another article about supplements that benefit the eyes and [the rest of the] brain, and the important links between the two, to the point that an examination of the levels of lutein in the retina can inform clinicians about the levels of lutein in the brain as a whole, and strongly predict Alzheimer’s disease (because Alzheimer’s patients have significantly less lutein), here:

    Brain Food? The Eyes Have It!

    Now, let’s tie these two ideas together

    In a recent (June 2024) meta-analysis of high-quality observational studies from the US and around the world, involving nearly a quarter of a million people over 40 (n=241,151), researchers found that a higher intake of omega-3 is significantly linked to a lower risk of macular degeneration.

    To put it in numbers, the highest intake of omega-3s was associated with an 18% reduced risk of early stage macular degeneration.

    They also looked at a breakdown of what kinds of omega-3, and found that taking a blend DHA and EPA worked best of all, although of people who only took one kind, DHA was the best “single type” option.

    You can read the paper in full, here:

    Association between fatty acid intake and age-related macular degeneration: a meta-analysis

    A word about trans-fatty acids (TFAs)

    It was another feature of the same study that, while looking at fatty acids in general, they also found that higher consumption of trans-fatty acids was associated with a higher risk of advanced age-related macular degeneration.

    Specifically, the highest intake of TFAs was associated with a more than 2x increased risk.

    There are two main dietary sources of trans-fatty acids:

    • Processed foods that were made with TFAs; these have now been banned in a lot of places, but only quite recently, and the ban is on the processing, not the sale, so if you buy processed foods that contain ingredients that were processed before 2021 (not uncommon, given the long life of many processed foods), the chances of them having TFAs is higher.
    • Most animal products. Most notably from mammals and their milk, so beef, pork, lamb, milk, cheese, and yes even yogurt. Poultry and fish technically do also contain TFAs in most cases, but the levels are much lower.

    Back to the omega-3 fatty acids…

    If you’re wondering where to get good quality omega-3, well, we listed some of the best dietary sources in our main omega-3 article (linked at the top of today’s).

    However, if you want to supplement, here’s an example product on Amazon that’s high in DHA and EPA, following the science of what we shared today 😎

    Take care!

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  • What Is Making The Ringing In Your Ears Worse?

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    Dr. Rachael Cook, an audiologist at Applied Hearing Solutions in Phoenix, Arizona, shares her professional insights into managing tinnitus.

    If you’re unfamiliar with Tinnitus, it is an auditory condition characterized by a ringing, buzzing, or humming sound, and ffects nearly 10% of the population. We’ve written on Tinnitus, and how it can disrupt your life, in this article.

    Key Triggers for Tinnitus

    Several everyday habits can make your tinnitus louder. Caffeine and nicotine increase blood pressure, restricting blood flow to the cochlea and worsening tinnitus. Common medications, such as pain relievers, high-dose antibiotics, and antidepressants, can also exacerbate tinnitus, especially with higher or long-term dosages.

    Impact of Diet and Sleep

    Dietary choices significantly impact tinnitus. Alcohol and salt alter the fluid balance in the cochlea, increasing tinnitus perception. Alcohol changes blood flow patterns and neurotransmitter production, while high salt intake has similar effects. Poor sleep quality elevates stress levels, making it harder to ignore tinnitus signals. Addressing sleep disorders like sleep apnea and insomnia can help manage tinnitus symptoms.

    Importance of Treating Hearing Loss

    Untreated hearing loss worsens tinnitus. Nearly 90% of individuals with tinnitus have some hearing loss. Hearing aids can reduce tinnitus perception by restoring missing sounds and reducing the brain’s internal compensatory signals. Combining hearing aids with sound therapy is said to provide even greater relief.

    Read more about hearing loss in our article on the topic.

    Otherwise, for a great guide on managing tinnitus, we recommend watching Dr. Cook’s video:

    Here’s hoping your ear’s aren’t ringing too much whilst watching the video!

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  • Beat Osteoporosis with Exercise – by Dr. Karl Knopf

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    There are a lot of books about beating osteoporosis, and yet when it comes to osteoporosis exercises, it took us some work to find a good one. But, this one’s it!

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    Click here to check out Beat Osteoporosis With Exercise, and stay strong!

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  • Vit D + Calcium: Too Much Of A Good Thing?

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    Vit D + Calcium: Too Much Of A Good Thing?

    • Myth: you can’t get too much calcium!
    • Myth: you must get as much vitamin D as possible!

    Let’s tackle calcium first:

    ❝Calcium is good for you! You need more calcium for your bones! Be careful you don’t get calcium-deficient!❞

    Contingently, those comments seem reasonable. Contingently on you not already having the right amount of calcium. Most people know what happens in the case of too little calcium: brittle bones, osteoporosis, and so forth.

    But what about too much?

    Hypercalcemia

    Having too much calcium—or “hypercalcemia”— can lead to problems with…

    • Groans: gastrointestinal pain, nausea, and vomiting. Peptic ulcer disease and pancreatitis.
    • Bones: bone-related pains. Osteoporosis, osteomalacia, arthritis and pathological fractures.
    • Stones: kidney stones causing pain.
    • Moans: refers to fatigue and malaise.
    • Thrones: polyuria, polydipsia, and constipation
    • Psychic overtones: lethargy, confusion, depression, and memory loss.

    (mnemonic courtesy of Sadiq et al, 2022)

    What causes this, and how do we avoid it? Is it just dietary?

    It’s mostly not dietary!

    Overconsumption of calcium is certainly possible, but not common unless one has an extreme diet and/or over-supplementation. However…

    Too much vitamin D

    Again with “too much of a good thing”! While keeping good levels of vitamin D is, obviously, good, overdoing it (including commonly prescribed super-therapeutic doses of vitamin D) can lead to hypercalcemia.

    This happens because vitamin D triggers calcium absorption into the gut, and acts as gatekeeper to the bloodstream.

    Normally, the body only absorbs 10–20% of the calcium we consume, and that’s all well and good. But with overly high vitamin D levels, the other 80–90% can be waved on through, and that is very much Not Good™.

    See for yourself:

    How much is too much?

    The United States’ Office of Dietary Supplements defines 4000 IU (100μg) as a high daily dose of vitamin D, and recommends 600 IU (15μg) as a daily dose, or 800 IU (20μg) if aged over 70.

    See for yourself: Vitamin D Fact Sheet for Health Professionals ← there’s quite a bit of extra info there too

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  • Statistical Models vs. Front-Line Workers: Who Knows Best How to Spend Opioid Settlement Cash?

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    MOBILE, Ala. — In this Gulf Coast city, addiction medicine doctor Stephen Loyd announced at a January event what he called “a game-changer” for state and local governments spending billions of dollars in opioid settlement funds.

    The money, which comes from companies accused of aggressively marketing and distributing prescription painkillers, is meant to tackle the addiction crisis.

    But “how do you know that the money you’re spending is going to get you the result that you need?” asked Loyd, who was once hooked on prescription opioids himself and has become a nationally known figure since Michael Keaton played a character partially based on him in the Hulu series “Dopesick.”

    Loyd provided an answer: Use statistical modeling and artificial intelligence to simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the best use of settlement dollars.

    Loyd serves as the unpaid co-chair of the Helios Alliance, a group that hosted the event and is seeking $1.5 million to create such a simulation for Alabama.

    The state is set to receive more than $500 million from opioid settlements over nearly two decades. It announced $8.5 million in grants to various community groups in early February.

    Loyd’s audience that gray January morning included big players in Mobile, many of whom have known one another since their school days: the speaker pro tempore of Alabama’s legislature, representatives from the city and the local sheriff’s office, leaders from the nearby Poarch Band of Creek Indians, and dozens of addiction treatment providers and advocates for preventing youth addiction.

    Many of them were excited by the proposal, saying this type of data and statistics-driven approach could reduce personal and political biases and ensure settlement dollars are directed efficiently over the next decade.

    But some advocates and treatment providers say they don’t need a simulation to tell them where the needs are. They see it daily, when they try — and often fail — to get people medications, housing, and other basic services. They worry allocating $1.5 million for Helios prioritizes Big Tech promises for future success while shortchanging the urgent needs of people on the front lines today.

    “Data does not save lives. Numbers on a computer do not save lives,” said Lisa Teggart, who is in recovery and runs two sober living homes in Mobile. “I’m a person in the trenches,” she said after attending the Helios event. “We don’t have a clean-needle program. We don’t have enough treatment. … And it’s like, when is the money going to get to them?”

    The debate over whether to invest in technology or boots on the ground is likely to reverberate widely, as the Helios Alliance is in discussions to build similar models for other states, including West Virginia and Tennessee, where Loyd lives and leads the Opioid Abatement Council.

    New Predictive Promise?

    The Helios Alliance comprises nine nonprofit and for-profit organizations, with missions ranging from addiction treatment and mathematical modeling to artificial intelligence and marketing. As of mid-February, the alliance had received $750,000 to build its model for Alabama.

    The largest chunk — $500,000 — came from the Poarch Band of Creek Indians, whose tribal council voted unanimously to spend most of its opioid settlement dollars to date on the Helios initiative. A state agency chipped in an additional $250,000. Ten Alabama cities and some private foundations are considering investing as well.

    Stephen McNair, director of external affairs for Mobile, said the city has an obligation to use its settlement funds “in a way that is going to do the most good.” He hopes Helios will indicate how to do that, “instead of simply guessing.”

    Rayford Etherton, a former attorney and consultant from Mobile who created the Helios Alliance, said he is confident his team can “predict the likely success or failure of programs before a dollar is spent.”

    The Helios website features a similarly bold tagline: “Going Beyond Results to Predict Them.”

    To do this, the alliance uses system dynamics, a mathematical modeling technique developed at the Massachusetts Institute of Technology in the 1950s. The Helios model takes in local and national data about addiction services and the drug supply. Then it simulates the effects different policies or spending decisions can have on overdose deaths and addiction rates. New data can be added regularly and new simulations run anytime. The alliance uses that information to produce reports and recommendations.

    Etherton said it can help officials compare the impact of various approaches and identify unintended consequences. For example, would it save more lives to invest in housing or treatment? Will increasing police seizures of fentanyl decrease the number of people using it or will people switch to different substances?

    And yet, Etherton cautioned, the model is “not a crystal ball.” Data is often incomplete, and the real world can throw curveballs.

    Another limitation is that while Helios can suggest general strategies that might be most fruitful, it typically can’t predict, for instance, which of two rehab centers will be more effective. That decision would ultimately come down to individuals in charge of awarding contracts.

    Mathematical Models vs. On-the-Ground Experts

    To some people, what Helios is proposing sounds similar to a cheaper approach that 39 states — including Alabama — already have in place: opioid settlement councils that provide insights on how to best use the money. These are groups of people with expertise ranging from addiction medicine and law enforcement to social services and personal experience using drugs.

    Even in places without formal councils, treatment providers and recovery advocates say they can perform a similar function. Half a dozen advocates in Mobile told KFF Health News the city’s top need is low-cost housing for people who want to stop using drugs.

    “I wonder how much the results” from the Helios model “are going to look like what people on the ground doing this work have been saying for years,” said Chance Shaw, director of prevention for AIDS Alabama South and a person in recovery from opioid use disorder.

    But Loyd, the co-chair of the Helios board, sees the simulation platform as augmenting the work of opioid settlement councils, like the one he leads in Tennessee.

    Members of his council have been trying to decide how much money to invest in prevention efforts versus treatment, “but we just kind of look at it, and we guessed,” he said — the way it’s been done for decades. “I want to know specifically where to put the money and what I can expect from outcomes.”

    Jagpreet Chhatwal, an expert in mathematical modeling who directs the Institute for Technology Assessment at Massachusetts General Hospital, said models can reduce the risk of individual biases and blind spots shaping decisions.

    If the inputs and assumptions used to build the model are transparent, there’s an opportunity to instill greater trust in the distribution of this money, said Chhatwal, who is not affiliated with Helios. Yet if the model is proprietary — as Helios’ marketing materials suggest its product will be — that could erode public trust, he said.

    Etherton, of the Helios Alliance, told KFF Health News, “Everything we do will be available publicly for anyone who wants to look at it.”

    Urgent Needs vs. Long-Term Goals

    Helios’ pitch sounds simple: a small upfront cost to ensure sound future decision-making. “Spend 5% so you get the biggest impact with the other 95%,” Etherton said.

    To some people working in treatment and recovery, however, the upfront cost represents not just dollars, but opportunities lost for immediate help, be it someone who couldn’t find an open bed or get a ride to the pharmacy.

    “The urgency of being able to address those individual needs is vital,” said Pamela Sagness, executive director of the North Dakota Behavioral Health Division.

    Her department recently awarded $7 million in opioid settlement funds to programs that provide mental health and addiction treatment, housing, and syringe service programs because that’s what residents have been demanding, she said. An additional $52 million in grant requests — including an application from the Helios Alliance — went unfunded.

    Back in Mobile, advocates say they see the need for investment in direct services daily. More than 1,000 people visit the office of the nonprofit People Engaged in Recovery each month for recovery meetings, social events, and help connecting to social services. Yet the facility can’t afford to stock naloxone, a medication that can rapidly reverse overdoses.

    At the two recovery homes that Mobile resident Teggart runs, people can live in a drug-free space at a low cost. She manages 18 beds but said there’s enough demand to fill 100.

    Hannah Seale felt lucky to land one of those spots after leaving Mobile County jail last November.

    “All I had with me was one bag of clothes and some laundry detergent and one pair of shoes,” Seale said.

    Since arriving, she’s gotten her driver’s license, applied for food stamps, and attended intensive treatment. In late January, she was working two jobs and reconnecting with her 4- and 7-year-old daughters.

    After 17 years of drug use, the recovery home “is the one that’s worked for me,” she said.

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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    Subscribe to KFF Health News’ free Morning Briefing.

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