Pharmacist Challenges Concept of Chronic Conditions and Maintenance Meds

You’ve probably heard the term “chronic condition” in relation to elevated blood pressure, elevated cholesterol, elevated blood sugar (in type 2 diabetes), and other medical problems. You may have been told that these chronic conditions must be treated with medication for the rest of your life. The implication is that these conditions are “chronic” just like type 1 diabetes and require maintenance meds.

What Are Maintenance Meds?

Pharmacists have a short-hand term for medications that are used to treat chronic conditions. When speaking with pharmacy technicians, pharmacists often refer to drugs that are taken long term as “maintenance meds.”

Soon after graduation from pharmacy school, I worked for a large chain that (at least in my district) had a very relaxed attitude toward pharmacists phoning doctors for refill authorizations for what were viewed as “maintenance meds” (those for blood pressure, cholesterol, type 2 diabetes, etc.).

Refills Without Prior Authorization?

For example, the unstated and unofficial attitude in my district seemed to be: The patient isn’t going to be cured of his/her hypertension (or elevated cholesterol, type 2 diabetes, depression, etc.) any time soon, so what’s the big deal with pharmacists going ahead and giving a few more refills and calling the doctor for authorization when we’re not busy at some point in the future?

As a result of one of my commentaries in Drug Topics, I received the following e-mail from a pharmacist who, like me, questions the common use of the term “chronic” disease:

“Whenever the doctor’s office had not called back with the customer’s refill authorization, besides being annoyed, many customers would respond by saying:

“’I don’t know why the doctor does not give more refills. I’m going to be on the medication for the rest of my life.’”

“I always felt like going over to the customer and saying, ‘How do you know that you are going to be on the medication for the rest of your life?’”

Pharma clearly has a financial incentive to expand the concept of chronic illness. Pharma wishes every illness were seen as chronic, long term, permanent, unpreventable, genetic, or an unavoidable consequence of aging. With such an outlook, people are not motivated to look for things they could do themselves (like dietary and lifestyle changes) that could eliminate the need for drugs.

Examples of True Chronic Conditions:

Of course, there are some conditions that can legitimately be defined as “chronic” and the term “maintenance meds” is accurate for these conditions. People with type 1 diabetes are maintained with insulin. Similarly, people with underactive thyroid are maintained with drugs like levothyroxine. Other truly chronic conditions include Parkinson’s disease, epilepsy, multiple sclerosis, rheumatoid arthritis, psoriasis, etc.

Are Classic “Chronic” Conditions Really Chronic?

But are elevated blood pressure, elevated cholesterol, and elevated blood sugar (in type 2 diabetes) necessarily chronic or permanent? That’s like asking whether obesity is permanent. Many people have been obese for a very long time but that does not mean obesity is permanent.

Is depression necessarily a chronic condition? If your spouse or coworkers are abusive toward you, or if your income is insufficient to cover your expenses, or if you have a mind-numbingly repetitive job and you are depressed as a result, does that make depression a chronic condition? Is depression caused by a chemical imbalance in your brain (as Pharma claims) or is it caused by many different factors?

Is Shyness a Chronic Condition?

Or consider shyness. Pharma has rebranded shyness with the more impressive-sounding moniker “social anxiety disorder” to make it sound like a serious medical condition requiring medication. I once read that someone who won millions of dollars in a state lottery suddenly lost his/her shyness. How is that possible if shyness is, as Pharma seems to imply, a chronic mental disorder?

In fact, many behavioral problems are closely related to our life circumstances. Getting a divorce, changing jobs, avoiding abusive relationships, etc. may be better solutions than pills for shyness, anxiety and depression.

How Pharma Distorts the Meaning of Chronic to Sell More Pills:

We need to re-examine Pharma’s strong desire to classify every persistent problem as a “chronic condition” for which “maintenance meds” are the solution.

Pharma clearly loves the concepts of chronic conditions and maintenance medications. That’s why drug advertisements on TV are overwhelmingly for conditions that are viewed as long term. You see very few (if any) drug ads on TV for antibiotics.

Antibiotics treat infection and are frequently prescribed for only 5 to 10 days. Pharma doesn’t like to advertise drugs that are used for acute conditions like infections.

Advertisements for drugs that treat heartburn or gastro-esophageal reflux are common because acid problems are increasingly viewed as chronic. However, people who chronically take antacids, H2 antagonists and proton-pump inhibitors may be able to get off these drugs with weight loss and/or a significant change in diet.

You don’t see ads on TV for epinephrine injectors because the use of this drug is highly sporadic to treat severe allergic reactions to things like bee stings or peanuts. This is in contrast to drugs that are taken every day for high blood pressure, elevated cholesterol, type 2 diabetes, psoriasis, Crohn’s disease and depression.

Many cases of hypertension and type 2 diabetes are preventable and are thus not necessarily chronic.

For example, The Merck Manual (16th edition, p. 984) states:

“Thus weight reduction will lower the BP [blood pressure] of most hypertensives, often to normal levels, and will allow 75% of type 2 diabetics to discontinue medication.”

Ninety percent of people with diabetes have diagnoses that fall under the heading of type 2.

According to Dr. Jeffrey S. Bland (The Disease Delusion: Conquering the Causes of Chronic Illness for a Healthier, Longer, and Happier Life, New York: Harper Collins, 2014, inside front dust jacket):

“Contrary to conventional wisdom, chronic disease is not genetically predetermined but results from a mismatch between our genes and environment and lifestyle.”

Pharma clearly wants to expand the category of chronic conditions to assure the long term (chronic) profitability of the pill business. There have been many initiatives to “improve compliance” or “enhance adherence” to medication regimens. Not surprisingly, Pharma wants to enlist physicians and pharmacists to ensure patients continue to take their maintenance meds regardless of cost or adverse reactions.

I wish more doctors and patients would team up to prevent or control so-called chronic conditions with practical plans to implement lifestyle changes. It is time for health professionals to embrace tested techniques of health coaching to make this more feasible (Work, May 24, 2019; PLoS One, April 18, 2018; Global Advances in Health and Medicine, May, 2013).