July 27, 2023
AMDA’s Drive to Deprescribe (D2D) initiative put practitioners behind the wheel on medication optimization. During a recent AMDA On-The-Go podcast, guest host Jennifer Pruskowski, PharmD, MS, BCPS, BCGP, CPE, sat down with Michael Steinman, MD, co-director of the U.S. Deprescribing Research Network, to talk about how to keep the momentum going.
“Our goal is to categorize research on deprescribing and help people determine how to advance their own deprescribing research,” said Dr. Steinman. While the research community is their prime audience, he noted, “We have a strong interest in how to translate research into daily clinical practice and making sure research is relevant to practitioners, and we have helped increase the awareness of deprescribing and the science of medication optimization.”
Working to make describing efforts real and viable to those working in post-acute and long-term care (PALTC) is a priority for Dr. Steinman. He gave an example of a successful collaboration in that regard. “We worked with [Dr.] Nicole Brandt to create a list of medications that we might temporarily or permanently deprescribe in older institutionalized adults. We did this at the height of the pandemic, largely as a way to reduce med passes and infection risk,” Dr. Steinman said, noting that this was an example of “where interest in research has led to ‘spin off’ effects that could have a more direct impact on clinical practice.”
Deprescribing research is not without its challenges, Dr. Steinman observed, particularly in PALTC. Some of these relate to understanding what drugs should be considered for stopping, he said, adding that there is a great deal of uncertainty about the optimal medication regimens to help patients achieve their goals safely. He also noted that there is sometimes a “huge psychological barrier” to stopping drugs. He explained, “Patients may feel we are taking something away from them, and practitioners might be afraid to stop meds because of the ‘what ifs.’ There sometimes is a disincentive for us to deprescribe because we don’t want to rock the boat.” All these barriers, he said, can be a real impediment to deprescribing.
Dr. Steinman stressed, “One key lesson we’ve learned about deprescribing is that it needs to be concordant with each patient’s goals, and they need to be involved in the decision. If we don’t do this in a way that they are on board, it can cause more harm than good.” Deprescribing is not just a technical matter of identifying and stopping medications, he said, and added, "We need to communicate with the patient and do it in a way that considers their goals and respects their values. It is as much a psychological process as a technical one.”
For practitioners looking to get started on deprescribing or formalizing their efforts, Dr. Steinman said, “I would tell them to think about focusing on where you’ll get the biggest ‘bang for your buck,’ defined by what patients will benefit the most and which medications are most problematic.” For instance, he noted that it may be rather simple to stop every resident’s multivitamin, but it won’t move the needle for most. Contrast that, he suggested, with stopping sedatives/hypnotics, which is harder to do but would have a much greater impact. Ultimately, he said, “You need to be selective about what patients and what drugs we target. Don’t try to do something that is so broad-based that people are not likely to get the most benefits.”