De-prescribing: When, Why, & Getting Patient Buy-in

Learning Objectives

As a result of participating in this activity, learners will be able/better-able to: 

• Identify when to initiate de-prescribing, 
• Mitigate patient and clinical characteristics which are barriers to tapering.
• Improve patient buy-in to tapering programs.

Intro

Approximately 650,000 opioid prescriptions are dispensed daily in the United States. 2.5% of veterans under active care receive long-term opioid therapy. in 2015, 4.3Million Americans were taking opioids for chronic, non-cancer pain. Tapering unmasks brain adaptations within the mesolimbic system that were both created and suppressed by long-term opioid therapy.

Accreditation & Designation

Release date: This activity was released 8/19/2022.

Termination date: The content of this activity remains eligible for CME Credit until 8/18/2025, unless reviewed or amended prior to this date.

Claiming Credit: Watch the entire presentation and complete the Improvement Plan/Evaluation.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity includes discussions of unlabeled or investigational uses of commercial and/or developmental products.

California Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill
AB487 requires physicians licensed in California to complete a one-time CME activity for 12 hours of credits that addresses both pain management and the appropriate care and treatment of the terminally ill. This activity contributes to achievement of requirements with AB487.

Disclosure of Financial Relationships

Neither the presenter, reviewers nor any other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, any financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Additional Reading

• Davis, M. P., Digwood, G., Mehta, Z., & McPherson, M. L. (2020). Tapering opioids: a comprehensive qualitative review. Ann Palliat Med, 9(2), 586-610.
• Ballantyne, J. C., Sullivan, M. D., & Koob, G. F. (2019). Refractory dependence on opioid analgesics. Pain, 160(12), 2655-2660.
• Manhapra, A., Sullivan, M. D., Ballantyne, J. C., MacLean, R. R., & Becker, W. C. (2020). Complex persistent opioid dependence with long-term opioids: a gray area that needs definition, better understanding, treatment guidance, and policy changes. Journal of General Internal Medicine, 35(3), 964-971.
• Townsend, C. O., Kerkvliet, J. L., Bruce, B. K., Rome, J. D., Hooten, W. M., Luedtke, C. A., & Hodgson, J. E. (2008). A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission. Pain, 140(1), 177-189.
• Nelson, A. M., Battersby, A. S., Baghdoyan, H. A., & Lydic, R. (2009). Opioid-induced decreases in rat brain adenosine levels are reversed by inhibiting adenosine deaminase. The Journal of the American Society of Anesthesiologists, 111(6), 1327-1333.
• Cagle, J. G., McPherson, M. L., Frey, J. J., Sacco, P., Ware, O. D., Wiegand, D. L., & Guralnik, J. M. (2020). Estimates of medication diversion in hospice. JAMA, 323(6), 566-568.
• Pergolizzi Jr, J. V., Rosenblatt, M., Mariano, D. J., & Bisney, J. (2018). Tapering opioid therapy: clinical strategies. Pain Management, 8(6), 409-413.
• Berna, C., Kulich, R. J., & Rathmell, J. P. (2015, June). Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. In Mayo Clinic Proceedings (Vol. 90, No. 6, pp. 828-842). Elsevier.
• Kantor, E. D., Rehm, C. D., Haas, J. S., Chan, A. T., & Giovannucci, E. L. (2015). Trends in prescription drug use among adults in the United States from 1999-2012. JAMA, 314(17), 1818-1830.
• McPherson, A. L., & McPherson, M. L. (2019). Deprescribing: right-sizing medication regimens to optimize outcomes in palliative care. Current Geriatrics Reports, 8(1), 21-30.
• Sloane, P. D., & Zimmerman, S. (2018). Deprescribing in geriatric medicine: challenges and opportunities. Journal of the American Medical Directors Association, 19(11), 919-922.
• Cook, H. (2020). Deprescribing: A tool to optimize medications across the continuum of care. Caring for the ages, 21(8), 18.
• Jansen, J., Naganathan, V., Carter, S. M., McLachlan, A. J., Nickel, B., Irwig, L., ... & McCaffery, K. (2016). Too much medicine in older people? Deprescribing through shared decision making. BMJ, 353.
• Hilmer, S. N., Mager, D. E., Simonsick, E. M., Cao, Y., Ling, S. M., Windham, B. G., ... & Abernethy, D. R. (2007). A drug burden index to define the functional burden of medications in older people. Archives of Internal Medicine, 167(8), 781-787.
• Holmes, H. M. (2009). Rational prescribing for patients with a reduced life expectancy. Clinical Pharmacology & Therapeutics, 85(1), 103-107.
• Morin, L., Vetrano, D. L., Rizzuto, D., Calderón-Larrañaga, A., Fastbom, J., & Johnell, K. (2017). Choosing wisely? Measuring the burden of medications in older adults near the end of life: nationwide, longitudinal cohort study. The American Journal of Medicine, 130(8), 927-936.
• Van der Meer, H. G., Taxis, K., & Pont, L. G. (2018). Changes in prescribing symptomatic and preventive medications in the last year of life in older nursing home residents. Frontiers in Pharmacology, 8, 990.
• Arevalo, J. J., Geijteman, E. C., Huisman, B. A., Dees, M. K., Zuurmond, W. W., van Zuylen, L., ... & Perez, R. S. (2018). Medication use in the last days of life in hospital, hospice, and home settings in the Netherlands. Journal of Palliative Medicine, 21(2), 149-155.
• Woodward, M. C. (2003). Deprescribing: achieving better health outcomes for older people through reducing medications. Journal of Pharmacy Practice and Research, 33(4), 323-328.
• Tegegn, H. G., Tefera, Y. G., Erku, D. A., Haile, K. T., Abebe, T. B., Chekol, F., ... & Ayele, A. A. (2018). Older patients’ perception of deprescribing in resource-limited settings: a cross-sectional study in an Ethiopia university hospital. BMJ Open, 8(4), e020590.
• Sirois, C., Ouellet, N., & Reeve, E. (2017). Community-dwelling older people's attitudes towards deprescribing in Canada. Research in Social and Administrative Pharmacy, 13(4), 864-870.
• Kalogianis, M. J., Wimmer, B. C., Turner, J. P., Tan, E. C., Emery, T., Robson, L., ... & Bell, J. S. (2016). Are residents of aged care facilities willing to have their medications deprescribed?. Research in Social and Administrative Pharmacy, 12(5), 784-788.
• McPherson, A. L., & McPherson, M. L. (2019). Deprescribing: right-sizing medication regimens to optimize outcomes in palliative care. Current Geriatrics Reports, 8(1), 21-30.