Drugs can help, but do you really need all of them?
What you need to know about deprescribing.
Most of us have taken a drug to treat a symptom, to avoid making a condition worse, or to prevent disease. Often, the benefits of these drugs outweigh the potential adverse effects and there is value in taking the treatment. However, have you wondered how long you need to take that prescribed medication? Some drugs are meant to be continued until a change in your condition occurs or unless the side effects become apparent or too risky. Other medications are meant for a short, defined period. The drug that was beneficial for you when you started the medication years ago might not be good for you now. It is very important to ask your prescriber how long they intend for you to stay on the treatment.
Stopping too soon can result in incomplete treatment or risk developing resistant bacteria, as in the case of stopping an antibiotic before the treatment course is complete. Antibiotics, which treat an infection by killing bacteria, must be continued long enough to eradicate the infection and kill off all of the bacteria to limit the chances of some remaining and becoming resistant to the treatment. This is why your physician and pharmacist instruct you to take antibiotics until the entire prescription is finished and not to stop just because you are feeling better.
This is not to say that all drugs have a short or specific duration of treatment, such as with antibiotics, but many drugs should have a finite treatment period that depends on the condition being treated, the drug used, and the individual. There are some drugs that are initiated with an indefinite duration of treatment because they are based on the individual’s response and the balance of their benefits compared to the risks. A drug started for any reason can have different effects as we age, develop other conditions, or take a new medication. In some cases, the drug that was started to provide benefit can end up causing more harm than good because of these changes. Your drug therapies should be re-assessed on a regular basis to determine their need and appropriateness as you age and your health situation changes.
With our healthcare system, and our desire for convenience in medical care, we find ourselves seeing different physicians or prescribers as well as receiving our prescription drugs from different pharmacies. This increases the risk of duplicate therapies and a mounting pile of medications being consumed, some of which may be unnecessary.
Why Are Some People Taking Too Many Medications?
Without a universally accessible electronic health record, each health practitioner is unaware of your full medical history and what the care plan is from each practitioner. Many will not know what each health provider has prescribed for you for the same condition. This results in members of your healthcare team working in silos, unknowingly making health decisions, albeit for your best interest, but unclear of what else is going on. British Columbians have somewhat of an advantage since in the province of BC, everyone with a personal health number has their list of medications in one place, within the individual’s BC PharmaNet medication profile.
The PharmaNet is a provincial database that captures all prescriptions a resident fills in any pharmacy in BC, regardless of location or affiliation. This comprehensive collection of drugs in PharmaNet is accessible by every pharmacy and Emergency Room in BC and can be accessed by any practicing physician in BC who is willing to put in the effort and expense to have access. There are still a few missing pieces due to privacy reasons and other considerations when this system was established. PharmaNet does not capture all oncology drugs and does not list HIV treatment related drugs. Despite its shortcomings and being established in 1995, PharmaNet is still on the leading edge as far as having a comprehensive list of prescription medications a patient is taking compared to what else is available worldwide. There is no other comparable database that is accessible to all care providers within a single jurisdiction regardless of where you live, who your doctor is, or which pharmacy you frequent.
The list of prescriptions is only one piece of your health record. Your laboratory information, your medical conditions, and physician notations are all separate systems, which are not accessible to the entire healthcare team members. This isolation of your health information in our current system means, as a patient, you need to take an active role in your healthcare. You cannot rely on your healthcare team members to know or be able to look up all the necessary information and history about your health.
What is Deprescribing?
With the increasing reliance on medications for treatment, the number of medications being used by our population leads us to the important topic of deprescribing. You may not have heard this term before, but you can probably guess that it means removing or discontinuing prescription drugs you are currently taking. That is essentially it. The word “deprescribe” or “deprescribing” does not exist in the Merriam-Webster or Oxford dictionaries, but it is now becoming a common term in Medicine and Pharmacy. One group refers to deprescribing as “the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit. Deprescribing is part of good prescribing – backing off when doses are too high, or stopping medications that are no longer needed”.1 Another definition offered by the Canadian Deprescribing Network is that, “Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life. Deprescribing involves patients, caregivers, healthcare providers and policy makers.”2
The overuse and faith in drug therapy leads to taking unnecessary drugs and inappropriate use of multiple medications. This can result in wasted resources, costs, and a decreased quality of life resulting from adverse effects, duplicated therapies, and dangerous drug interactions, especially in those who are elderly.
When is Deprescribing Useful?
As the definition becomes more grounded and recognized, so is the practice of deprescribing. The practice is receiving greater recognition by healthcare professionals and is being applied to people on unnecessary medications or taking a dose that may be higher than needed. This should result in greater attention to eliminating unnecessary drugs and reducing doses when appropriate.
People who are older than 65 years of age are at an increased risk of receiving unnecessary medications as well as being more susceptible to their side effects. In addition, as you age, your body can become more sensitive to the effects of drugs and their adverse effects. Studies have identified an association of older age with a higher number of regular medications used. This can be partially explained by the fact that as we age, not only do we change in physical appearance, but our organs are less efficient at metabolizing drugs and clearing them from the body. Our bodies respond differently when we are young and active compared to when we are older and less active, meaning that we generally require smaller medication doses. With the onset of new conditions as we age, there is also an increase in the number of drugs we need, which sometimes results in inadvertent treatment duplication. The use of too many medications is referred to in medicine as ‘polypharmacy’. The 2016 Drug Use Among Seniors in Canada report3 identifies that close to two-thirds of Canadian seniors were prescribed five or more drugs and more than one-quarter of them were prescribed ten or more drugs. The analysis also found that the number of drugs used by seniors was the most common cause of hospitalizations related to adverse drug reactions. Studies have identified that many of these adverse drug reactions can be prevented.
Research has also identified a list of drugs that are frequently associated with negative outcomes and hospitalizations. An astounding $419 million is spent annually in Canada on these potentially harmful drugs for seniors. Even more outrageous is that an estimated $1.4 billion is spent each year in healthcare to treat the harmful effects from these drugs in seniors. A study found that one of these drugs was prescribed to more than one-third of seniors in Canada.4 The administration of these risky medications in seniors is associated with a high incidence of medication-related harms such as memory problems, falls, and fractures. Frequently, the risk of use outweighs the benefits. Although an evidence-based list of these risky drugs is published and recognized in medical guidelines, you should not stop a prescription drug without first consulting your physician or pharmacist to evaluate the benefits and risks, and making a shared informed decision, especially if the drug has been used over a long duration.
Safe Deprescribing
Deprescribing is not yet a regulated act, and many individuals have intentionally stopped a medication and therefore have deprescribed that drug for themselves, rightly or wrongly. For your best health outcome, a licensed healthcare professional with the appropriate knowledge and information should be involved in deprescribing any drug you are taking. Stopping a drug improperly can lead to the worsening of a condition, withdrawal side effects, or cause other harm to your body. Even if no longer necessary, most drugs cannot be stopped abruptly, and guidance from a licensed and knowledgeable healthcare practitioner is needed. Before you even consider stopping any drug you are on, it is in your best interest to seek a full assessment of each medication you are taking. For some drugs, your physician may not have records as to why it was started, and you may not recall who even prescribed it, especially if it has been 10 years or more. In practice, I have encountered many occasions where people tell me that they cannot recall why a medication was being taken or even who prescribed it and why. You do not have to feel bad about not knowing, as the current health system does not have the supports in place to make it easy to track. However, this reinforces the fact that you have to be proactive, take charge of your own health, and be part of the decision-making process in your treatments. It also helps to keep track of your own records or at least have your pharmacist prepare a medication list for you.
An Example of Deprescribing
Here is a common example of when deprescribing can be used, which results in lower cost to the patient and healthcare system, and has the potential to improve well-being and overall health. Consider the situation of Mary, who was in a minor motor vehicle accident, resulting in arm and back pain and trouble sleeping. A physician at the medical walk-in clinic assesses Mary and gives her prescriptions for Tylenol #3® (acetaminophen with codeine) and a sleeping pill, Imovane® (zopiclone), as well as a recommendation to see a physiotherapist to help with rehabilitation of her injuries. Mary feels better and is able to get back to her normal functioning. Her sleep improves while taking these medications. Mary refills these medications a few times with different physicians from different walk-in clinics because she does not have a regular family physician and goes to whichever clinic is convenient and has a short waiting list. It has now been three years since her car accident, she recovered from her injuries a couple of years ago, and she continues to take the medications because each time she tries to stop them or misses a pill, she feels uncomfortable or cannot sleep well. In short, her body has become reliant or physically dependent on these medications. Even though she no longer has a therapeutic need for them, they are very difficult to discontinue without experiencing some negative effects.
Over time and with the resolution of her injuries from the accident, Mary might no longer require the therapeutic benefits of the drugs initially prescribed. However, her body had adapted to them and seems to still need them. An abrupt change, such as not taking the drug, seems to result in withdrawal effects, preventing her from stopping the drug. Mary might perceive that she needs the sleeping pill because each time she does not take it she has trouble falling asleep. Therefore, from Mary’s perspective, it seems logical that she still needs the sleeping pill. For her pain medication, each time she stops, fatigue, pain, and discomfort recurs. Again, she feels that taking the drug is beneficial. In reality, she is experiencing a type of dependence on these medications. Her body is used to having these drugs present and has compensated over time in such a way that removing the drug feels abnormal, leading to these negative symptoms. Even though Mary may think these drugs are providing her a health benefit, they are likely causing other side effects and harming her body in ways that she might not recognize. Any drug has the potential for both beneficial and adverse effects. A study published in the Canadian Family Physician journal found evidence that the efficacy of sleeping pills can diminish within weeks, but the adverse effects may persist longer.5 The good news is Mary does not have to be stuck taking these medications for the rest of her life and continually exposing her body to these drugs while paying for the expense and inconveniences associated with getting prescriptions, filling these medications, and taking them.
You may be thinking that it’s going to be challenging or even dangerous to try stopping these medications, but that is not the case when approached with appropriate guidance. There are algorithms for tapering off certain drugs and for others, clinical judgment by pharmacists and/or physicians come into action. The body has just adapted to the presence of these drugs in such a way that removing them suddenly leaves a hole. This can be illustrated by the example situation of someone who may initially have trouble falling asleep with the sound of the ocean, but over time they become accustomed to the sound and find that they can sleep fine, perhaps later on even finding it difficult to fall asleep without the sounds of crashing waves. The body adjusts. To deprescribe these medications, ideally Mary’s physician and pharmacist would work together collaboratively with her to create a care plan to gradually reduce and eventually stop these medications. It is best to target one medication at a time for discontinuation, choosing the one that has the least beneficial impact before moving on to the next. The slow decrease is done over several weeks, with monitoring, and the time it takes is individualized to the person. People who have been on drugs for many years may take many months to taper off. With ongoing monitoring and the help of a symptom diary, adjustments are made to the duration and rate of dosages and reductions based on the patient’s needs. As we are all unique, some individuals who are particularly sensitive may require very slow dose reductions of some medications and there may be a need to work with a compounding pharmacy to prepare dosages that are a fraction of a milligram smaller than the last. For those who may be sensitive, the more gradual the dose reduction, the better the tapering regimen will be tolerated and the higher the success rate of discontinuing the drug.
Infrequently, during the dosage reduction, the patient experiences adverse drug withdrawal effects. These effects may occur because the lowering of the dose or removing the drug is done before the body is ready. Withdrawal effects may include dizziness, headaches, anxiety, poor concentration, irritability, insomnia, sweating, chest tightness or discomfort, increased heart rate, nausea, abdominal pain, diarrhea, vomiting, muscle weakness, muscle aches, twitching, fatigue, tingling, or other symptoms that can depend on which drug is being removed.
What Can You do if You Think You Are on a Drug You no Longer Need?
Speak with your physician or pharmacist about your medications. Pharmacists are more easily accessible and pharmacists in most provinces are funded through the provincial public health ministry to carry out a medication review. This can be one of the first steps to help identify any unnecessary medication, but public coverage may be insufficient to reimburse all the costs and time associated with the proper deprescribing of a drug. In our current situation, with a limited number of physicians for the Canadian population, it may not be easy to find a physician who has the time to focus on assessing all of your medications and deprescribe target agents. Geriatric Medicine Specialists are a group of physicians who specialize in deprescribing drugs in the elderly. Your family practitioner may refer you to a specialist or a pharmacist who has specialized in deprescribing.
Deprescribing should be done with the guidance of a qualified healthcare professional and can result in discontinuing the drug or finding the lowest effective dose of a drug if it is still necessary. In some circumstances, a health professional can identify a safer, less expensive, and more effective alternative therapy if a therapeutic need is recognized. If you are taking any medication, then it is very important to routinely assess its benefits and risks and whether it continues to be necessary in your current health situation.