Modern medications have made a significant and positive impact on human health. For the past 100 years they have been reducing symptoms, managing chronic disease, improving quality of life, and reducing mortality.
But when used for longer than required, or in certain combinations, they can be dangerous.
So prevalent is the problem that doctors and pharmacists have coined the term “potentially inappropriate medication” to describe medications where the potential for harm outweighs the potential for benefit.
The overuse of these medications, particularly in older adults who are more susceptible to their effects, has been linked to increased falls, fractures, hospitalizations and death. It seems crazy that we would use these medications, however, data shows that 50 percent of seniors in Canada are prescribed potentially inappropriate medications each year.
Older people are also in the frontline of so-called “polypharmacy”, commonly defined as when a person takes five or more medicines. The reason is simple – as people get older and develop more medical conditions, they are more likely to be prescribed more and more medications – but it can get out of hand quickly.
In Canada, for example, two out of three seniors take five or more prescription medications and a quarter of them take 10 or more prescription medications each day.
Medications prescribed for individual conditions, when taken together can increase the risk of drug interactions and harmful effects. The Lown Institute in America refers to this as “over-medication”. They call it America’s “other drug problem” leading to 750 older adults being hospitalized each day in the US due to medication side effects.
It’s a similar story in the UK. The Chief Pharmacist of England recently outlined how overprescribing has grown dramatically over the past 25 years and now poses serious problems to the health system.
In an effort to address these problems, in 2019 Australia's federal government announced that “Quality Use of Medicines and Medicines Safety” would be the 10th National Health Priority area. Similarly, in Canada, there is increasing pressure to “create and implement a national strategy on appropriate prescribing”.
What is deprescribing?
Deprescribing — the process where a patient and their health care provider both assess the potential benefits and harms of each medication and re-assess if the medication still aligns with the patients goals of care — could be the answer.
Just because a medication was good for you when it was started 10 years ago, doesn’t mean it’s still good for you now. Things can change over time: how our bodies interact with medications; our health status or our vulnerability to the medication’s side effects, for example. New evidence may emerge, and new treatments come available.
For all these reasons it’s really important to have patients’ medications reviewed to make sure they are still appropriate for them.
Many healthcare providers assume patients are reluctant to have their medications stopped. But research from all over the world consistently shows most patients are willing to stop one of their medications if their doctor thinks it is necessary. Similarly many patients are reluctant to question their healthcare providers, assuming everything is OK with their medications.
Canada is showing how deprescribing can be done, and save lives.
Educating patients and prescribers
In one trial, called ‘EMPOWER’, patients were mailed an educational brochure on the benefits and harms of their medications and alternate treatments they could consider. Patients were encouraged to start a conversation with their doctor or pharmacist and ask them if the medication was still necessary for their care.
This simple approach reduced the use of sleeping pills by 27 percent. In some cases doctors and pharmacists told patients that since they hadn’t had an issue with the medication until then, deprescribing wasn’t required. Consequently, a follow-up study asked pharmacists to educate both patients and prescribers about deprescribing. This approach increased the reduction in the number of medications to 43 per cent.
Inspired by the results of direct-to-public engagement, the Canadian government of Manitoba adapted the EMPOWER trial from sleeping pills to opioid medications.
The TAPERING trial randomized the entire population of Manitoba who took opioids for chronic non-cancer pain. Over the next six months, opioid use fell and there was a significant reduction in mortality after three months.
There was a similar story in the province of Newfoundland and Labrador, Canada, which, in 2018, had some of the highest use of sleeping pills and proton pump inhibitors (PPIs) for reflux across Canada.
Health authorities there collaborated with the Canadian Deprescribing Network, the University of Montreal and the Memorial University of Newfoundland to create SaferMedsNL. It allocated new funding to pharmacists to talk to patients about deprescribing.
While final results are not in, an interim analysis shows that 20 percent of patients who pharmacists spoke to went on to deprescribe their medications.
The pharmacist program was bolstered by a public awareness campaign to educate people about the benefits and harms of their medications. Awareness of PPI overuse increased significantly across the province which can increase patient-led conversations about deprescribing.
One in six people reported that their doctor or pharmacist had spoken to them about deprescribing. Governments now have a research-based roadmap to successfully reduce harmful medications.
(Dr Justin Turner, is an Assistant Professor at the Faculty of Pharmacy, University of Montreal,and Co-Director of the Canadian Deprescribing Networ)