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Health Services Research & Development

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Advice from Veterans and Clinicians:
In this section we illustrate the themes that were identified from our analysis of semi-structured interviews with Veterans and clinicians (physicians, pharmacists, and nurses) about their first-hand experiences with deprescribing. The following strategies were described by the participants as being critical to successful deprescribing efforts.

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Click on the themes below to see supporting quotes from the Veteran and the treatment team:

"Once I establish a good relationship with the patient and they trust me and I work with them, then I think I succeed more. The first time you meet them, you lose them if you say something like, 'Stop driving,' 'Stop opioids,' 'Stop alcohol' or 'Do this.' They will never come back." – Clinician

"I fight every time they change residents to make sure that I have the same supervisor [attending physician]. I trust the supervisor, and you know if it is something that she says I need to do, I pretty much go with it." – Veteran

"I will do it in a very caring way, when I can tell someone's really attached to [a benzodiazepine], I put on the brakes; reassure them, 'We don't have to make any changes today. But we'll talk about it more next time…' And when we get to the next time, it'll be 'okay, I know this is going to be a little scary for you. But I have some ways of doing this…and let me remind you again about all the reasons why you should be ready to give this a shot.' So I'm always reinforcing that this is for their own health and wellbeing not for me." – Clinician

"I came to see him [physician] and I was pretty upset — my back hurt a lot, and I kind of broke down. He said 'Look, there are some new studies out about this–these combinations. If you take this and this together they affect you mentally, the way you feel about your pain, and how you deal with it.' …When he was telling me I was going 'Oh yeah, that's me.' … So, it was kind of like 'yeah, that is what I need,' and he explained it and that was good." – Veteran

"You've [patient] got to ask questions. The provider needs to…make sure that you understand what is going on here." – Veteran

"Maybe…provide a handout because sometimes it's easier to see it in the black and white, the pros and cons kind of thing. It's like, 'Okay, now, I understand,' because you can look back to it and go, 'Okay, maybe the doctor is right, maybe I'm too emotional about this decision versus thinking more logically about my health and my long-term goals.' Sometimes, seeing things written down is much easier and they can take it with them and think about it." – Veteran

"I think for some patients there is a real attachment to their medications. And that might be for a variety of reasons. It could be that they tried a bunch of things that didn't work, and then they found what did work. So they really don't want any changes made to it. Or just by being on the same medication for many years, kind of like, if it's not broke, don't fix it. I think it can also be part of a person's identity, like 'I have chronic pain. These are my medications.'" – Clinician

"I would be yelling and screaming if [the deprescribing] had something to do with my sleep or nightmares because it wouldn't take long before I would be climbing the walls. I don't drink anymore. I have been clean and sober for almost nine years now. So, I am kind of comfortable [taking this medication]." – Veteran

"Get to know your patient and understand their relationship to the drug as best you possibly can." – Clinician

"It's easy to [look at recommendations and guidelines] on paper for a specific disease process, but then when you put it in terms of a person, it can be really hard to sort out what's going to work and not work for this person. And where am I going to let go of the guideline and…bring in the patient's preferences and goals. [My patient described] feeling like his care team wasn't looking at him as a person, [but focusing] instead on his medication list. That was the main takeaway for me, that sense that he didn't feel like his care was being individualized." – Clinician

"I'm having a pretty good time in life without the statins. I was in such pain; I would trade whatever ill effects the lack of statins might be doing with the increased joy I now have in my life." – Veteran

"So maybe the rationale for the taper at the beginning seemed to be a concern for him. Other than the insomnia, he kept bringing up quality of life. Like, 'I'm old. As far as I'm concerned, I don't mind the risks. I just want my clonazepam back so I can sleep. I'm not that concerned about the long-term risks. I want my quality of life.' And that argument, you hear that, especially with the geriatric patients. They're like, well, I don't have a lot of life left to live. So why are you taking away something from me that makes me feel good?'" – Clinician

"Sleep is important, especially if you have anxiety. Because if you don't sleep, things go around in your head all night long." – Veteran

"I came to see him [physician] and I was pretty upset — my back hurt a lot, and I kind of broke down. He said 'Look, there are some new studies out about this–these combinations. If you take this and this together they affect you mentally, the way you feel about your pain, and how you deal with it.' …When he was telling me I was going 'Oh yeah, that's me.' … So, it was kind of like 'yeah, that is what I need,' and he explained it and that was good." – Veteran

"You've [patient] got to ask questions. The provider needs to…make sure that you understand what is going on here." – Veteran

"Maybe…provide a handout because sometimes it's easier to see it in the black and white, the pros and cons kind of thing. It's like, 'Okay, now, I understand,' because you can look back to it and go, 'Okay, maybe the doctor is right, maybe I'm too emotional about this decision versus thinking more logically about my health and my long-term goals.' Sometimes, seeing things written down is much easier and they can take it with them and think about it." – Veteran

"You always need to understand that you are working for them and with them. You are not here to take away the medical decision from them. I always tell the candidate, 'You are part of the team. You are one of us and we are going to work together…'" – Clinician

"Well, the doctor would ask questions and he would throw out suggestions and just work with me. Not, 'This is the way it's going to be, period, and that's all you need to know.' I [controlled] part of it, of deciding what I wanted to do for my own health." – Veteran

"I don't [deprescribe] several medications at the same time. I let the patient pick, 'Which is the one that you think is not helping you? Let's start with the one that you don't think is helpful or making you feel comfortable.'" – Clinician

"My husband [also a Veteran] just asked his physician, 'Why do I need to be on this medication because I don't have a problem with my blood pressure?' And the doctor was like, 'Well, we put you on it because of the fact that you had a stroke.' So, they went through all the benefits of being on it versus going off of it, and the doctor was great, she said, 'Well, let's take you off of it, but we're going to monitor it. I want you to take your blood pressure three times a day, and I want you to get back to me after a week.'" – Veteran

"I will try to tailor my approach to what I think is most likely to succeed, and I will go extremely slowly when I pick up on somebody being really hesitant and scared. They believe this is the drug that has helped them more than anything in their whole life. So I will reassure people like, 'Look, no worry, I'm going to keep giving you the information that you need. And we're going to work together on this.' In other cases, I will have the discussion with someone who I feel like is not crazy-scared of what's going to happen if they take less. And I'll set up a more rapid, tapering schedule, and have them come back and see me in like six weeks. And when they come back, they're off." – Clinician

"There's one gentleman who was on a couple of antidepressants for years. And I started [tapering] and felt like he was really on board with it and wanted to go, and we went at his speed. And then somewhere in there, he told me that he was really pretty angry with me because from his perspective, I had taken him off the medicine too fast. And it was a little shocking for me to hear that. I was like, every step of the way trying to make sure it was okay, and it seemed like it was." – Clinician

"When I said that the ultimate goal is usually to get them down to as needed only, the even more penultimate goal is to get them where they have their little bottle with eight pills in it, but they never need to take one. They know it's there and just knowing that the bottle is there, calms them and reassures them." – Clinician

"I asked Doctor if we could go back to part benzos and part other medications. So, that's what we did. Now…I sleep a whole lot better. And I'm not taking as much as I used to." – Veteran

"I don't take away medicine without offering them an alternative." – Clinician