When You Teach Prescribing, Also Teach Deprescribing

Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Back in 1983, during the early Reagan era, I wrote, "What can explain a physician's gait? Why, humankind need perseverate." That editorial in JAMA[1] was about appropriate and inappropriate ordering of laboratory tests.

Politics may change, but humans do not change much. Perseveration of ordering lab tests is not the only form of American physician perseveration. How about polypharmacy?

Approximately one third of all prescriptions written in the United States are written for the elderly.[2] The average elderly American takes more than five prescription medications; the average patient in long-term care takes seven.[2] And that does not include over-the-counter medications and nutritional supplements.

Polypharmacy has been associated with an elevated risk for adverse drug events, harmful drug interactions, cognitive deficits, falls, functional decline, potential hospitalization, and even increased mortality. And I am not only talking about opioids. Some medications cause more harm than good.

Optimizing medication through targeted deprescribing can be a vital part of managing chronic conditions, avoiding adverse effects, and improving outcomes.[3] Sometimes, deprescribing will lead to adverse drug withdrawal events. These could be as simple as worsening pain while reducing the dosage of a pain medication. Some medications need to be reduced slowly to avoid withdrawal effects. Deprescribing is best not done by the patient alone, but by the patient and the physician acting together.

Formalized Deprescribing?

Many of American medicine's very best programs have originated north of the border—"evidence-based medicine," for example, especially the McMaster University version. Again, we owe the Canadians a thank-you for proposing that formalized deprescribing may be the way to go.

From, that Canadian project, we quote[3]:

Prescribers have said that it's difficult to stop medications when prescribing guidelines only talk about starting them. The "Deprescribing Guidelines for the Elderly" project developed evidence-based deprescribing guidelines to support clinicians in safely reducing or stopping medications. We conducted a national survey to identify priorities for deprescribing guidelines. Then, we used an evidence-based approach to develop deprescribing guidelines for three specific drug classes—proton pump inhibitors, benzodiazepine receptor agonists, and antipsychotics. We piloted these guidelines in three long-term care and three Family Health Teams in the Ottawa area in Ontario, Canada.

Some American groups are also active in this effort. From the American Geriatrics Society, a Choosing Wisely recommendation[4]:

Don't prescribe a medication without conducting a drug regimen review. ...Medication review identifies high-risk medications, drug interactions and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly.

And, perhaps the most important of all prescribing recommendations—in 2017, the American Society of Anesthesiologists in Choosing Wisely[5]:

Don't prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient. ...Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (such as urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.

Unfortunately, the American physician and patient attitude has often been, "You've got a problem? I've got a drug that'll fix that for you. You don't have a problem? There must be something wrong with you that one of the drugs I can prescribe will make better. I mean, really, you saw the ad about those symptoms on TV, right?"

Once upon a time, in a management course I was taking, I was told that "every organization should have a vice president in charge of killing things." I propose that for every teaching lesson about prescribing a particular drug, the curriculum should also include how to deprescribe that same drug.

Do not get into something unless you have figured out how to get out of it, if needed. That includes writing prescriptions.

That is my opinion. I am Dr George Lundberg, at large for Medscape.


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