When Less Is More – Pharmacists’ Role in Deprescribing
Chances are, you’re still filling a prescription for a patient years after you first dispensed it. You’ve probably also had to alert patients or their doctors that a prescription they brought in might not be a good fit with what they’re currently taking. With so much of healthcare becoming drug based, it was probably inevitable that people would end up being prescribed more meds, for longer, than is good for them.
Older adults are particularly vulnerable. According to the Canadian Journal on Aging, 2 out of 3 people over age 65 take at least 5 prescriptions, and 1 out of 4 takes at least 10. About 1/3 of older adults in the U.S. and Canada filled a prescription for a med that guidelines say they should probably avoid. Anecdotes abound of older adults facing unintended consequences from polypharmacy, such as a fall and resulting hip fracture caused by the dizziness of a sedative prescribed for insomnia. Given healthcare’s aim to make patients well, it’s not surprising that a countermovement to medication excess is burgeoning.
What Is deprescribing?
An article in The New York Times helps explain. While it’s no revelation that many people are taking prescriptions the wrong way, newer efforts to fight it can be explained by the sheer volume of providers and prescriptions today, along with longer life spans that leave people facing more health concerns and thus more vulnerable to over-prescription. The Canadian Deprescribing Network defines deprescribing as the planned and supervised process of reducing or stopping medications that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden and harm, while maintaining or improving quality of life.
Isn’t this a doctor thing?
No doubt. And a pharmacist thing, a patient thing – really an everybody thing. Studies have shown pharmacists’ ability to move the needle here. For example, one trial had pharmacists give a pamphlet to patients coming in to refill benzodiazepines and other sedative hypnotics (BSH) medications. The pamphlet talked about the harms versus benefits of BSH meds and included a tapering tool. Of people who got a pamphlet, 62% talked to either their pharmacist or primary care provider about the safety of the medication; 11% reduced their dosage and 27% stopped it. Of people who didn’t get a pamphlet, only 5% discontinued their prescription.
How would I start?
The American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults is a good place. It lists medications in 5 groups, from those to avoid with older adults unless in a hospice/palliative setting, to those to prescribe in lower doses for people with reduced kidney function. The AGS website notes that the criteria include additional resources like a mobile app and pocket reference card (available from GeriatricsCareOnline.org). QS/1’s pharmacy management systems will alert you to Beers drugs during processing for patients 65 and older, as these drugs can decrease CMS Five-Star Ratings.
Medication compliance is a chronic issue, so it would be naïve to think that getting people to stop taking meds they’re used to taking is not going to run into the same issues as getting people to take them. But experience with non-adherence tells us some of the same approaches will help: education, reminders, and enlisting support people. To initiate conversations with patients, family members, and doctors, consider printing off some online resources to hand out. Tools to aid older adults and caregivers in understanding what “potentially inappropriate” medications mean are available for free from HealthinAging.org. To talk to providers, the forms here serve as just an example.
It’s probably safe to say that you wouldn’t be a community pharmacist if your goal was simply to sell as many prescriptions as possible regardless of consequences. You’re there to make sure people receive the help that medications can provide. So when the drug isn’t helping, you’re there to help people evaluate discontinuing it. As our population ages, and as the wave of new medications coming onto the market continues, these efforts will only make your role more important.
Do you encounter over-prescribing among your patients? What do you do about it? We’d like to hear.