Clinical research around deprescribing (the discontinuation or dose reduction of unnecessary or harmful medications) is imperative for reducing medication harm. But what kind of research and what specific topics, should we be focusing on? In a keynote address for the US Deprescribing Research Network conference, Dr. Cara Tannenbaum provided her thoughts on these key questions. (Watch the full talk on the US Deprescribing Research Network website!)
Tannenbaum is a Professor on the faculties of Medicine and Pharmacy at the University de Montreal in Quebec, Canada, and the Director of the Canadian Deprescribing Network. Her talk focused on the question, “What are we doing to advance transformative–not just incremental–change in medication use?”
We should be focusing on how to motivate clinicians to deprescribe, rather than continuing to build a better mousetrap.
Since the 1990s, we have had useful measures for deprescribing, like the Beers Criteria (drugs to avoid in older adults), Medication Appropriateness Index. More recently, Tannenbaum and colleagues developed the EMPOWER brochure and other communications tools to explain medication harms to patients. We have also known for decades that nursing home residents, veterans, and older adults in the community are particularly susceptible to medication overload and are good targets for deprescribing. Yet having a target population and the tools to deprescribe have not led to widespread deprescribing– why not?
Tannenbaum argued that we should be focusing on how to motivate clinicians to deprescribe, rather than continuing to “build a better mousetrap” and refine tools and definitions that we already know are helpful.
In order to do this, we have to learn from other disciplines that work on behavioral change, such as cognitive theory, linguistics, economics, and political science. For example, the Canadian Deprescribing Network used the COM-B model (capability, opportunity, motivation) to try and affect members’ behavior. They recognized several different ways to motivate clinicians: appealing to the goal-oriented nature of doctors, showing altruistic nurses the ways that deprescribing helps patients, and giving analytic pharmacists the research they need to see to change their behavior. Everyone has different things that motivate them, so using multiple methods is key.
Tannenbaum also pointed to Covid-19 as a example we can learn to change behaviors. When trying to get young people to wear masks, researchers found that acknowledging people’s feelings of ambivalence about masks, supporting and validating their concerns, and appealing to social identity and shared values were effective. On the other hand, shaming people, overpromising benefits, and using fear usually backfired.
We can and should test similar methods to convincing doctors and patients to deprescribe when necessary. For example, clinicians can appeal to their shared values with patients by saying, “I know you care about being able to play with your grandchildren, and I worry being on this many drugs will make you too fatigued to do that. What do you think about getting you off one of these medications?”
Of course, this necessitates a trusting relationship between clinicians and patients, which some audience members noted can be threatened by the lack of time that clinicians have with patients. Trust also requires including the voices of all stakeholders across regions and cultures. For example, the Canadian Deprescribing Network collaborated with First Nations Elders on a project that uses storytelling to start a conversation about polypharmacy.
“You can have the most effective intervention in the world, but if no one uses it, there will be no change.”
Dr. Cara Tannenbaum
Rather than continuing to research what we already know, Tannenbaum urged the audience to dive into interdisciplinary studies, and test implementation strategies for deprescribing. What strategies work for whom, for which drugs, in which context? Doing this research will improve “buy-in” and lead to more meaningful change. “You can have the most effective intervention in the world, but if no one uses it, there will be no change,” she said.