Deprescribing – the New Kid on the Block!

When I see words such as “deprescribing” I immediately think of advertising spin and the need to address our “sick” society.
And make no mistake, these new spin words are introduced through the medical profession to highlight doctors as “good guys” and pharmacists as “bad guys”.
“Deprescribing” is simply overprescribing inappropriately by doctors, directly creating polypharmacy or hyperpolypharmacy (associated with the name of the “bad guys”).

Our collectively Australian sick society as in not as bad as the US, and still reasonably good on the OECD health indicators in the top countries list, but definitely not good in areas of cardiology, cancer, obesity and other chronic illnesses that cause Australian patients to fill GP surgeries with patients that go on to flood pharmacies with prescriptions.

Our health system is unsustainable because it requires political intervention at periodic intervals to savagely reign in costs, disrupting the majority of genuinely motivated pharmacists in particular.
People die, pharmacists go bankrupt and doctors go elsewhere to work – this is not a good system by any measure and “deprescribing” will not go any way towards solving the problems, even if it might add a short period of lifespan to a polypharmacy patient.
None of this adds up to a quality of life to match any extension in lifespan that we humans do seem to value.

Without a doubt, polypharmacy is the result of over-prescribing and hyperpolypharmacy (a new term for patients taking > 10 medications simultaneously) is beginning to increase in prevalence.
There are existing checks and balances within the current system, but they are consistently ignored by the prescribers – the very people who cause the problem in the first place!

Medical prescribers have it within their power to order a Home Medicines Review (HMR) when >5 medications are being used by their patients i.e. the first level of polypharmacy.
At the point of introducing a fifth prescribed medication it should be mandatory for that patient to be given access to an accredited pharmacist for a review of their medications (in a home setting to get the full picture).
It should also be allowable for a patient to be able to confer with the same reviewing pharmacist with one or more follow-up interviews in an office/pharmacy/home setting, depending on patient mobility.
This to ensure adequate independent guidance education and advocacy planning is available for the patient.
These types of interviews (if they were allowed to exist) could cost government in the vicinity of $70-100 each.
But the overall savings would be considerable.

Quoting from Debbie Rigby’s recent LinkedIn discussion under the title
Pharmacy Guild’s A Healthy Future:
Quote: A $208 Home Medicines Review for an elderly patient on 11 or more medicines saves the health system an average of $8238. 
Not sure where that data comes from, but great to see the Guild promoting the value of HMRs.

A Healthy Future

Community pharmacies are a vital part of our national health system with the potential to make an even bigger contribution to the health of all Australians. The highly accessible national network of pharmacies is ideally placed, with the skills…

Because there is a need for advocacy for the patient and a further need for the reviewing pharmacist to be at arms-length from the doctor and the pharmacy’s owner(s) only independent contractors should be able to provide this type of service.
Independent, because on one hand a critique of the doctor’s prescribing is being presented (with the potential for a bruised ego in the doctor’s case) which should also embrace a mandatory collaboration with the reviewing pharmacist on behalf of the patient.
Arms-length is also required from any pharmacy involvement because the process actually requires a reduction in prescription volume for these patients.
If the doctor refuses a collaboration, or does not attempt to modify the number and type of prescribed medicines, then the patient must have an avenue of appeal to some form of multidisciplinary prescribing panel that can impose a suitable result for the patient.

Even the doctors are now recognising the dangers from their own lack of diagnostic and prescribing skills.
Remember, it is the AMA driving a debate for primary health care services to be led only by doctors.
In a recent MJA Insights article it states:

“Leading doctors want to create a culture of “deprescribing” among the medical profession, saying inappropriate polypharmacy is a growing threat to Australia’s ageing population.

Two Clinical focus articles in this week’s MJA make a case for doctors to consider a careful trial of withdrawing potentially unnecessary medications, particularly in elderly patients and those taking 10 or more medications, noting that drugs initially prescribed appropriately can become inappropriate with ageing and new medical conditions. (1)(2)

On analysis within the same article, it seems the authors conclude there is no real justification for polypharmacy in the first instance:

“The authors noted that up to 30% of hospital admissions for patients over 75 years of age were medication related, and up to three-quarters were potentially preventable.

“Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death; and reduced adherence by patients to essential medicines”, they wrote.”

The authors further noted:
“The single most important predictor of inappropriate prescribing and risk of adverse drug events was the number of medications a person was taking, with an 82% risk for people taking seven drugs or more. Yet 20% of older Australians received more than 10 prescription or over-the-counter medicines, the authors wrote.”

It would seem that once patients have been established on a polypharmacy routine there is great reluctance by both the GP and the patient to start reducing the total number of drugs because of the unknowns in so doing.
But having gotten this far it would seem to me that any considerations for deprescribing should include:

* The evidence that was used to introduce a drug to the general marketplace in the first instance. Has it been properly verified through trial replication and was all data available and published in a final report. Also, was the design of the original research study valid.

* Is it not time to go beyond the nonsense promoted by some vested interests to not use other forms of medicine e.g. like those used by integrative health practitioners.
There are many substances that can be used with medications that can reduce the dose of a medication but with improved efficacy for the new combination.
In some instances, “softer” alternatives can eliminate the need totally for specific drugs in the first place.
The volume of “noise” created by Big Pharma’s tends to drown out any attempt to use these cheaper, non-patentable forms of treatment that need to be highlighted as genuine alternatives.

* Is it also not time to encourage studies into food contamination (chemical and genetically modified), water and air pollution?
We know little about the effects of continued ingestion of substances that should not be in our bodies at all, yet we see poor regulation in the industries that cause the problems.
We also see widespread illness, often described as epidemic in proportion such as diabetes, obesity and a range of other lifestyle disorders.

It would seem to me that “deprescribing” is only the tip of the iceberg in respect of patient good health.
I can see a range of direct and indirect issues caused from poor diagnosis and prescribing, but to be fair, the evidence is just not available for a range of environmental illnesses.
However, there is a vast market for a group of investigative pharmacists operating in multi-channels of potential illness generators, starting with “deprescribing” and the potential to initiate research projects in their own right.

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