Are you stuck on THE CASCADE?

Once upon a time, a long long year ago, when I worked in retail pharmacy….there was a particular scene that would replay itself over and over. I would be humming along, busily checking for medication interactions, counseling on side effects and fixing insurance issues when --BAM!!-- I would suddenly find myself playing Tetris, trying to fill that little white bag up to the tippy top with a stimulant (Adderall, Concerta, etc.), an antidepressant (or two) and a sleep aid all mixed into a jumble of orange bottles. And I would take a long pause, a deep breath, and start to contemplate exactly how this bag representing this human got filled in this particular way.

You see, there are valid reasons for someone to take each and every one of these medications (in my opinion). I wouldn’t have bothered being a pharmacist at all if I felt they were just a money grab. Honestly, I wouldn’t. I like to sleep at night.

The problem is “THE CASCADE.”

dun dun dun!!! ::cue evil laugh here::

What’s “the cascade?”

Well I’m so glad you asked!

You see, “THE CASCADE” starts out very innocently.

You are prescribed a medication for a particular problem. A valid problem. For the sake of this example, let’s say you have recently hit a rough patch in life…a really rough patch. A close family member passed away or you have postpartum anxiety or you honestly just never recovered from the things you saw and the conversations you had during the rough COVID years. Either way, you can no longer function in your daily life. You bring it to your physician’s attention ( like you should ). You are prescribed an antidepressant like paroxetine or sertraline. The fog starts to lift. You can function again. AMAZING.

The only thing is…. now you are experiencing some of the side effects of your medication : weight gain, maybe a loss of libido, and you are suddenly aware of the feeling that people around you are moving a little bit faster, working a little bit harder, looking a little bit skinnier….and you also start caring about that (where as maybe before, in the fog of your depression, these things weren’t even noticed because you COULDN’T FUNCTION, much less “compete”).

You go back to your doctor to check in ( like you should ). You report that your depression is not so debilitating anymore. AMAZING! But the thing that would reeeeeaallly get you to a good place mentally is if you could just focus more, have a little more energy ( maybe eat a little less too, to get that extra weight off ). You think maybe you actually have ADD (attention deficit disorder) and just never noticed before! Obviously the depression was hiding your ADD. You have lots of work friends who take amphetamines and it really seems to work for them.

So, at your request, you get tested and sure enough, you’re eligible for a stimulant. So you add a stimulant. You start to feel GREAT. You have so much more energy and focus to get things accomplished now! The only thing is…now you have trouble falling asleep at night. So you report this at your next visit (like you should)....and you are prescribed an antianxiety medication… to act as a downer, to counteract the side effects of the stimulant upper, to counteract the side effects of the medication that you started THREE YEARS AGO during a rough patch.

Friend, you have entered “THE CASCADE.” You are now taking more medications to manage side effects than you are to manage the initial problem(s).

And it can be entered from many different directions!

(Ex: Start taking an over the counter pain medication like ibuprofen or naproxen regularly = increase in blood pressure → start anti-hypertensive medication = insomnia or a dry hacking cough that keeps you up at night → start a sleep aid/sedative…and…you get the picture)

This is SO SO common. Frustratingly common.

A recent study looking at patients who received a prescription for a stimulant (amphetamines or methylphenidate) found that almost half of them (45.5%) were also receiving an antidepressant and a little over 30% were also taking an antianxiety or sedative medication.1

The concern your friendly local pharmacist has with this (It’s me. Hi! I’m the pharmacist. It’s me!) is that every time you add a medication to your cabinet you are exponentially increasing the chance that they will interact or result in an adverse event (unintended or serious pharmacologic event — different from side effects, which are usually undesired, but can often be predicted and will also often resolve with time).

So, what to do?

First of all, do NOT simply stop taking your medication in an effort to jump from the CASCADE. I repeat: DO NOT STOP TAKING YOUR MEDICATION COLD TURKEY!!! (x 10000 exclamation marks!)

Imagine that the cascade is a train and you are YOU (not a superhero). You will get smashed. It will hurt. There’s a good chance you will experience painful and even potentially dangerous side effects.

You have to get the train to slow down before you jump off (if that’s the right choice for you).

If you feel like this was written for you, talk to your doctor about your concerns.

Or call me if the idea of trying to do this feels too intimidating or if you get the impression that your physician doesn’t have time to fully listen and address all of your concerns in a comprehensive way. I genuinely want to help you explore how that bag you pick up every month got filled in this particular way. I can help by getting your full, uninterrupted story, looking at your complete medication history and helping you come up with a clear way to communicate these concerns to your physician so that this gets the attention it deserves.

If appropriate, your prescriber may then be able to help you come up with a plan that could include titrating medications down, substituting problematic medications or whatever you and your provider decide is best for YOU.

Be open to the idea that you may have to make some lifestyle changes in order to get back to a place that feels healthy for you. But friend, you are so worth the investment!

#medicationcascade #heathcareadvocate #patienthealthadvocate #pharmacisttruthbombs

For a free phone consultation to see if I am a good fit for you, reach out to me HERE or email me at Krista@atlasadvocates.com

Citation:

1. Moore TJ, Wirtz PW, Curran JN, et al Medical use and combination drug therapy among US adult users of central nervous system stimulants: a cross-sectional analysisBMJ Open 2023;13:e069668. doi: 10.1136/bmjopen-2022-069668