Little Known Facts about Medication Deprescribing
Updated: Sep 19, 2021
Are you a medical provider? Are you concerned when you see your patient on a l-o-n-g list of medications? Do you ever worry the drug-to-drug interactions might be negatively affecting your patients' functioning? Do you worry about the efficacy of these medications?
Or are you yourself the one with a health issue? Do you take many medications daily? Are you often overwhelmed by the administration schedule, needing to take medications several times during the day? Can you honestly say they are all helpful in having a better day and better quality of life?
America is currently in a critical situation related to over-reliance on medications. While pharmaceutical advancements have lead to improvement of lifespan and quality of life, it is a known fact that America is facing an epidemic of polypharmacy. Some would argue that the 'opioid crisis' in reality is a crisis of polypharmacy, as many individuals with opioid prescriptions also take additional prescription medications to treat anxiety, insomnia, muscle spasm, mental health issues, real issues that need to be addressed. We know these medications can have a synergistic effect on one another, with the potential of leading to impaired cognition, mobility, slower reflexes, etc.
During the years I've spent as medical director of a functional restoration program for adolescents with chronic non-malignant pain, I have encouraged hundreds, maybe thousands, of patients to take an honest look at their medications and consider discontinuing those both they and their providers do not find beneficial. And more importantly, most of these patients have been very successful in tapering or eliminating a medication, becoming aware that it really wasn't beneficial for them in the long run. In this particular patient population, it is not uncommon to have ten or more prescription medications/supplements for the various conditions with which they present. Knowing which medications are truly 'helping' is sometimes impossible.
Before I continue, I would like to specify the medications we should be concerned about, namely opioids, benzodiazepines, sleep aids, muscle relaxants, diphenhydramine, antiemetics (antinausea meds), supplements, and salt, to name just a few. By nature of some medications, days or weeks may be required to take effect and some require a slow titration to a therapeutic dose. It can become frustrating for an individual to be compliant with a prescription, only to have to wait to see the effects, and then have doubts as to whether it truly is 'working'. Such is the nature with medications such as amitriptyline, nortriptyline, gabapentin, and pregabalin (Lyrica), medications often prescribed for chronic pain.
While improved quality of life and functionality of millions of individuals has been in part a result of medications, I would argue that there can be negative consequences, a burden, in continuing to take a medication that is not meeting your expectations. Of course seeing the results of some medications is more simple than others. For example, medications such as antihypertensives or hypoglycemic medications (for high blood pressure or diabetes, respectively) have results that can be measured (objective results); it is often easier to see the changes in blood pressure or blood glucose over time and note the benefit. With other medications that have a more subtle and subjective effect (based on an individual's opinion and personal experience), measuring 'success' can be more challenging. Sometimes you'll try anything to feel better but when that doesn't happen, might search for the next solution in a different pill.
Efforts to minimize polypharmacy should start even before writing that prescription. It is our responsibility as medical providers to anticipate our patients' questions about medications and to provide them with the knowledge to make an informed decision as to whether to start a medication or not.
Helpful Questions to Consider When Prescribing A Medication
1 - What is the expected effect of the medication? Why is the medication being prescribed?
2 - How long will it take to know if the medication is 'working'?
3 - Will I be able to be compliant with the medication regimen? (Will I find a way to make sure I take the medication as directed? Is there a complicated administration schedule that will make it difficult to remember?)
4 - What are the risks of taking the medication?
5 - What are the alternatives to taking the medication?
6 - If the medication is not helpful, what is the plan for tapering and discontinuing the medication?
While this may seem like an unnecessary practice, all individuals have the right to understand the burdens and expectations of medications they are prescribed. After all, it is their body and the burden of taking the medication falls onto them. I believe in the pre-emptive approach; doing so could save time, money, improves communication and safety, and provides informed consent of the risks/benefits/expectations of their medications. I am often surprised of how little patients truly understand about their medications, and it often is related to our challenges of providing informed consent and facilitating understanding on the part of the patient.
Once you have started a medication, it is important to communicate to your provider if you experience an adverse side effect or if you feel the medication is not meeting your expectations. This may seem trivial but I feel there can be a real burden to taking a medication that you may be ambivalent about, and this affects the way your body responds to a medication. Your doctor may not broach the subject of the medication 'not working' as they want you to have relief and feel better. However I feel they have a responsibility to be transparent about the expectations and the plan to eliminate the medication if it does not meet your expectations over the long term.
I want to stress that before considering any changes for yourself as a patient, you must have an honest discussion with your own physician/medical provider to access the true ongoing 'need' for your own medications. And as providers, we should be forthcoming and open to these questions from patients. I believe this should occur on a regular basis, during an annual or scheduled visit for example, not just when you have a concern about your medication. So whether this discussion has occurred when introducing a new medication or not, here are some questions to ponder.
Disclaimer Medication deprescribing needs to occur under the direct guidance of a qualified medical provider so do not stop a medication without their knowledge.
Helpful Suggestions for Implementing a Medication Taper
1- Help the patient be clear about why they want to taper. Perhaps they have not found the medication helpful, there is a burden to taking the medication, it is disruptive in their daily life. Commend the patient for their willingness to take this important step and remind them they are doing something positive for their health. This will be important later when doubts might creep into the patient's mind as to whether this was a sound decision or not. You can be there to support them despite some challenges along the way.
2 - Encourage the patient to regain or maintain their daily functioning.
Medications given for pain and symptoms cannot work in isolation. In other words, medications are just part of the treatment plan. If other components are not attended to such as maintaining level of daily activity, stress management, healthy sleep habits, well-balanced diet, mood regulation, medications cannot be expected to work. So make sure these issues are addressed simultaneously. Primary care providers and psychologists are excellent resources for lifestyle management in individuals with chronic medical conditions.
3 - Set the stage for success and help patients maintain control during the taper.
We want this to be a positive experience, for them to feel empowered that they can taper successfully. Many patients may have had a negative experience with tapering and are fearful the taper will not go well. The medication taper may have been too fast, with too many symptoms, with few resources. Often these patients have reverted back to taking the full dose of the medication. The stage was set for another disappointing experience. In relinquishing some control to the patient we seek to obtain their 'buy in' and create some ownership for the process, For example, in a medication taken twice daily, does it matter if the morning or evening dose of the medication is tapered first? As the provider you may not have a preference. However, the patient may have insight as to which might be easier for them. So just ask them. And encourage the patient to keep track of their medication usage so they can see their own progress. The Sprout app is a great platform to chart your medications.
4 - Provide clear instructions for a slow taper.
This sets the patient up for success. This will also decrease the chance of withdrawal symptoms and make the tapering more comfortable.
5- Be tolerant of some increased symptoms.
When it comes to pain, don't completely rely on the feeling of increased pain to put doubts in your mind as to whether you should be tapering the medication or not. Pain is a complex emotional experience and as such can wax and wane based on stress, sleep problems, nutritional deficiencies, everyday challenges. It is common for pain and symptoms to increase once a medication titration starts; this may be a 'nocebo' effect, specifically your knowledge that you are tapering the medication can bring about an exaggeration of symptoms (and put doubt in your mind as to whether you are doing the right thing by tapering). If you responded to this doubt in your mind, you wouldn't continue tapering the medication and might stay on that medication for much longer time than planned. Good news is that this 'nocebo' effect can diminish once you signal to yourself that you are committed to discontinuation of the medication. So acknowledge this but remember your original reason for wanting to taper the medication.
And know that withdrawal symptoms, although uncomfortable, are not usually dangerous. The exception to this is with benzodiazepines so always make sure you are tapering as directed by a qualified medical provider.
6 - Keep the goal in mind (but also have some flexibility).
Your patient should be commended for having the courage to taper a medication so don't let a few setbacks disrupt them from the plan. This means that with the start of the taper, if the patient experiences increased symptoms, support them, validate them that their symptoms are REAL, remind them of the 'nocebo' effect, and perhaps slow the taper down. However, I would discourage one from increasing the dose back to baseline if based only on subjective report. This only confirms erroneously to the patient that they 'need' the medication which may not be reality and will sabotage future attempts to taper.
While the specific details of tapering recommendations will vary depending upon the medication, condition, and specific individual, these are some general rules that I have adhered to over the past several years in my practice. For additional guidelines, consult other medical resources, such as the Prescribers' Digital Reference and always assure to taper under the guidance of a qualified medical professional.
1- Provide informed consent to your patient (or ask for it from your provider) when considering a new medication prescription (expected effect, dosing schedule, risks, alternatives, plan for tapering)
2- Broach the subject of medication efficacy during annual or other visits
3- Be clear as to why the patient wants to taper the medication
4- Encourage age-appropriate typical functioning when tapering a medication (balanced eating, daily activities, physical activities, stress management, sleep management, hydration)
5- Set the stage for success. Give the patient control. Slow taper and be flexible.
6- Refrain from automatically increasing to the baseline dose despite the worsening of symptoms. Be tolerant of some withdrawal symptoms.
7- Have some flexibility. Sometimes the taper needs to be slowed down, or a patient stays on a dose of a medication for a few extra days if they have other challenging things happening with their health.
8- Keep the goal in mind for best success for tapering. Remind the patient and again applaud their efforts. Validate their feelings, that their symptoms ARE real.
I'd like to hear from YOU! Have you assisted one of your patients in tapering a medication? What additional tools do you use to accomplish this? What difficulties have you experienced in assisting them or what did they struggle with?
If you are an individual who has tapered off a medication, what was your experience? Do you have any helpful tips would like other individuals to know about tapering?