Once every several weeks, Stephanie Chapin has a pill day.
The rural Cloquet woman assembles all of her mother's medications on the kitchen counter, separated in paper cupcake holders. Then each morning's and each evening's supply goes into small plastic bags purchased from a craft store and marked with a yellow slip of paper for morning or a dark blue slip for evening.
In the Lester Park neighborhood, Peggy Rich uses nine-drawer containers she bought at a hardware store to keep track of her pills and, until he went to a nursing home, her husband's.
Chapin and Rich are part of a growing phenomenon: As the population ages and an ever-increasing number of pharmaceuticals are produced to deal with chronic illnesses, patients are dealing with 10, 15, even 25 pills in a day. Some are taken in the morning, some at night, some with meals, and some might have to be split in half.
About every 20 years the number of outpatient prescriptions in the U.S. doubles, according to Randall Seifert, senior associate dean at the University of Minnesota College of Pharmacy, Duluth campus. It's up to about 5.6 billion per year. Moreover, the "intensity" -- the number of prescriptions per person -- nearly doubles every 20 years or so.
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Ann Yapel, a clinical pharmacist at Essentia Health's Lakewalk and Proctor clinics, said she has patients with more than 25 doses per day.
Among adults 65 or older, 12 percent use 10 or more medications, according to the U.S. Center for Technology and Aging. Failure to use those medications properly contributes to 23 percent of nursing home admissions, the agency reported in 2010.
The Centers for Disease Control and Prevention reported, also in 2010, that "adverse drug events" lead to 700,000 emergency room visits every year, and that's twice as likely to happen to adults older than 65. Pharmacists, caregivers and patients say part of the reason is confusion over all those pills.
Chapin helps manage the 13 pills a day taken by her mother, Agnes Jones, 83, of Midway Township. "When you have 13 bottles and you take half a pill of this and some in the morning and some at night, it's extremely confusing," Chapin said.
Adding to the confusion:
- Lack of communication among medical professionals.
Mark Schneiderhan, associate professor at the College of Pharmacy in Duluth, has researched the link between psychiatry and primary care.
"Sometimes a patient may have multiple specialists, and none of them are communicating," Schneiderhan said. "It gets complicated when you have other prescribers in there making changes."
Jim Gottschald, employee relations director and formerly benefits manager for St. Louis County, has seen the same thing.
"People may not go to the same doctor for all of their conditions," Gottschald said. "They may not go to the same pharmacy for all of their prescription drugs, and there's really no single gatekeeper to give them the full story of how everything is tied together."
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- The same pill can change shape or color.
"There's multiple manufacturers of products, and each one can make their tablet look a little bit different, and it can be very scary," Yapel said.
Patients notice.
"I told my doctor I wish they wouldn't change the color," said Chuck Lundberg of Superior, who takes medication for his heart, for cholesterol and for gout. "Leave them the color they were so I know what they are."
Managing medicines
Pharmacists say the industry is responding to the problem.
They tout medication therapy management, which changes their role from that of primarily dispensing medicine to primarily guiding patients in the use of medicine.
Among others, St. Louis County, Douglas County, the city of Superior, the city of Duluth, Sappi Paper and the University of Minnesota offer medication therapy management as a health benefit for their employees. It's also available as part of Medicare and Medicaid plans.
Megan Undeberg, a pharmacist who teaches at the College of Pharmacy, offers medication therapy management in Cloquet with funding from the Arrowhead Area Agency on Aging. The program, operated out of Community Memorial Hospital, began in March, and Undeberg works with about 40 patients. She offers a thorough review of a patient's medication, helps the patient set up his or her doses and works on resolving issues that might be causing the patient not to take needed drugs.
"They're dizzy from a pill," she said. "We look at it and say, 'Well, goodness, if you took it at this time of the day instead of this other time of day, or with food or something different, we can eliminate that side-effect."
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Patients sometimes will bring all their meds in a paper bag and pour them out on a table, Undeberg said. Yapel sees the same thing.
"We often see people come in with a grocery bag and they just kind of plunk it all down," Yapel said. "And it's the best way because you get to actually see what they're doing."
At Essentia clinics, an initial medication review takes 60 minutes and costs $100; a follow-up visit takes 30 minutes and costs $70.
St. Louis County began offering medication therapy management as a health benefit in September 2009, Gottschald said. Employees with any of five chronic health conditions -- diabetes, chronic obstructive pulmonary disease, depression, asthma and heart disease -- are eligible. As an incentive to enroll, they're offered reductions in their co-payments for many prescriptions. They're required to take two medication review sessions per year.
Those review sessions act as that needed gatekeeper in sorting out pill confusion, Gottschald said.
"We think that people initially participated in the program because of the co-pay savings," he said. "But what we're hearing back from them after they have these visits is: 'Wow. I didn't realize that I shouldn't be taking these two medications together, and that's why I have heartburn at night.' "
The University of Minnesota adopted medication therapy management as part of a wellness program three years ago in response to the success of a pilot program at the Duluth campus.
"There's lots of benefits to the university ... in terms of lowering our benefits cost," said Judith Karon, director of human resources at UMD. "And lots of benefits to employees in terms of being healthier."
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Like St. Louis County, the university offers reduced co-pays for employees who enroll in the program, Karon said. And the medication reviews are offered in-house at the College of Pharmacy.
At the drug store
Chances are, they also are available at your neighborhood drug store.
When Tim Affeldt became pharmacy supervisor for the Duluth Walgreens stores four years ago, "We were maybe doing this with one pharmacist in one store in Duluth," he said. Now, all of the company's pharmacists are trained in medication therapy management. A medicine review session costs about $80, although it's rare for anyone to seek a session if it's not covered by their insurer.
Charley Korsch, pharmacist at Arrow Pasek Pharmacy in downtown Duluth, said it takes anywhere from five minutes to half an hour to go through the proper use of medications with a customer. He doesn't charge but said he has an expectation the customer will continue to use Arrow Pasek.
Arrow Pasek offers a variety of dispensers to help patients keep track of their medicines. One is called Dispill and has punch-out containers for each day of a week and for breakfast, noon, evening and bedtime of each day.
At home
But some patients and caregivers have come up with their own methods.
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Peggy Rich's husband, Joe, 86, who has Parkinson's disease, recently moved into the Veterans Home in Silver Bay. She managed his medications for the disease for 26 years before that. Peggy Rich, 85, also has numerous prescriptions, for diabetes and high blood pressure.
She found med boxes to be "a pain" because the compartments were so small it was hard to keep the pills in the right places, Rich said. The containers from the hardware store, designed for fishing tackle or nuts and bolts, worked better for her. She used to carry a kitchen timer to remind her of pills her husband needed to take every two hours. And she put a chart inside a kitchen cupboard door of all the medicines and when they should be taken. The Riches' grown children, two of whom live in the Twin Ports, know where the charts are.
Chapin created a spreadsheet of her mother's medications, listing each drug, what the dosage is and what its purpose is.
"Once the list is done it's awesome because every time they go to see a doctor, they bring the list with them and then everybody's on the same page," Chapin said.
The pill boxes didn't work for her mother, either. "If the box got tipped then everything got mixed up, so we gave up on that one," Chapin said.
She settled on the small craft bags for their portability, she said. "It's small enough to slip in your purse or your coat pocket."
