Program: There's not enough advice on how to wean off medication

Shelby Traynor: One of the issues with shortages could be that there's such a high demand for medications and that demand might be higher than it should be. 

Norman Swan: Yes, the paper has come out looking at the issue of what's called deprescribing, so you can have artificially high demand if you're on a medication that you actually don't need to be on, or perhaps you need to be on a lower dose. And the emphasis around drugs is getting you on the drug, but you may want to come off a drug, or you may need to come off a drug. The lead researcher on this paper where they reviewed, I think, about 80 guidelines to see whether they advised on deprescribing and what they advised was Dr Aili Langford, who's a lecturer in the pharmacy school at the University of Sydney. 

Aili Langford: There was a large study in the UK recently that estimated that 10% of all medications are potentially inappropriate, and there's a little bit more data, particularly in older adults, to say that nearly half to one-third of older adults are taking at least one inappropriate medication that may be suitable for deprescribing.

Norman Swan: So that's an enormous impact on the individual, as well as on our budget.

Aili Langford: Definitely. Of course there's harms to the individuals, like side effects. Some medications increase the risk of falls. If someone's having a fall and then going into the hospital system, as you said, there's huge potential implications on the costs at the healthcare system level as well.

Norman Swan: But we're also being denied expensive drugs when there's waste going on. 

Aili Langford: Yes, and there's a huge amount of research as well about the potential environmental impacts of overprescribing as well. So I think the potential implications are quite significant. 

Norman Swan: You've looked in this study at the advice doctors get about deprescribing, and it's not a pretty picture.

Aili Langford: That's correct, so we wanted to find out whether guidelines in general contain deprescribing recommendations, and of the ones that do, what do those recommendations look and sound like. So we searched a range of different guideline registries and databases, and we found that a little bit less than a third of guidelines contain recommendations about deprescribing. And then perhaps one of the more concerning findings was of those that do, a lot of them don't have detailed information about how to actually go about deprescribing.

Norman Swan: So they say you should get off this drug when you need to, but don't tell you how. 

Aili Langford: Exactly. And I think that's concerning, because a lot of medications we know need to be perhaps tapered slowly, or if they're stopped abruptly they can lead to withdrawal effects or other patient harms. 

Norman Swan: We've spoken about some of this before in the Health Report, particularly with antidepressants, the new form of antidepressants, how you really cannot stop those suddenly, you've got to taper them and so on. Opioid painkillers are obviously another one. Are those the two main ones? Or are there other medications as well?

Aili Langford: Yes, from our review we did find that neurological drugs were the ones that most commonly had deprescribing recommendations, things like antiepileptics were also a focus within the review. And then we did, of course, find types of medication classes or disease states where perhaps there were less focus on deprescribing recommendations, so things more like cardiovascular disease, respiratory conditions.

Norman Swan: Do we know how to deprescribe with most medications, or is it guesswork?

Aili Langford: That is a good question, and many of the recommendations that we did find were based on low certainty evidence, and there's a few reasons potentially for that, that people aren't conducting studies to look at continuation versus deprescribing of a medication and the benefits and harms of that. Another consideration is that often deprescribing will probably have to be individualised. There may not be a one-size-fits-all solution in terms of the exact approach of how to, say, stop an antidepressant. Some people may need to go slightly slower, or may be able to tolerate faster tapers than others. But I think it's still important for clinicians to have guidance around a general approach or a range that might be safe and appropriate to guide patients on how they may begin to reduce their doses. 

Norman Swan: Of course, people get a bit anxious at the thought that you're going to stop my drug. 

Aili Langford: Yes, I think they can be. And on the other hand, I think there's some people who perhaps have taken medications for a long time and then make a decision that they may want to trial reducing or stopping it, and say that 'I've never been given any information about when and how I could go about this process.' So I think both sides are true.

Norman Swan: Now, the whole system is focused on getting you on drugs rather than getting you off drugs. It's in the pharmaceutical industry's interests, the trials are biassed towards getting on drugs and seeing the benefit versus placebo. Are deprescribing studies easy to do, and who's going to fund them? 

Aili Langford: Well, there is a lot of emerging evidence and research being conducted currently looking at deprescribing, both here in Australia and internationally, and even in Australia there's been a range of other initiatives recently to try and promote deprescribing. In March this year, the Society of Hospital Pharmacists of Australia worked with a range of different organisations under a campaign called Meds Aware Week, which was trying to empower people to ask their healthcare professionals; do I still need to be on this medication? Because I think they think that's an important first step to having these conversations about deprescribing.

Norman Swan: Giving the doctor the permission to do it. 

Aili Langford: Yes, exactly.

Norman Swan: Which was going to be my final question, which is what's your practical advice for somebody listening to this who thinks they've been on it too long, or they want to try time off it?

Aili Langford: When a medication is first prescribed, I think it's really important for people to have a conversation about what is the expectation around the duration of use. And I think by having that conversation early on, you can sort of plan ahead for whether deprescribing may be appropriate. I think one of the main findings from our review, though, is that if that evidence isn't available for healthcare professionals in their clinical practice guidelines, that then makes it potentially difficult for them to support their patients to deprescribe, if that is what they indeed want to pursue. 

Norman Swan: Aili, thanks for joining us. 

Aili Langford: Thank you very much.

Norman Swan: Dr Aili Langford is a lecturer in Pharmacy at the University of Sydney.