How is medication prescribing ceased? A systematic review

Deprescribing: An umbrella review

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial

BACKGROUND

Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians.

METHODS

This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely.

RESULTS

There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change.

CONCLUSIONS

Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions.

TRIAL REGISTRATION

NCT03984396. Registered on 13 June 2019.

Hypnotic Discontinuation in Chronic Insomnia

Insomnia disorder is common in adults and children. The estimated prevalence ranges from 9% to 15% in the general population, with higher prevalence in certain subpopulations. Hypnotic medications are those that tend to produce sleep and are frequently used to treat insomnia. Commonly used hypnotics in adults include benzodiazepines (BZDs), BZD receptor agonists, antihistamines, antidepressants, melatonin receptor agonists, orexin receptor antagonists, and antipsychotics. However, hypnotic discontinuation is difficult and often unsuccessful. This article discusses strategies to discontinue hypnotics and evidence supporting their use.

Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial

Background

Individuals with dementia or mild cognitive impairment frequently have multiple chronic conditions (defined as ≥2 chronic medical conditions) and take multiple medications, increasing their risk for adverse outcomes. Deprescribing (reducing or stopping medications for which potential harms outweigh potential benefits) may decrease their risk of adverse outcomes.

Objective

To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment.

Design, Setting, and Participants

This pragmatic, patient-centered, 12-month cluster randomized clinical trial was conducted from April 1, 2019, to March 31, 2020, at 18 primary care clinics in a not-for-profit integrated health care delivery system. The study included 3012 adults aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications.

Interventions

An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings.

Main Outcomes and Measures

The number of prescribed long-term medications and the percentage of individuals prescribed 1 or more potentially inappropriate medications (PIMs). Analysis was performed on an intention-to-treat basis.

Results

This study comprised 1433 individuals (806 women [56.2%]; mean [SD] age, 80.1 [7.2] years) in 9 intervention clinics and 1579 individuals (874 women [55.4%]; mean [SD] age, 79.9 [7.5] years) in 9 control clinics who met the eligibility criteria. At baseline, both groups were prescribed a similar mean (SD) number of long-term medications (7.0 [2.1] in the intervention group and 7.0 [2.2] in the control group), and a similar proportion of individuals in both groups were taking 1 or more PIMs (437 of 1433 individuals [30.5%] in the intervention group and 467 of 1579 individuals [29.6%] in the control group). At 6 months, the adjusted mean number of long-term medications was similar in the intervention and control groups (6.4 [95% CI, 6.3-6.5] vs 6.5 [95% CI, 6.4-6.6]; P = .14). The estimated percentages of patients in the intervention and control groups taking 1 or more PIMs were similar (17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = .08). In preplanned subgroup analyses, adjusted differences between the intervention and control groups were -0.16 (95% CI, -0.34 to 0.01) for individuals prescribed 7 or more long-term medications at baseline (n = 1434) and -0.03 (95% CI, -0.20 to 0.13) for those prescribed 5 to 6 medications (n = 1578) (P = .28 for interaction; P = .19 for subgroup interaction for PIMs).

Conclusions and Relevance

This large-scale educational deprescribing intervention for older adults with cognitive impairment taking 5 or more long-term medications and their primary care clinicians demonstrated small effect sizes and did not significantly reduce the number of long-term medications and PIMs. Such interventions should target older adults taking relatively more medications.

Trial Registration

ClinicalTrials.gov Identifier: NCT03984396.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study

OBJECTIVE

Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community.

METHODS

Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development.

RESULTS

Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital."

CONCLUSION

The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves.

PRACTICE IMPLICATIONS

Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

Effectiveness of interventions aiming to reduce inappropriate drug prescribing: an overview of interventions

Objective

Inappropriate prescribing of drugs is associated with unnecessary harms for patients and healthcare costs. Interventions to reduce these prescriptions are widely studied, yet the effectiveness of different types of interventions remains unclear. Therefore, we provide an overview regarding the effectiveness of intervention types that aim to reduce inappropriate drug prescriptions, unrestricted by target drugs, population or setting.

Methods

For this overview, systematic reviews (SRs) were used as the source for original studies. EMBASE and MEDLINE were searched from inception to August 2018. All SRs aiming to evaluate the effectiveness of interventions to reduce inappropriate prescribing of drugs were eligible for inclusion. The SRs and their original studies were screened for eligibility. Interventions of the original studies were categorized by type of intervention. The percentage of interventions showing a significant reduction of inappropriate prescribing were reported per intervention category.

Key findings

Thirty-two SRs were included, which provided 319 unique interventions. Overall, 61.4% of these interventions showed a significant reduction in inappropriate prescribing of drugs. Strategies that were most frequently effective in reducing inappropriate prescribing were multifaceted interventions (73.2%), followed by interventions containing additional diagnostic tests (antibiotics) (70.4%), computer interventions (69.2%), audit and feedback (66.7%), patient-mediated interventions (62.5%) and multidisciplinary (team) approach (57.1%). The least frequently effective intervention was an education for healthcare professionals (50.0%).

Conclusion

The majority of the interventions were effective in reducing inappropriate prescribing of drugs. Multifaceted interventions most frequently showed a significant reduction of inappropriate prescribing. Education for healthcare professionals is the most frequently included intervention in this overview, yet this category is least frequently effective.

Deprescribing anticholinergic medication in the community mental health setting: A quality improvement initiative

BACKGROUND

Chronic anticholinergic medication (ACM) prescribing with antipsychotics when no longer clinically indicated can lead to serious side effects and adversely impact patient quality of life.

OBJECTIVES

Through modifications of previously described deprescribing strategies undertaken in an academic, schizophrenia clinic, this quality improvement (QI) project aimed to bolster ACM deprescription where clinically appropriate among patients with schizophrenia and other psychiatric disorders at a community mental health center.

METHODS

A multidisciplinary team involving clinical pharmacists and psychiatrists created web streaming video medical education accredited modules, supplemented by small groups sessions and case consultations, and provided these to psychiatrists and nurse practitioners at a community mental health center over a one-year period. Electronic medical record reports were also generated, highlighting patients who were receiving one of two ACM used in the clinic: benztropine and/or trihexyphenidyl; these were periodically distributed to support appropriate deprescription. Patient education infographic material focused on ACM were also created and deployed.

RESULTS

One hundred and twenty-six patients were identified as receiving benztropine or trihexyphenidyl in March 2019. One hundred and six (84%) were on one or both of these medications for at least six months. The mean (±SD) age of the study sample was 53.4 (±12.6) years; a third of the sample was over 60 years. Thirty-seven patients, or 29.4%, had their ACM discontinued or the dosage reduced. Deprescription was not associated with age, sex, race, or diagnosis. Deprescription was not associated with antipsychotic polypharmacy, first versus second generation, or oral versus long acting preparation.

CONCLUSIONS

These results suggest that deprescription of ACM in a community mental health center can occur with prescriber education and support. However, results from previous stages of this QI project, where much higher rates of deprescription were demonstrated, indicate the important benefit of more direct clinical pharmacist support and involvement in the process.

Designing a Primary Care-Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

BACKGROUND

Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.

OBJECTIVES

To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.

DESIGN

Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians.

PARTICIPANTS

Patients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.

APPROACH

We used constant comparison to identify and compare themes between patients, caregivers, and physicians.

KEY RESULTS

We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers' expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.

CONCLUSIONS

Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.

Hypnotic Discontinuation in Chronic Insomnia

Patients with chronic insomnia are commonly prescribed hypnotic medications. The long-term effects of chronic hypnotics are not known and discontinuation is encouraged but often difficult to achieve. A gradual taper is preferred to abrupt cessation to avoid rebound insomnia and withdrawal symptoms. Written information provided to the patient about medication discontinuation may be helpful. Cognitive behavioral therapy or behavioral therapies alone can improve hypnotic discontinuation outcomes. There is limited evidence for adjunct medications to assist in hypnotic cessation for insomnia.

The Patient Perceptions of Deprescribing (PPoD) Survey: Short-Form Development

INTRODUCTION

Deprescribing, the intentional reduction of medication, is recognized as an important component of clinical care; however, standardized identification of patient attitudes and beliefs that contribute to deprescribing may be limited due to the length of current surveys. We sought to develop a short-form (≤ 15 items) of the patient perceptions of deprescribing (PPoD) questionnaire, a validated 30-item instrument that assesses dimensions relevant to deprescribing, to be used in clinical and research settings.

METHODS

We conducted a secondary analysis of data from 803 US veteran respondents to the original PPoD survey, randomly divided into derivation and validation samples. In the derivation sample, we used ordinary least squares linear regression with R² model selection to identify candidate items reflective of overall readiness for deprescribing. We then used iterative multitrait analysis, followed by confirmatory factor analysis (CFA) in the validation sample to assess the psychometric properties of the proposed short form.

RESULTS

The resulting short-form PPoD consisted of 11 items representing two overarching domains reflective of overall readiness for deprescribing: 'Motivation for Deprescribing' and 'Primary Care Provider Relationship'. CFA fit statistics supported the proposed structure and the two new scales demonstrated high internal consistency reliability (Cronbach alphas: 0.82 and 0.91, respectively) and good discriminant validity (interscale correlation - 0.30).

DISCUSSION

The proposed short-form PPoD captures two important sources of variance in patient readiness for deprescribing: motivation and patients' relationships with their primary care providers. This brief, 11-item survey may help foster the inclusion of patient perceptions into clinical decision making for deprescribing to yield safer, more appropriate medication use.

The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial

Background

Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI.

Methods

With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions.

Discussion

The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC.

Trial registration

NCT03984396. Registered on 13 June 2019

Reduction of the long-term use of proton pump inhibitors by a patient-oriented electronic decision support tool (arriba-PPI): study protocol for a randomized controlled trial

BACKGROUND

Proton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool.

METHODS

The arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient.

DISCUSSION

Our principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.

Effectiveness and feasibility of deprescribing of symptomatic medications in a Singapore rehabilitation hospital

Introduction:

This study aims to determine the effectiveness, cost savings and feasibility of implementing a systematic process of deprescribing medications for symptomatic management, namely, acid suppressants, laxatives, analgesics and antiemetics for patients of a Singapore rehabilitation hospital.

Methods:

A total of 200 patients were randomized to a deprescribing intervention ( n = 100) or control (usual care) group ( n = 100). The patient-centred deprescribing process was utilized. Symptomatic medications were deprescribed following initial pharmacist assessment, discussion with doctors and consideration of patients’ preferences regarding discontinuation or dose reduction. Symptom recurrence, adverse drug withdrawal events (ADWEs) and the need for drug re-initiation or initiation of new symptomatic medications after deprescribing were monitored in the first, second and sixth weeks.

Results:

The mean age of patients was 72.8 years and 68.6 years in the intervention and control groups. There were no significant reductions in the monthly cost and total number of medications between both intervention and control groups. Systematic deprescribing of acid suppressants was the highest among the four target drug classes. Recurrence of pain and re-initiation of analgesics occurred in two out of seven cases of discontinuation. However, no ADWEs or constipation were noted in the intervention group. On average, a total of 19 minutes was required by pharmacists and doctors to complete the deprescribing process.

Conclusion:

The systematic deprescribing of symptomatic medications did not reduce costs nor the total number of medications. The risk of symptom recurrence and adverse events was negligible. Knowledge, attitudes and collaboration among healthcare professionals regarding deprescribing are critical.

Trial registration:

Clinicaltrials.gov, number NCT03354845.

Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview

Opioid analgesics and antibiotics prescribed by dentists is a useful and cost-effective measure when prescribed appropriately. Common dental conditions are best managed by extracting the offending tooth, restoring the tooth with an appropriate filling material, performing root canal therapy, and/or fabricating a prosthesis for the edentulous space. Unnecessary prescription of opioid analgesics and antibiotics to treat dental pain and bacterial infection is a growing public health concern. This article highlights the state of the literature on opioid analgesic and antibiotic prescribing practices in dentistry, the impact of opioid analgesic overdose, and prevention strategies to reduce opioid analgesics and antibiotic overprescription.

The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people

The area of "deprescribing" has rapidly expanded in recent years as a positive intervention to reduce inappropriate polypharmacy and improve health outcomes for (older) people with multimorbidity. While our understanding of deprescribing as a process has greatly improved and existing approaches all have patient-centered elements, there is still limited literature exploring the importance of the individual patient context in deprescribing decision-making. This is clearly an important consideration to ensure that any deprescribing approach is ethical, respectful, and successful. To address this gap in the literature, we have developed a conceptual framework in the form of a rainbow - with five different deprescribing determinants - and place the person at the center of the deprescribing process. This framework is informed by literature on patient-centered care for older people and people with multimorbidity. We illustrate the potential application of this framework to a complex patient case to highlight the importance of the different clinical, psychological, social, financial and physical deprescribing determinants, and how this approach could be adopted by those working in clinical practice.

Effectiveness of an intervention to optimise the use of mirabegron for overactive bladder: a quasi-experimental study in primary care

BACKGROUND

Overactive bladder is a composite of lower urinary tract storage symptoms. Pharmacological treatment is widely employed despite markedly modest efficacy data, adverse effects, and costs for the health system.

AIM

To determine the 12-month efficacy of an intervention delivered by GPs on mirabegron revision and, if appropriate, discontinuation of treatment.

DESIGN AND SETTING

Multicentre, quasi-experimental study in Barcelona (Catalonia), Spain.

METHOD

Two groups composed of 17 intervention and 34 control practices were formed. The follow-up period was 12 months, from 1 January to 31 December 2017. A structured intervention was designed consisting of initiatives with GPs and urology/gynaecology specialists. The primary outcome was mirabegron use at 12 months.

RESULTS

Of the 1932 patients, a significant discontinuation in treatment was observed at 12 months' follow-up in the intervention group (IG) (n = 433 out of 762, 56.8%), in contrast with the control one (CG) (n = 484 out of 1170, 41.4%) (P<0.001). There was also a reduced incorporation of new treatments in the IG (n = 214 out of 762, 28.1%) compared with the CG (n = 595 out of 1170, 50.9%) (P<0.001). In relation to patients with treatment at the beginning and end of the period, there was a decrease of 219 (28.7%) patients in the IG and an increase of 111 (9.5%) in the CG (P<0.001).

CONCLUSION

The structured intervention showed optimisation in the use of mirabegron. When considering discontinuation it is necessary to provide clear data on the benefits and/or risks for patients and their caregivers, as such information is a precondition for shared decision making.

Promoting oral potassium administration in a tertiary care hospital: An eleven-year study

INTRODUCTION

Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified.

OBJECTIVES

To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital.

METHODS

Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database.

RESULTS

The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P<0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold.

CONCLUSION

Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration

OBJECTIVES

Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications.

MAIN OUTCOME MEASURES

The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences.

RESULTS

Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R² = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist.

CONCLUSION

More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.

Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing

BACKGROUND

One approach to prevent adverse drug events is to discontinue ("deprescribe") medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers' preferences for interventions that would improve their ability to appropriately and proactively discontinue medications.

METHODS

We conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would "most improve [their] ability to discontinue medications." We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs.

RESULTS

Among the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was "Requiring all medication prescriptions to have an associated 'indication for use.'" This preference was followed by "Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)" and "Increased patient involvement in prescribing decisions." This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs.

CONCLUSIONS

Continued efforts to improve clinicians' ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians' preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.

Novel tool for deprescribing in chronic patients with multimorbidity: List of Evidence-Based Deprescribing for Chronic Patients criteria

AIM

To create a tool to identify drugs and clinical situations that offers an opportunity of deprescribing in patients with multimorbidity.

METHODS

A literature review completed with electronic brainstorming, and subsequently, a panel of experts using the Delphi methodology were applied. The experts assessed the criteria identified in the literature and brainstorming as possible situations for deprescribing. They were also asked to assess the influence of life prognosis in each criterion. A tool was composed of the most appropriate criteria according to the strength of their evidence, usefulness in patients with multimorbidity and applicability in clinical practice.

RESULTS

Out of a total of 100, 27 criteria were selected to be included in the final list. It was named the LESS-CHRON criteria (List of Evidence-baSed depreScribing for CHRONic patients), and was organized by the anatomical group of the Anatomical, Therapeutic, Chemical (ATC) classification system of the drug to be deprescribed. Each criterion contains: drug indication for which it is prescribed, clinical situation that offers an opportunity to deprescribe, clinical variable to be monitored and the minimum time to follow up the patient after deprescribing.

CONCLUSIONS

The "LESS-CHRON criteria" are the result of a comprehensive and standardized methodology to identify clinical situations for deprescribing drugs in chronic patients with multimorbidity. Geriatr Gerontol Int 2017; 17: 2200-2207.

Patient Perceptions of Deprescribing: Survey Development and Psychometric Assessment

BACKGROUND

Although clinicians ultimately decide when to discontinue (deprescribe) medications, patients' perspectives may guide the process.

OBJECTIVES

To develop a survey instrument that assesses patients' experience with and attitudes toward deprescribing.

RESEARCH DESIGN

We developed a questionnaire with established and newly created items. We used exploratory factor analysis and confirmatory factor analysis (EFA and CFA) to assess the psychometric properties.

SUBJECTS

National sample of 1547 Veterans Affairs patients prescribed ≥5 medications.

MEASURES

In the EFA, percent variance, a scree plot, and conceptual coherence determined the number of factors. In the CFA, proposed factor structures were evaluated using standardized root mean square residual, root mean square error of approximation, and comparative fit index.

RESULTS

Respondents (n=790; 51% response rate) were randomly assigned to equal derivation and validation groups. EFA yielded credible 4-factor and 5-factor models. The 4 factors were "Medication Concerns," "Provider Knowledge," "Interest in Stopping Medicines," and "Unimportance of Medicines." The 5-factor model added "Patient Involvement in Decision-Making." In the CFA, a modified 5-factor model, with 2 items with marginal loadings moved based upon conceptual fit, had an standardized root mean square residual of 0.06, an RMSEA of 0.07, and a CFI of 0.91. The new scales demonstrated internal consistency reliability, with Cronbach α's of: Concerns, 0.82; Provider Knowledge, 0.86; Interest, 0.77; Involvement, 0.61; and Unimportance, 0.70.

CONCLUSIONS

The Patient Perceptions of Deprescribing questionnaire is a novel, multidimensional instrument to measure patients' attitudes and experiences related to medication discontinuation that can be used to determine how to best involve patients in deprescribing decisions.

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.

Deprescription: The prescription metabolism

Deprescribing is a structured approach to drug discontinuation. An alternative suggested term is "prescription metabolism." The major aim of deprescription is to purge the drug(s) considered unwanted in a given patient, especially in the elderly patients with multiple comorbidities or in those suffering from chronic disease. Like drug metabolism, prescription metabolism is a way of eliminating unwanted, troublesome, or cost-ineffective medications. The removal of such drugs has been found to decrease the incidence of adverse drug reactions and improves the rate of medication adherence, thereby reducing the economic burden on the patient as well as on the health care providers. Certain categories of drugs are to be tapered rather than abruptly stopped. Despite the availability of many tools to minimize drug therapy-related problems, there is little guidance for the process of deprescribing in general clinical practice. Various methods to reduce the risks of polypharmacy include patient education, physician education, and regulatory intervention. The suggested S and S approach (seek and screen, save and severe, sensitize and supervise) may be tried for deprescribing in general practice. More research on deprescribing is the need of the hour in almost all branches of clinical medicine which may pave the way for the betterment of health care.

Community-dwelling older people's attitudes towards deprescribing in Canada

BACKGROUND

While there is evidence that supervised withdrawal of inappropriate medications might be beneficial for individuals with polypharmacy, little is known about their attitudes towards deprescribing.

OBJECTIVE

This study aimed to describe the situation among older community-dwelling Canadians.

METHODS

A self-administered survey was adapted from the Patients' Attitudes Towards Deprescribing questionnaire and distributed to 10 community pharmacies and 2 community centers. The participants rated their agreement on statements about polypharmacy/deprescribing on a 5-point, Likert-type scale. Correlations between the desire to have medications deprescribed and survey items were evaluated using Spearman's Rho and Goodman and Kurska's gamma rank correlations.

RESULTS

From the 129 participants, 63% were women [median age: 76 (IQR:71-80); median number medication: 6 (IQR: 3-8)]. A proportion of 50.8% (95%CI: 41.6%-60.0%) expressed the desire to reduce their number of medications. This desire was strongly correlated with the individuals' feeling of taking a large number of medications and moderately correlated with the belief that some of the medications were no longer needed or that they were experiencing side effects.

CONCLUSIONS

The results show that older individuals in the community are eager to undertake deprescribing, especially if they have a large number of medications, are experiencing side effects or feel some medications are no longer necessary.

Organising medication discontinuation: a qualitative study exploring the views of general practitioners toward discontinuing statins

BACKGROUND

Discontinuing medications is a complex decision making process and an important medical practice. It is a tool in reducing polypharmacy, reducing health system expenditure and improving patient quality of life. Few studies have looked at how general practitioners (GPs) discontinue a medication, in agreement with the patients, from a professional perspective. Three research questions were examined in this study: when does medication discontinuation occur in general practice, how is discontinuing medication handled in the GP's practice and how do GPs make decisions about discontinuing medication?

METHODS

Twenty four GPs were interviewed using a maximum variation sample strategy. Participant observations were done in three general practices, for one day each, totalling approximately 30 consultations.

RESULTS

The results show that different discontinuation cues (related to the type of consultation, medical records and the patient) create situations of dissonance that can lead to the GP considering the option of discontinuation. We also show that there is a lot of ambiguity in situations of discontinuing and that some GPs trialled discontinuing as means of generating more information that could be used to deal with the ambiguity.

CONCLUSIONS

We conclude that the practice of discontinuation should be conceptualised as a continually evaluative process and one that requires sustained reflection through a culture of systematically scheduled check-ups, routinely eliciting the patient's experience of taking drugs and trialling discontinuation. Some policy recommendations are offered including supporting GPs with lists or handbooks that directly address discontinuation and by developing more person centred clinical guidelines that discuss discontinuation more explicitly.

General practitioners’ decisions about discontinuation of medication: an explorative study

Purpose

– The purpose of this paper is to investigate how general practitioners’ (GPs) decisions about discontinuation of medication are influenced by their institutional context.

Design/methodology/approach

– In total, 24 GPs were interviewed, three practices were observed and documents were collected. The Gioia methodology was used to analyse data, drawing on a theoretical framework that integrate the sensemaking perspective and institutional theory.

Findings

– Most GPs, who actively consider discontinuation, are reluctant to discontinue medication, because the safest course of action for GPs is to continue prescriptions, rather than discontinue them. The authors conclude that this is in part due to the ambiguity about the appropriateness of discontinuing medication, experienced by the GPs, and in part because the clinical guidelines do not encourage discontinuation of medication, as they offer GPs a weak frame for discontinuation. Three reasons for this are identified: the guidelines provide dominating triggers for prescribing, they provide weak priming for discontinuation as an option, and they underscore a cognitive constraint against discontinuation.

Originality/value

– The analysis offers new insights about decision making when discontinuing medication. It also offers one of the first examinations of how the institutional context embedding GPs influences their decisions about discontinuation. For policymakers interested in the discontinuation of medication, the findings suggest that de-stigmatising discontinuation on an institutional level may be beneficial, allowing GPs to better justify discontinuation in light of the ambiguity they experience.

A Delphi process to address medication appropriateness for older persons with multiple chronic conditions

Background

Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.

Methods

Modified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.

Results

The panel reached consensus on a set of markers to identify problems with medication regimens, including patient/caregiver report of non-adherence, medication complexity, cognitive impairment, medications identified by expert opinion as inappropriate for older persons, excessively tight blood sugar and blood pressure control among persons with diabetes mellitus, patient/caregiver report of adverse medication effects or medications not achieving desired outcomes, and total number of medications. The panel also reached consensus on approaches to address these problems, including endorsement of strategies to discontinue medications with known benefit if necessary because of problems with feasibility or lack of alignment with patient goals.

Conclusions

The results of the Delphi process provide the basis for an algorithm to improve medication regimens among older persons with MCCs. The algorithm will require assessment not only of medications and diagnoses but also cognition and social support, and it will support discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do not align with goals.

Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process

Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term 'deprescribing' has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.

No medicine is sometimes the best medicine

A 76-year-old woman was admitted to hospital from the rheumatology outpatient clinic for investigation of fatigue, malaise, emotional lability, muscle weakness, productive cough and postural hypotension. She had been taking prednisone 60-40 mg daily for 6 weeks for suspected giant cell arteritis, along with six other regular medications, and had recently finished a course of antibiotics. During her admission she underwent many investigations (mostly negative) and treatments (largely harmful). When the diagnosis of adverse drug reaction was eventually reached, her medications were withdrawn and her symptoms gradually resolved. She was discharged home 1 month after admission, vowing never to return following her 'stormy course'. Adverse drug reactions are a common cause of avoidable hospital admissions in the elderly, estimated to cost billions every year. The single greatest risk factor for adverse drug reactions is the number of medications a person takes. Deprescribing to reduce potentially inappropriate medication is a possible way forward.

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study

PURPOSE

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.

METHODS

In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.

RESULTS

Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0% were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.

CONCLUSION

Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.

Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials

BACKGROUND

The use of benzodiazepines has been advised against in older people, but prevalence rates remain high.

AIMS

To review the evidence for interventions aimed at reducing benzodiazepine use in older people.

METHOD

We conducted a systematic review, assessment of risk of bias and meta-analyses of randomised controlled trials of benzodiazepine withdrawal and prescribing interventions.

RESULTS

Ten withdrawal and eight prescribing studies met the inclusion criteria. At post-intervention, significantly higher odds of not using benzodiazepines were found with supervised withdrawal with psychotherapy (odds ratio (OR) = 5.06, 95% CI 2.68-9.57, P<0.00001) and withdrawal with prescribing interventions (OR = 1.43, 95% CI 1.02-2.02, P = 0.04) in comparison with the control interventions treatment as usual (TAU), education placebo, withdrawal with or without drug placebo, or psychotherapy alone. Significantly higher odds of not using benzodiazepines were also found for multifaceted prescribing interventions (OR = 1.37, 95% CI 1.10-1.72, P = 0.006) in comparison with control interventions (TAU and prescribing placebo).

CONCLUSIONS

Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?

Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.

Proton pump inhibitor prescriptions and subsequent use in US veterans diagnosed with gastroesophageal reflux disease

BACKGROUND

Empiric proton pump inhibitor use is common for gastroesophageal reflux disease (GERD), but initial proton pump inhibitor (PPI) prescription patterns in Veterans are unknown.

OBJECTIVE

The study aims were to determine initial PPI prescriptions in Veterans diagnosed with GERD, and to characterize subsequent PPI use over the 2 years following initial prescription.

DESIGN

We conducted a retrospective study using Veteran's Administration (VA) administrative data and chart review.

STUDY POPULATION

Patients diagnosed with GERD and provided an initial PPI prescription at Hines VA Hospital from 2003 to 2007, with 2 year follow-up for each patient (through 2009). MEASURES AND OUTCOMES: Initial PPI prescriptions were categorized as standard total daily dose or high total daily dose, and accuracy was confirmed by manual chart review. Descriptive statistics were calculated and bivariate analyses were used to assess for differences in demographics, prescriptions, and subsequent use by initial PPI dosage category.

RESULTS

Of the 1,621 patients included in the study, 378 (23.3 %) had high total daily dose initial PPI prescriptions and 1,243 (76.7 %) patients had standard total daily dose initial prescriptions. The majority of patients (65.8 %) received a 90-day or greater initial prescription. Over the 2 years following the initial PPI prescription, 13.0 % of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7.1 % of patients with initial high daily dose PPI prescriptions had evidence of step-down therapy. A large majority of patients (83.8 %) had at least one refill over 2 years, and the overall medication possession ratio was 0.86.

CONCLUSIONS

Many Veterans receive high total daily dose PPI prescriptions as initial therapy for a GERD diagnosis, and few patients have evidence for cessation or reduction of therapy. These results provide detailed data on prescribing and use of PPIs to help guide efforts for optimal PPI use in US Veterans.

Deciding when to stop: towards evidence-based deprescribing of drugs in older populations

Minimising the harm from inappropriate prescribing in older populations is a major urgent concern for modern healthcare systems. In everyday encounters between prescribers and patients, opportunities should be taken to identify patients at high risk of harm from polypharmacy and reappraise their need for specific drugs. Attempts to reconcile life expectancy, comorbidity burden, care goals and patient preferences with the benefits and harms of medications should be made in every patient at significant risk. Drugs identified by this process of reconciliation as conferring little or no benefit and/or excessive risk of harm should be candidates for discontinuation. Evidence supporting a structured approach to drug discontinuation (or deprescribing) is emerging, and while many barriers to deprescribing exist in routine practice, various enabling strategies can help overcome them.

Benzodiazepines revisited--will we ever learn?

AIMS

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

METHODS

A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

RESULTS

Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.

CONCLUSIONS

The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.