Many people have stopped seeking medical attention during the COVID-19 pandemic out of fear of catching the virus at a doctor’s office or clinic. As a result, fewer people may die from adverse drug reactions to prescription medicine. — author Alan Cassels, UBC pharmaceutical drug policy researcher. This article first appeared in Focus on Victoria, and is reprinted here with permission. Ed.
WHEN YOU WITHHOLD MEDICINE, people die, right? Well, not quite.
We are currently living in a massive medical experiment that may reveal a number of surprises. Down the road, as researchers look back and parse through what happened in the year 2020, they will undoubtedly discover a goldmine of evidence of the impact of the pandemic—both the good and the bad. We know that things won’t be the same in many dimensions of our lives, and we may discover things that make us fundamentally rethink much of what we do in medicine. Despite all the hardship, anxiety, and economic impact inflicted on the world by the COVID pandemic, there may be some silver linings.
One particular area of interest is the ceasing of the delivery of medical interventions. Undoubtedly many types of harm have been inflicted by imposed lockdowns, shutting hospital beds, cutting off of elective surgeries, isolating elderly people from their loved ones, and the general heightened level of fear imposed by social distancing rules. The fact that people have been generally fearful of going near any doctor or health facility may have prevented them from accessing important healthcare. At the same time, not going to the doctor on a massive scale will allow researchers to examine the full effects of stopping medical delivery and possibly uncover unexpected benefits.
This is not the first time stopping medical delivery has been studied.
Much has been studied about the impact of doctor strikes over the last 40 years, and the results generally point in the same direction: when doctors strike, fewer people die. A systematic review of five doctor strikes between 1976 and 2012 found that patient mortality either stayed the same or fell. It didn’t—as one might expect—increase.
How does one explain this? One of the key answers is iatrogenesis, which is harm that is inflicted by the medical system itself—so that any medical activity, including tests, drugs, scans, and hospital stays, can involve harm. Less contact with the medical system, less avoidable death. At least that’s the theory.
Currently there are many voices delivering dire warnings about the pandemic’s effects on the health of the population, beyond the risk of the virus. Other voices, perhaps more muted, include some who suggest there could even be some general health improvements.
I talked to my friend Dr Eddy Lang, an emergency room physician from Calgary and a member of the Canadian Task Force on Preventive Health Care. He told me: “Some signals are suggesting increased mortality in countries hard hit by the virus, but it is unclear if this is uncounted COVID deaths or collateral damage, as others claim.”
We know that, for example, during doctor strikes the kinds of hospital infections and other complications associated with surgery go way down. Some patients who might have mild heart conditions will avoid the hospital, where they may avoid the stent or other bypass surgery they’d get in normal times. This might be a good thing as there is some evidence that we are doing too many of these cardiac interventions in low-risk patients.
In mid-July Dr Lang and colleagues published a piece in the British Medical Journal which echoed these thoughts and called for rigorous studies to investigate the effects of reduced healthcare. It noted that “looking beyond the crisis, our collective learning about the effects of the large falls in healthcare use can help inform and intensify efforts to reduce unnecessary care. This in turn can prevent avoidable harm to patients, enhance healthcare equity, and improve the sustainability of health systems everywhere.”
What about drugs?
If reductions in physician office visits mean that patients aren’t getting new prescriptions, or renewals of existing prescriptions, three things could happen: Their health may worsen, it may stay the same, or, possibly, it might improve. In those serious cases, such as when a person with asthma avoids getting a puffer prescription refilled or a diabetes patient avoids renewing their insulin prescription—this kind of avoidance could turn fatal. But for many conditions, a drug holiday might be very good for you. Dr Lang reminded me that many prescriptions for antibiotics, for example, are unneeded and often cause more harm than good.
For longer-term drug use, people who take drugs in a class called proton pump inhibitors (PPIs) including Losec, Pariet, or Pantaloc, which are prescribed mostly for heartburn, might see their health improve if they slowly weaned themselves off the pills. A study published last year examined over 200,000 US veterans who took PPIs and found that long-term therapy with these drugs, with other things being equal, increases the risk of death.
Adverse drug reactions (ADRs) associated with many commonly used prescriptions, are a real thing. As well, as Dr Lang points out: “The trials that looked at these drugs actively avoided recruiting frail folks with co-morbidities.” What this means is that older and more frail people are likely at even more risk. Being injured or hospitalized because of a medication reaction is commonplace and some estimates say as many as 220,000 Canadians suffer ADRs per year in Canada, of which about 10 percent, or 22,000, are fatal. “Not to mention the thousands of avoidable hospitalizations,” adds Dr Lang. Obviously if the harm exceeds the benefit of any medication, stopping it might be the right and healthy thing to do.
ADRs are often overlooked and underreported, but if you broke down the estimated ADRS by province, BC alone would have about 2,860 ADR deaths per year, or about 8 deaths per day due to what are regular, normal prescribed drugs. As of mid-July in BC, we’ve had about 190 COVID deaths in the last 120 days, or about 1.5 per day.
So you could look at it this way: If people stopped taking drugs that were causing excessive ADRs, that act alone could potentially save up to five times more lives than we are losing to the virus.
In the future, stopping certain medications could be a lot more “normal” than it currently is.
Some of the major chronic conditions like high cholesterol, type 2 diabetes or high blood pressure, result in a lot of long-term drug use, but probably not as much as you’d think. Many people naturally stop taking their drugs for whatever reason, or get to the point where they’d rather not live with the hassle or expense.
Drugs for type 2 diabetes are almost universally prescribed to alter blood sugars, yet for most people any change in your numbers brought on by these drugs don’t automatically translate into a longer or healthier life. Even the guidelines (which are underwritten by the drug industry) advise that the most important step in helping type 2 diabetics is altering diet and exercise patterns—before you ever consider taking a drug.
But what about high blood pressure?
Stopping medications has always been difficult because clinicians and patients worry that stopping a drug will worsen their health. But what about drugs for high blood pressure?
Well, even here there is growing evidence that stopping antihypertensive drugs (drugs to lower blood pressure) may not be bad for you, especially if you’ve never had a heart attack and are not afflicted by cardiac issues.
Dr Lang reminds me that “elders have a higher risk of ADRs and may not benefit at all from a lower blood pressure.”
A recent systematic review by Cochrane agreed with him. It looked at six studies with over 1000 healthy patients over 50 and found that those who stopped their high blood pressure pills did as well (in terms of heart attacks and deaths) as those who continued. This review was rated as “low certainty” of evidence, so it is not the last word on the question. What it did show is that there is no evidence of increased risk if older people without established heart disease stop taking their antihypertensive medications. The implications of this itself could be huge.
Let’s not downplay the seriousness of hypertension, which is considered a risk factor for strokes, heart attacks, and chronic kidney disease. At the same time, you would only want to be taking these drugs if you were sure they are reducing your overall risks, instead of just altering your numbers. But as Eddy Lang notes: “Knowing for sure is almost impossible. Best you could hope for is a decent chance of benefit.” In any event, it’s certainly worth a discussion with your doctor.
Stopping medications, for older people who face the many problems that often come with too many drugs, is becoming more and more mainstream. There are a number of groups who are actively concerned with overprescribing and working to reduce the harm of too much medicine. The Canadian Deprescribing Network, and Choosing Wisely Canada are two such organizations.
As a researcher I’m particularly hopeful that this pandemic will prove to be an opportunity to discover which medical treatments or drugs we could use less of.
It’s a natural experiment that is happening around the world. With some good international collaboration and good data on how we have faired with less medicine and less medication, we might learn some valuable lessons.
Alan Cassels lives in Victoria where he studies and writes about pharmaceuticals. He works for UBC but the opinions represented here are his own.