"It is a lot easier to prescribe than to deprescribe, particularly when patients are coming to you with complaints of symptoms."
Clinical Psychiatrist, VA
Clinicians often struggle to strike a balance between prescribing multiple medications to address various medical problems and the risks that use of multiple medications may create, especially for older Veterans. Deprescribing is a comprehensive process of drug review, decreasing dose, or discontinuation that aims to reduce medication risk in the context of patients' co-morbidities, functional status, preferences, goals, and life expectancy. Deprescribing requires trust, communication, coordination, and patience. The following story, based on in-depth interviews of a Veteran, clinician and pharmacist describes the process of tapering off of a benzodiazepine from multiple perspectives.
Mr. Holland, 68
(1967 – 1975)
Dr. Hansen, 52
Psychiatrist, General Mental Health
VA Medical Center
Dr. Wilkins, 34
Clinical Pharmacist, Mental Health Team
VA Medical Center
MOTIVATIONS FOR DEPRESCRIBING
"My goal is to take a medication for sleep and anxiety that does not make me feel super groggy in the morning…Is there something bigger, badder, and better than this clonazepam?"
Mr. Holland has been on clonazepam for over twenty years, but his main concern is having trouble with sleep. Currently, Mr. Holland takes 12 medications daily. A lengthy medication list and multiple comorbidities are not uncommon among Veterans. That is why the deprescribing process can be complex and often require a team approach. For psychiatrists like Dr. Hansen, the motivations for using a particular treatment approach can be different from those of the patient.
"I think the memory impairment was probably at the forefront… in general with elderly patients, there's increased risk of dementia, falls and fractures with any benzo. There's increased risk of impaired driving. They're not processing their meds as well as they were when they were younger… It doesn't matter if you're a veteran or not, if you're an elderly person, and you keep taking the same dose of benzodiazepines, eventually, you're going to have serious trouble with it…"
Clinical Psychiatrist, VA
CONSIDERING TREATMENT OPTIONS
Veterans like Mr. Holland who take benzodiazepines such as clonazepam may experience withdrawal when missing doses or when trying to reduce the dose. Withdrawal effects can seem very much like anxiety – the symptom that clonazepam is supposed to treat. Patients often fear that their symptoms may return if benzodiazepines are reduced or discontinued.
In Mr. Holland's situation, Dr. Hansen must take into account multiple factors including the age of his patient, the patient's preferences, and the possibility of withdrawal symptoms that might arise as the patient tapers off the benzodiazepine.
"I usually like to do one thing at a time pharmacologically… Just pulling away something while adding something else creates and just adds to the mess in a way."
Decision-making between doctor and patient should include clear messages about possible reactions to tapering the medication, agreement on the frequency of check-ins and desired outcome, and an emphasis on the importance of patience and trust while walking through the deprescribing process.
"I will do it in a very caring way, when I can tell someone's really attached to it… I've learned you can figure out how attached somebody is to their benzodiazepine. And if they're super attached to it, 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…"
MAKING DECISIONS TOGETHER
Doctors and pharmacists are aware that each patient will require a unique deprescribing plan. Communication is key. By including the patient in the process, the deprescribing process is more likely to reach a satisfactory outcome. Sometimes patients and clinicians don't agree on the optimal outcome, but working together, an acceptable compromise may be achieved. Some patients may prefer to stay on the same medication, but at a lower dose, which may be acceptable to the clinician.
"You 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 as a team to help our Veteran'."
"Dr. Hansen would ask questions and he would throw out suggestions and just work with me…I felt like I was part of the team, you know…I'm feeling very good. I had a different experience with another doctor that would say, 'This is what I'm going to do.' Period. And I would say, 'Well, why are you going to do that?' She would not answer my questions. I told her, 'You're upsetting me for the simple fact that you you're not answering questions.' And so, I told her, 'I would like to be assigned another doctor.'"
Sometimes it is challenging for a clinician and patient to reach full agreement on a treatment approach or outcome. Bringing in another team member, such as a pharmacist, can help. Though pharmacists cannot prescribe some scheduled drugs like clonazepam, their knowledge of medications and their effects on the body is extensive.
"[His] main complaint was actually his insomnia, not his anxiety. And so even through multiple attempts to try to convince him to stick with the taper, offering a lot of support on medications for insomnia [he asked to go back on clonazepam]."
Clinical Pharmacist, VA
"The withdrawals were simply… I would fall asleep but then, I would soon wake up two or three hours later and then, I would stay awake for like half of the night."
"After a lot of attempts to add supportive meds, or adjustive meds in lieu of the extra benzo, Dr. Hansen ended up kind of relenting and giving him back the clonazepam."
"He kept begging to go back on clonazepam. We finally threw up our hands and switched him back over. That is kind of where we are at now. I think [this is where] he is going to wind up."
"I can sleep now. Sleep is important, especially if you have anxiety. Because if you don't sleep, things go around in your head all night long."
A successful deprescribing process often requires sustained follow up. Each member of the triad plays their part so that the Veteran does not feel alone in the process. Although Mr. Holland resumed taking clonazepam, in the end, the dose was reduced; further attempts at reducing the dose are anticipated.
"…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. I mean, honestly, some people are just literally terrified. They believe this is the drug that has helped them more than anything in their whole life… so I will reassure people like that, at the outset, look, no worry, no hurry, I'm going to keep giving you the information that you need. And we're going to work together on this."
"The only thing that was challenging was having to come up here to see the two doctors every week, two weeks. But that's normal, there's nothing you can do about it. So, it is what it is, you know?"
"The end result is we've got medications down that seem to work fairly well. We may need to make a small change later on but for now, they're working pretty good, yeah."