Multimodal vs. Polypharmacy

Nothing in medicine is certain. For every issue, there are proponents and opponents, pros and cons. Although we wish we could just learn the "right answer" in medical school, clinical medicine is never that simple. Different practitioners view the same problem in polar lights. For example, in geriatrics, there is a strong focus to avoid "polypharmacy," the administration of too many medications. An elderly patient may have several antihypertensives, diabetic medications, pain medications, antidepressants, osteoporosis medications, proton pump inhibitors, and a handful of miscellaneous pills. Anybody with that regimen is prone to confuse things and make mistakes. This can have dire consequences if critical pills are missed, doses are wrong, meds are substituted, or any number of potential discrepancies. Thus, to avoid polypharmacy, geriatricians advocate simplifying the medication regimen to reduce medications, frequency of dosing, and interactions.

On the other hand, pain management physicians advocate "multimodal" pain therapy. We try to tackle pain from multiple angles, targeting many different receptors, creating a cocktail of medications that reduce the doses of any single drug. Instead of putting someone on high dose opiates, we throw in gabapentin, a tricyclic antidepressant, and an NSAID; these adjuncts allow us to lower the dose of the opiate. This avoids the side effects, complications, and marginal gain with high doses of any one drug. But of course, this is simply polypharmacy. We want to use multiple drugs when perhaps one drug might cut it.

Each side has its arguments and probably the right answer differs between patients. For some who have trouble taking medications, we want to simplify the regimen as much as possible. For others who cannot tolerate side effects but are less prone to make mistakes, multimodal therapy might be the way to go. This illustrates how medicine is an art as well as a science, that there are no perfect answers for everyone, and how different specialties may disagree on the optimal management.