Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review

Niznik, Joshua D.; Collins, Brendan J.; Armistead, Lori T.; Larson, Claire K.; Kelley, Casey J.; Hughes, Trevor; Sanders, Kimberly A.; McCall, Rebecca; Ferreri, Stefanie P.

doi:10.1016/j.sapharm.2021.07.012

Cited by 21 publications

(19 citation statements)

References 56 publications

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“…Systems-level barriers to deprescribing (e.g., lack of time and devolved responsibility) are difficult to overcome and may require organizational-level policy changes or the development of innovative practice models to facilitate deprescribing. A recent review highlighted opportunities for pharmacists to facilitate deprescribing of opioids and BZDs in older adults [ 25 ], which may alleviate the time-intensive processes of developing individualized tapering plans and identifying alternate therapies. The potential beneficial role of a pharmacist was mentioned briefly by prescribers in our focus group, but having a dedicated clinical pharmacist may not be financially sustainable for many practices.…”

Section: Discussionmentioning

confidence: 99%

Primary-Care Prescribers’ Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults

et al. 2022

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Purpose Opioids and benzodiazepines (BZDs) are frequently implicated as contributing to falls in older adults. Deprescribing of these medications continues to be challenging. This study evaluated primary-care prescribers’ confidence in and perceptions of deprescribing opioids and BZDs for older adults. Methods For this study, we conducted a quantitative analysis of survey data combined with an analysis of qualitative data from a focus group. A survey evaluating prescriber confidence in deprescribing opioids and BZDs was distributed to providers at 15 primary-care clinics in North Carolina between March-December 2020. Average confidence (scale 0–100) for deprescribing opioids, deprescribing BZDs, and deprescribing under impeding circumstances were reported. A virtual focus group was conducted in March 2020 to identify specific barriers and facilitators to deprescribing opioids and BZDs. Audio recordings and transcripts were analyzed using inductive coding. Results We evaluated 61 survey responses (69.3% response rate). Respondents were predominantly physicians (54.8%), but also included nurse practitioners (24.6%) and physician assistants (19.4%). Average overall confidence in deprescribing was comparable for opioids (64.5) and BZDs (65.9), but was lower for deprescribing under impeding circumstances (53.7). In the focus group, prescribers noted they met more resistance when deprescribing BZDs and that issues such as lack of time, availability of mental health resources, and patients seeing multiple prescribers were barriers to deprescribing. Conclusion Findings from quantitative and qualitative analyses identified that prescribers were moderately confident in their ability to deprescribe both opioids and BZDs in older adults, but less confident under potentially impeding circumstances. Future studies are needed to evaluate policies and interventions to overcome barriers to deprescribing opioids and BZDs in primary care. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-022-00967-6.

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Section: Discussionmentioning

confidence: 99%

Primary-Care Prescribers’ Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults

et al. 2022

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“…To date, there have been few large randomized studies of pharmacist interventions targeting deprescribing of both opioids and BZDs [ 17 ]. Prior studies have shown that pharmacist interventions are effective in reducing the use of high-risk medications, but few large studies have examined whether this leads to meaningful reductions in important outcomes such as falls.…”

Section: Discussionmentioning

confidence: 99%

“…Deprescribing is the supervised process of gradually reducing or discontinuing medications that may cause more harm than benefit [ 16 ]. Several studies have evaluated the effectiveness of targeted pharmacist-involved interventions to deprescribe BZDs in older adults, but few have addressed opioids in this population [ 17 ]. Interventions have included patient- or provider-targeted educational materials, electronic pharmacist communications, and pharmacist-led deprescribing services, all with varying degrees of success.…”

Section: Introductionmentioning

confidence: 99%

A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial

Niznik

Ferreri

Armistead

et al. 2022

Trials

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Background Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. Methods We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. Discussion This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. Trial registration Clinicaltrials.govNCT04272671. Registered on February 17, 2020

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“…Although research on the causal effect of sleep disorders on lung cancer incidence is still lacking, many lung cancer patients were also diagnosed with sleep disorders or pain in our study. Use of estazolam, a benzodiazepine, increases the risk of falls in older adults and co-prescribing of opioids exponentiates this risk ( Niznik et al, 2022 ). Meanwhile, long-term use of benzodiazepines will increase the risk of respiratory depression and overdose with administration of benzodiazepine in older patients with sleep disorders.…”

Section: Discussionmentioning

confidence: 99%

Increasing Trends of Polypharmacy and Potentially Inappropriate Medication Use in Older Lung Cancer Patients in China: A Repeated Cross-Sectional Study

Tian

Chen

et al. 2022

Front. Pharmacol.

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Objectives: Polypharmacy and potentially inappropriate medication (PIM) use are frequent in older lung cancer patients. This study aimed to examine the trends of polypharmacy and PIM use and explore risk factors for PIM use based on the 2019 Beers criteria in older Chinese lung cancer outpatients with multimorbidity.Methods: A repeated cross-sectional study was conducted using electronic medical data consisting of the prescriptions of older lung cancer outpatients in China from January 2016 to December 2018. Polypharmacy was defined as the use of five or more medications. The 2019 Beers criteria were used to evaluate the PIM use of older cancer outpatients (age ≥65 years), and multivariate logistic regression was used to identify the risk factors for PIM use.Results: A total of 3,286 older lung cancer outpatients and their prescriptions were included in the study. The prevalence of polypharmacy was 14.27% in 2016, 16.55% in 2017, and 18.04% in 2018. The prevalence of PIM use, according to the 2019 Beers criteria, was 31.94% in 2016, 35.78% in 2017, and 42.67% in 2018. The two most frequently used PIMs in older lung cancer outpatients were estazolam and tramadol. The logistic regression demonstrated that age 75 to 79, polypharmacy, irrational use of drugs, and lung cancer accompanied by sleep disorders, anxiety or depression, or pain were positively associated with PIM use in older lung cancer outpatients.Conclusion: The prevalence of polypharmacy and PIM use in older lung cancer outpatients with multimorbidity was high in China, and polypharmacy and PIM use increased over time. Further research on interventions rationing PIM use in the older lung cancer patient population is needed.

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Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review

Cited by 21 publications

References 56 publications

Primary-Care Prescribers’ Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults

Primary-Care Prescribers’ Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults

A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial

Increasing Trends of Polypharmacy and Potentially Inappropriate Medication Use in Older Lung Cancer Patients in China: A Repeated Cross-Sectional Study

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