Tapering Plan Led by Pharmacists Shows No Benefit for Seniors
/By Crystal Lindell
If pharmacists helped taper elderly patients off opioids and benzodiazepines, would that reduce their risk of falling?
Turns out, the answer is no. Having pharmacists get involved in a senior’s treatment plan doesn’t significantly reduce fall risk or prescriptions for the medications, according to research recently published in JAMA..
Falling is a significant risk factor for seniors, because their bones fracture more easily and it takes longer for them to recover. Medications that impair balance – such as opioids and anti-anxiety drugs – raise the risk of falling, especially in seniors who take them concurrently.
Researchers at the University of North Carolina School of Medicine recruited 15 primary care clinics to participate in the study. Nearly 2,100 patients at the clinics met the study criteria, which was being over the age of 65 and having a long-term prescription for opioids and/or benzodiazepines.
Over 95% of the patients on opioids had chronic pain and about a third of them had a fall in the past year..
Pharmacists for about half the patients were encouraged to “deprescribe” them, when appropriate, by recommending a voluntary taper plan to their doctors The other patients received usual care from their doctors, without any tapering recommendations, and served as a control group.
A year later, doctors followed the pharmacists’ advice by tapering 21.4% of patients off of opioids. But that was only slightly more than the control group, which saw opioids discontinued for 19.9% of patients. The tapering rates for benzodiazepines were similar and “not statistically significant."
Notably, there was little difference in falls between the two groups, which were essentially “unchanged” by the tapering.
In other words, having a pharmacist make tapering recommendations to doctors had very little, if any, impact. Tapering occurred in both groups, whether a pharmacist was involved or not.
“Although reductions occurred in both groups, the intervention did not significantly reduce prescribing or falls at 1 year. Still, pharmacist recommendations were feasible to implement and accepted more often than rejected, indicating general practitioner receptiveness,” researchers concluded. “These results suggest that a consultant pharmacist–led intervention is feasible to implement in primary care clinics.”
Note the word, "feasible" rather than "effective." Sure, it can be done, but that doesn't mean it should be done.
I would guess that the program did not reduce prescriptions for opioids and benzodiazepines anymore than the control group because prescribing had already been reduced. At the start of the study, the average daily dose of opioids was 23.6 morphine milligram equivalents (MME), which is a low to moderate dose.
Given how much these medications are already being restricted, few patients are getting opioids or benzos if they don’t desperately need them – not even seniors.
Beyond that, I think it’s really important to take a step back when looking at research like this and consider the patient’s perspective.
How were the tapering plans presented to patients? Were they asked to weigh the pros and cons? Did they have a voice in their treatment?
I suspect if they were given the option of staying on a medication or reducing their fall risk, many seniors would choose to stay on the medication.
Unfortunately, the study authors seem to take the wrong lesson from the research, at least in my opinion. Although their study failed to prove much of anything, they concluded there should be “more intensive or sustained deprescribing strategies.”
There are a lot of studies looking at ways to reduce opioid prescriptions — I suspect because those are the easiest to fund — and I’m honestly glad this one failed.
The biggest problem many seniors face today is that they cannot get access to effective pain and anxiety treatment. If anything, researchers should be working to address that problem, rather than making it worse.
Instead of working on blanket reductions for these types of medications, I wish they would look at finding alternatives that actually work.
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