“Stabilise-reduce, stabilise-reduce”: A survey of the common practices of deprescribing services and recommendations for future services

Abstract

Background Public Health England recently called for the establishment of services to help people to safely stop prescribed drugs associated with dependence and withdrawal, including benzodiazepines, z-drugs, antidepressants, gabapentinoids and opioids. NICE identified a lack of knowledge about the best model for such service delivery. Therefore, we performed a global survey of existing deprescribing services to identify common practices and inform service development. Methods We identified existing deprescribing services and interviewed key personnel in these services using an interview co-produced with researchers with lived experience of withdrawal. We summarised the common practices of the services and analysed the interviews using a rapid form of qualitative framework analysis. Results Thirteen deprescribing services were included (8 UK, 5 from other countries). The common practices in the services were: gradual tapering of medications often over more than a year, and reductions made in a broadly hyperbolic manner (smaller reductions as total dose became lower). Reductions were individualised so that withdrawal symptoms remained tolerable, with the patient leading this decision-making in most services. Support and reassurance were provided throughout the process, sometimes by means of telephone support lines. Psychosocial support for the management of underlying conditions (e.g. CBT, counselling) were provided by the service or through referral. Lived experience was often embedded in services through founders, hiring criteria, peer support and sources of information to guide tapering. Conclusion We found many common practices across existing deprescribing services around the world. We suggest that these ingredients are included in commissioning guidance of future services and suggest directions for further research to clarify best practice.

‘We need more support and doctors that understand the process of tapering …’: A content analysis of free‐text responses to a questionnaire on discontinuing long‐term benzodiazepine receptor agonist use

“…Respondents raised a wide range of issues from challenges with identifying appropriate tapering methods to the lack of dedicated tapering services. A recent global survey highlighted a paucity of existing deprescribing services for medications associated with dependence 25 . Respondents to the current questionnaire also highlighted more specific requirements for tapering plans such as weighing scales, tablet crushers and water‐soluble tablets for achieving small dosage reductions.…”

“…A recent global survey highlighted a paucity of existing deprescribing services for medications associated with dependence. 25 Respondents to the current questionnaire also highlighted more specific requirements for tapering plans such as weighing scales, tablet crushers and water‐soluble tablets for achieving small dosage reductions. The topic of appropriate taper rates and durations for psychotropic medication is receiving considerable attention.…”

An ethics analysis of antipsychotic dose reduction and discontinuation: Principles for supporting recovery from psychosis.

“…It is important to remember that the decision to reduce or cease antipsychotic medication does not need to be permanent, and a trial period could be encouraged when there is a lot of uncertainty about the risks and benefits (Beauchamp & Childress, 2019). Slow, gradual (hyperbolic) tapering with close monitoring and psychosocial support is the suggested best practice for minimizing risk of relapse, and practical recommendations have been provided to guide clinicians (Cooper et al, 2023; Horowitz, Jauhar, et al, 2021; Horowitz et al, 2022). Meanwhile, further research is needed on tapering outcomes other than symptomatic exacerbation and relapse, effective strategies and supports for tapering, and involvement of people from diverse backgrounds to ensure the evidence reflects the real world.…”

Gradually tapering off antipsychotics: lessons for practice from case studies and neurobiological principles

“…It is well established that gradual tapering of psychiatric medications, like benzodiazepines, produces a better outcome than more rapid tapering [ 20 ], and this principle is increasingly accepted for other classes of psychiatric drugs as well [ 21 , 22 , 23 ▪ , 24 ]. In parallel, there is recognition that the manner in which long-term antipsychotics are ceased may have some bearing on the rate of relapse [ 2 ▪ , 25 ▪▪ , 26 ▪ , 27 , 28 ].…”