First-of-its-kind GP deprescribing roadmap launches

Experts from across Australia have joined forces in a first-of-its-kind program that zeroes in on deprescribing and overprescribing, as reports of harm from long-term medication use continue.
 
In efforts to protect patients from adverse events associated with unnecessary or inappropriate medicines, the SUPPORT-Meds program will arm GPs and other healthcare providers with the tools to deprescribe those causing harm or that are no longer helpful.
 
Led by Monash University in collaboration with peak medical bodies, including the RACGP, the program will first focus on deprescribing medicines for sleep issues in older people: benzodiazepines and non-benzodiazepines or ‘Z-drugs’, and opioids for persistent, non-cancer pain.
 
It will then expand to include proton pump inhibitors, antipsychotics for changed behaviours in people living with dementia, NSAIDs, and gabapentinoids for pain relief.
 
The SUPPORT-Meds program also includes a network of ‘knowledge broker’ national visits, online education modules and resources to equip healthcare providers to have informed conversations with patients about when it is time to stop a medication.
 
Also in development is a ‘tapering calculator’ to generate a personalised, step-by-step tapering plan for long-acting opioids for persistent non-cancer pain and benzodiazepines and Z-drugs for insomnia in older people.
 
The team behind the program acknowledges that many of these medicines carry risks that outweigh the benefits, and the goal is to establish stronger safeguards for patients by giving primary care providers skills, communication strategies and resources to safely deprescribe certain medicines.
 
‘As GPs, we’re trained to prescribe, but knowing when and how to safely stop or reduce a medication is just as important,’ GP and member of the project’s Advisory Group, Professor Parker Magin said.
 
‘This program gives clinicians across Australia the confidence and the practical tools to have these conversations and start a deprescribing plan.’
 
Meanwhile, latest figures reveal that unintentional deaths involving opioids and benzodiazepines are rising across Australia, with many of these among people using long-term for prescribed conditions.
 
In older people, risks associated with polypharmacy come as almost 40% of Australians aged 75 and older use five or more prescription medicines.
 
It is a stark reality that Dr Hester Wilson, Chair of RACGP Specific Interests Addiction Medicine and harm-minimisation advocate, says makes for a challenging and lengthy process to safely wean patients off these medicines.
 
‘We have patients which many of us in general practice will know as legacy patients or inherited patients, who’ve been on high-risk medicines for years,’ she told newsGP.
 
‘And the usual thing is the person comes in and says, “Doc, just come to get my repeat script, not having any problems, all going well.”
 
‘These medications are terrific for short-term indications, but by using these medications long term, there’s increased risk of harms including overdose, dependence, falls, cognitive impairment.
 
‘So to ask, do we actually still need this? There’s a certain skill that takes ... because we know people can come to harm if they just stop, the withdrawal symptoms can be incredibly distressing.’
 
Dr Wilson highlights the importance of setting up conversations from the beginning so patients are aware of not only the medication’s benefits, but that it might change and there are risks of side effects.
 
‘That is something that we do all the time,’ she said. ‘And we also need to put caveats in that we don’t want to continue medications for longer than we need to.  
 
‘But some patients do get to a point where they just can’t cut down and have developed a dependence, and we need to diagnose and manage that in general practice.
 
‘We can talk with our patients around the benefits of treating the side effects or conditions that have evolved out of their medications as well.’
 
And while she supports the new program in arming GPs with more skills and confidence to have these conversations, she says a lack of Medicare funding for longer consults remains a barrier.
 
‘We need funding to allow us to have long conversations with patients and manage their complex care needs,’ she said.
 
‘Education doesn’t change behaviour – if there are other barriers in the way of doing this work, they will get in the way, even if there is education.’
 
The SUPPORT-Meds initiative comes as a suite of deprescribing guidelines have been recently developed, including the RACGP-endorsed Maudsley guidelines, clinical practice guidelines for deprescribing in older people, and for deprescribing opioids.
 
The college also released best practice guidance for deprescribing antidepressants, and Australia’s peak sleep health organisation recommends cognitive behavioural therapy for insomnia as a first-line treatment before benzodiazepines and Z-drugs.
 
With GPs central to regular medication reviews and initiating trusted, supportive conversations with patients, Dr Wilson supports the addition of SUPPORT-Meds to this suite of resources.
 
‘GPs are highly trusted by our patients, and we have these ongoing longitudinal relationships which are just an absolute privilege,’ she said.
 
‘This is important, as we can work with people over time to support them to gently make the change around deprescribing.
 
‘Say to them, “We’re doing this together, I’m here for the long haul, let’s get the support in place that we need to do this – we’ll see each other frequently and anybody else who is involved in your care”.
 
‘For the most part, it can be quite challenging to have those conversations, but it’s also one of the most rewarding things to see patients decrease their risk by cutting their dose down.’
 
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