To Medicate or Not To Medicate?

When to Start, Stop, & Question Prescription Meds 💊

ICYMI 👉

• Medical Gaslighting: What to Do When Your Symptoms Are Dismissed

• Beyond “High Cholesterol”: Reframing the Conversation on Lipid Panels

• Primary Care is Broken. What Can You Do About It?

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Do you wonder when (or if) it’s appropriate to start or stop a medication? Or when it’s time to ask more questions? These conversations happen daily in my office. So, today I’ll tell you about two patients I saw on the same Tuesday last month (names changed for privacy reasons) who represent opposite ends of our often complex relationship with prescription medications:

Tom, age 55, sat across from me, politely declining my advice to start a statin despite persistently high cholesterol (LDL in the 150s), very elevated ApoB and Lp(a) levels suggesting an increased risk for atherosclerosis, and a father who died of a heart attack at 58. “Taking pills feels like a crutch,” he admitted.

A few hours later, Barbara, 86, presented me with a large ziplock bag containing 12 medication bottles prescribed by five different specialists. I was glad she brought the bottles in because she reported feeling dizzy and lightheaded. When I examined her, her blood pressure and heart rate were low. Her kidney blood test, done a few days prior at urgent care for the same complaints, indicated she was dehydrated. She was clearly suffering from medication interactions and side effects, but when I suggested we dial back her diuretic dose (one of her three blood pressure meds), she told me she was scared to stop anything. “What if I have a stroke?” she asked.

Photo by Valentin Balan on Unsplash

These patients reflect the opposite ends of the spectrum when it comes to the relationship with prescription meds. I witness this regularly: Some patients fear medication dependence while others cling to drugs to the point of harm. Some view taking pills as a moral failure—a sign of weakness or a stain on their otherwise healthy way of life—while some would rather swallow a pill than engage in behavioral changes that could obviate the need for medications at all.

I get it. Each perspective is valid and represents a unique perspective on the role of medications in our lives. Some of this stems from childhood. Some of it is cultural or religious or rooted in bias for or against the pharmaceutical industry. Wellness culture plays a role, too (read more on that topic here). “Natural” supplements are generally marketed as more wholesome while prescription medications are deemed potentially toxic. MAHA, anyone? American culture also tends to celebrate people who “get off their medications” through lifestyle changes while stigmatizing those who need pharmaceutical treatment for issues such as obesity or mental health problems.

Of course, prescription medications are essential for myriad medical conditions. We are fortunate to live in an era with insulin for diabetes, lithium for bipolar illness, and amoxicillin for strep throat, to name a few life-saving therapeutics. However, drugs are heavily marketed in the US and too often overprescribed. Polypharmacy—taking multiple medications, often to treat side effects of other medications—has more than doubled among American adults over the past two decades, rising from 8.2% to 17.1% (NHANES data, 1999-2018). Among adults over 65, approximately 42% take five or more prescription medications (Lown Institute, 2019). Studies show the risk of adverse drug events increases dramatically with each additional medication: from 13% with two medications to 58% with five, and over 80% when taking seven or more.

This can leave patients confused about when medications are appropriate and when they’re unnecessary. So, regardless of where you fall on the continuum of “I’d rather take a pill” or “I’d rather do this naturally,” today’s post is about when to start, when to stop, and when to question prescription meds.

The Framework for Thinking About Medications

Let’s start with a new frame: Medications are not panaceas or crutches; they are tools. Natural compounds aren’t automatically safer than pharmaceuticals. Supplements are less regulated, not necessarily more safe. Some of the most toxic substances in the world are completely natural. Conversely, not every problem requires a pharmaceutical solution. Sometimes cognitive behavioral therapy, physical therapy, lifestyle changes, or the mere tincture of time is a better solution for a health problem. For example, medications for stress-related symptoms don’t address the source of stress. Medication might help you cope, but it doesn’t fix a toxic workplace or unhealthy relationship with food, alcohol, or another human being.

When to Start a Medication

So, before starting any new medication, you should be able to answer these questions:

1. What problem is this solving?

Is it treating active disease? Preventing future problems? Managing symptoms? The answer matters because it affects how you consider benefits and risks. For example, antibiotics for bacterial pneumonia treat active, immediate disease, whereas statins for someone with an elevated cardiovascular risk can prevent heart attacks in the future. Get clear on what problem you are solving and how much it matters to you.

2. What happens if I don’t take it?

Understanding the alternative helps contextualize the decision. What happens if you don’t take the antibiotic for pneumonia? You might take the antibiotic if not taking it means could get seriously ill or die. But what if you waited a few days and reassessed your symptoms with time? Or what happens if you don’t take the statin? Maybe reducing the risk of heart attack over the next decade from 15% to 10% is meaningful to you. Or maybe it isn’t worth the downsides of the treatment. Understanding the cost-benefit ratio (plus the limitations on our ability to predict the future) is key for making smart decisions.

3. What’s my timeline for expected benefit?

Some medications work quickly—you feel better within days. Others take weeks to show benefit. Preventive medications may never make you “feel” different because they’re preventing problems you’ll never experience. Understanding this timeline matters because it affects adherence and expectations. If you’re expecting to feel better immediately from a medication that takes 6 weeks to work, you might stop too soon.

4. What are realistic side effects vs. rare ones?

Every medication has potential side effects. The question is how common they are and how severe. A side effect that affects 30% of users matters more than one that affects 0.1%. Also important: What are nuisance side effects vs. dangerous ones? Mild nausea that resolves in a week is different from liver damage or severe allergic reactions. Please keep in mind as you read lengthy package inserts on drugs: possible is not the same as probable. Ask your doctor for context where needed.

5. Are there alternative approaches we should try first?

Sometimes yes, sometimes no. If you have bacterial pneumonia, lifestyle changes aren’t a reasonable alternative to antibiotics. If you have borderline high blood pressure without other risk factors, perhaps lifestyle modifications might be worth trying before medication. If your blood pressure is dangerously high and causing heart strain, however, you wouldn’t wait to join a gym before starting medication for high blood pressure. Healthy habits are good for almost every medical problem, but they aren’t always sufficient or appropriate depending on the urgency of treating the problem.

6. How will we know if it’s working, and is there an endpoint?

This seems obvious but often goes undiscussed. Are we tracking symptoms? Measuring lab values? What improvement would tell us this medication is serving you well? Will this medication “fix” or cure the problem—or is it important for long-term management of a chronic problem? The lack of clarity on the answers to these questions explains why so many patients pile on more and more drugs as they age.

Medication Gray Zones

Some situations have such strong evidence that medications are clearly appropriate. For example, antibiotics for bacterial infections or insulin for type 1 diabetes. You have a disease; this treats it. But many medication decisions fall into less clear territory:

Preventive medications when risk is moderate: Do you start a statin when your 10-year cardiovascular risk is 8%? There’s no universal right answer—it depends on your personal values about prevention vs. taking daily medication.

Medications for symptoms that lifestyle might address: Do you take medication for acid reflux or first try losing weight and avoiding trigger foods? Both approaches have merit; the right choice depends on symptom severity, your lifestyle, and your preferences.

Treating numbers vs. treating symptoms: Should you take blood pressure medication when you feel fine but your pressure runs slightly high? Again, it depends on your complete risk picture and values.

These gray zones are where medicine becomes deeply personal. There are no universal right answers, only trade-offs that reflect your priorities. Would you rather take a daily pill to reduce future risk, or avoid medication until absolutely necessary? Maximize prevention, or minimize intervention? These aren’t medical questions—they’re values questions. The numbers can inform your decision, but only you can decide which trade-offs align with how you want to live.

What Happened with Tom and Barbara?

Tom’s resistance to starting a statin stemmed from viewing medication as failure—as if preventing a heart attack through pharmaceutical means was somehow less virtuous than preventing it through lifestyle alone. Knowing his perspective helped our conversation. I explained that his 10-year risk of heart attack or stroke was about 18%. A statin could reduce that to roughly 12%—a 6% absolute risk reduction, meaning for every 17 people like him who take statins for 10 years, one heart attack or stroke is prevented.

There was no drug, exercise routine or dietary change that could reduce his heart attack risk to zero. He was already using one tool in the toolbox (i.e., healthy habits). Why not use another when it could significantly reduce his risk? The choice was his to make, but this reframe helped Tom understand that a statin prescription was just another tool.

Six months later, Tom’s labs came back much improved. LDL cholesterol in the 60s, and ApoB in the 80s. Tom admitted to me that his resistance to statins was about ego, not health. Who could blame him?

Meanwhile, Barbara’s situation represents the opposite problem—too many medications creating a cascade of problems. So we conducted a systematic medication review. We were able to discontinue 6 meds: Two blood pressure medications (her BP was running low, causing dizziness), a PPI (Nexium) that was started years ago for heartburn that had resolved with a low-acid diet, a medication for anxiety that was actually causing more anxiety, and two medications treating side effects of other medications. We continued 6 medications for conditions that truly needed ongoing treatment, that were providing clear benefit without significant side effects, and where stopping would genuinely increase risk on issues that mattered most to her.

Within two weeks, Barbara’s dizziness resolved. She had more energy and felt more like herself. She was still protected for the conditions that truly needed medication, but freed from the burden of unnecessary meds.

When Should You Consider Stopping a Prescription Drug?

Of course you should always talk with your doctor, but here are some general tips:

Original indication no longer applies: Many medications get started for specific situations that resolve, but nobody stops them. The PPI started for acute gastritis that was treated. The anxiety medication prescribed during a period of acute stress that has passed.

Side effects outweigh benefits: Barbara’s dizziness and dehydration stemmed from the combination of blood pressure medications she didn’t need. Although it played a role when it was first prescribed, the diuretic medication was causing more harm than benefit.

Multiple medications causing interactions: Each medication Barbara took was individually reasonable. Together, they created problems greater than the sum of their parts.

Medication prescribed for another medication’s side effect: This cascade is common. Medication A causes side effect X. Medication B prescribed to treat X. But if we can reduce or stop Medication A, we don’t need B either.

The patient’s goals have changed: Barbara was taking numerous medications to prevent problems 10-20 years from now. At 86, an aggressive medication regime wasn’t her priority—avoiding falls and improving how she felt was. Barbara’s priorities had shifted from longevity to quality of life, but her medication list hadn’t adapted alongside her.

The Most Commonly Over-Prescribed Medications

Proton pump inhibitors (PPIs) like omeprazole: Often started appropriately for short-term use, then continued indefinitely without reassessment. Long-term use has risks including increased fracture risk and potential cognitive effects.

Benzodiazepines for anxiety: Evidence supports only short-term use, yet many patients take them for years or decades. Long-term use creates dependence, increases fall risk, and may worsen anxiety over time.

Opioids for chronic pain: Sometimes necessary, but often continued long after acute need has resolved, creating dependence and increasing risks without proportional benefit.

Medications started in the hospital: Patients get started on something during hospitalization that never gets reassessed afterward. Did you really need that medication long-term, or was it just for the acute situation?

Anticholinergic medications in elderly patients: Common drugs like diphenhydramine (Benadryl), certain bladder control medications, and some antidepressants have anticholinergic effects that can cause confusion, falls, and cognitive impairment in older adults.

Your Practical Approach: Annual Medication Review

At least once a year, sit down with your doctor and review every medication you’re taking:

1. Why am I taking each of these? If neither you nor your doctor can clearly articulate the reason, that’s a red flag.

2. What would happen if I stopped? Understanding the actual risk helps you make informed decisions.

3. Are there interactions we should worry about? Each additional medication increases interaction risk.

4. Are any causing symptoms I’m attributing to aging or other causes? Fatigue, confusion, dizziness, and other symptoms might be medication side effects.

5. Do my current health goals align with these medications? Your priorities may have changed since medications were started.

The Bottom Line

The goal isn’t to maximize or minimize medications. The goal is thoughtful decision-making based on evidence, your values, and your individual circumstances—free from cultural bias, pharmaceutical marketing, or rigid rules about what constitutes “good” health behavior. Medications are tools. Use them when they serve you. Question them when they don’t. And never let anyone—including yourself!—judge you for doing either.

🙋‍♀️ So tell me—what has your experience been, starting and/or stopping medications? Do you have a general perspective on the role of prescription meds? Has that perspective changed with time? I’m all ears!

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Disclaimer: The views expressed here are my own and are not a substitute for advice from your personal physician.

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