October 16th, 2018
Taking multiple medications concurrently, what researchers call polypharmacy, is often necessary for patients with several chronic conditions. However, taking many medications at once can put patients, especially older adults, at risk of a negative reaction to one or more drugs. More than 450,000 older Americans went to the Emergency Room in 2015 because of an adverse drug event.
Given the risks of taking too many medications, initiatives around the world have been started to encourage doctors to “deprescribe,” to take patients off medications that are unnecessary or harmful. However, taking patients off medications is easier said than done – there are not many guidelines for tapering medications, doctors may be reluctant to deprescribe a medication another doctor prescribed, and deprescribing is a significant time commitment that doctors often don’t have in their busy schedules.
Primary care doctors report that one of the biggest barriers to deprescribing is that patients don’t want to stop taking medications. Patients may perceive that the medication is making them healthier, even if it’s not; they may think the doctor is “giving up on them” by deprescribing; they may not realize that they can go back on the medication if necessary; or they may be under pressure from their family to keep taking the medication.
However, a new study in JAMA Internal Medicine shows that patients are not as resistant to deprescribing as doctors might think. Researchers Dr. Emily Reeve and colleagues analyzed answers from a Medicare survey module, focusing on two questions:
What they found was overwhelmingly positive. Out of 1981 patients surveyed, about 92% said they would be willing to reduce their medications, and about 66% reported that they wanted to reduce their medication burden. Respondents who were taking six or more medications already were more than twice as likely to want to reduce their number of medications, compared to patient taking fewer drugs.
Patients who reported having worse health were also more likely to want to reduce their medications, as were those who had a recent fall. It makes sense that patients who are feeling side effects from medications would want to deprescribe if possible.
The authors note that patient attitudes about medications are complex and sometimes contradictory. For example, most patients reported being willing to deprescribe, but nearly the same number of patients said they believe that all their medications are necessary. Additionally, a little more than half reported being reluctant to stop a medication they have been taking a long time.
These contradictions “reflect a combination of traditional deference to physician recommendations coupled with a medical culture focused on prescribing and starting medications rather than deprescribing,” the authors write. In other words, we believe in general that medications are good for our health, but we are willing to listen to our doctors when they recommend reducing medications.
This means that doctors should feel confident starting conversations with patients about deprescribing, knowing that most older patients are amenable to reducing medications that are potentially harmful. In fact, many patients are hoping to deprescribe, but believe their medications are all necessary. For these patients, a conversation on deprescribing may be the impetus they need to talk about side effects that are giving them trouble.
Deprescribing is not easy, but doctors may be able to take a leading role in initiating conversations with patients about their medications. As the authors write, doctors thinking about initiating these conversations should be reassured that a majority of older Americans are open to deprescribing. Rather than being an “obstacle” to deprescribing, patient attitudes might be an area of common ground on which we can build a movement.