Deprescribing is the process of reducing or stopping medications that are no longer necessary or may cause harm. This is especially important for dependency-forming medications (DFMs), which include opioids, benzodiazepines, z-drugs (zopiclone and zolpidem) and gabapentinoids (gabapentin and pregabalin).

Typically, these medications are prescribed to treat chronic pain, anxiety and mood disorders; conditions that have significant emotional component. Removing or reducing these medications can induce anxiety in patients, which can increase the potential for stress and make it harder for the clinician to initiate the deprescribing conversation.

Because patients might be unaware of the potential risks associated with DFMs, it's often better to manage patients' expectations with informed consent before prescribing, rather than having the difficult conversation after the event.

The National Institute for Health and Care Excellence (NICE) published guidelines in April 2022 (215 REF) that outline some useful strategies when deprescribing DFMs. This article will explore these and other frameworks that prescribers can use to work with patients, using shared decision making and working within integrated care systems (ICSs) to ensure that patients receive consistent information about prescribing limits for DFMs.

More on this topic:

• The MDU's Dr Ellie Mein looks at avoiding medico-legal risks of opioid prescribing in this article for GP Online
• Watch the recording of our free our webinar on opioids and the coroner, with Dr Alia Darweish Medniuk

Part 1: approaching deprescribing

When to deprescribe

Regular medication reviews can identify patients who might be at risk of dependence or other adverse effects of DFMs, particularly those with comorbidities. They allow the prescriber and the patient to monitor effects of the DFM, and to maintain a dialogue about continuing the prescription.

Withdrawing a DFM is indicated if it no longer offers the patient benefit, the clinical indication for it has resolved, tolerance and dependence have developed, the harms outweigh the benefits or the patient wants to stop taking it.

GMC guidance

The General Medical Council (GMC) guidance, Good practice in prescribing and managing medicines and devices, notes that doctors have the right to decline to prescribe medication if they do not believe it is safe, clinically indicated, or in the patient's best interests. Conflict when deprescribing can therefore arise where a patient is insistent on continuing a medication despite the prescriber's/doctor's concerns about safety or clinical appropriateness.

Where a clinician is hesitant to prescribe a medication, open and honest communication with the patient and discussing alternative treatments is the first approach. Nonetheless, this has the potential for the professional relationship to break down, leading the patient to "doctor shopping" to find another prescriber, who will write a prescription for the medication.

This can be anticipated and mitigated through collaboration and agreement between practices with the system wide approach, offering prescribers support and clear, consistent communication with all patients within a given population.

Part 2:  practical deprescribing

Deprescribing opioids

It is well documented that long-term use of opioids can lead to dependence, tolerance and other serious side effects, including constipation, hormonal, immune and significantly, respiratory depression. In recent years, concerns of opioid misuse and overdose have led to a need for increased awareness and stewardship of these medications.

The British Pain Society recommends a maximum daily dose of 120 mg of morphine equivalent dose (MED) for opioids in non-cancer pain, which is a useful reference point for safer target doses when deprescribing opioids.

Depending on the duration of treatments, weaning the total dose should be done gradually, often over several months, with the patient monitored regularly for any withdrawal symptoms or signs of pain exacerbation.

NICE recommends a gradual reduction of the (morphine equivalent) daily dose by 5-20% every four weeks; in practical terms it may be more achievable to target an MED below 120 mg, encouraging patient engagement, before consideration weaning completely to cessation.

A 5% percent reduction every four weeks may be more realistic for patients who have been prescribed opioids for many years. A gradual reduction sustained over months is more likely to be successful than rapid tapering, which can trigger increasing doses due to increased pain perception or subjective feelings of withdrawal (objective withdrawal can be measured against the Clinical Opioid Withdrawal Scale).

• Useful resources for deprescribing opioids include Opioids Aware and Oxford GP Resources

Deprescribing gabapentinoids

Gabapentinoids (gabapentin and pregabalin) are commonly prescribed for long term and neuropathic pain, but can also cause dependence through the promotion of feelings of well-being and euphoria, with dose escalation through tolerance. When combined with opioids, gabapentinoids can lead to increased central nervous system depression and respiratory depression. (REF/REF)

To minimise withdrawal, NICE {125} guidelines recommend a slow taper of gabapentinoids by 10% of the total daily dose every 1-2 weeks. In practice, it may be more useful to develop a fixed dose reduction plan, 50 – 100 mg per week dose reduction for pregabalin, and 300 mg per week for gabapentin.

Deprescribing benzodiazepines and z-drugs

Benzodiazepines and so-called z-drugs (zopiclone and zolpidem) are commonly prescribed for anxiety and sleep disorders, but can also cause dependence and tolerance that can lead to rapid dose escalation. Abrupt cessation of benzodiazepines can lead to withdrawal symptoms, with potential for rebound anxiety or insomnia and disengagement from dose reduction plans.

When considering safe therapeutic target doses for initial weaning discussions with patients, it can help to convert all prescribed benzodiazepine doses to a "diazepam equivalent dose", aiming for initial dose reduction plan to 30 mg diazepam equivalent, as reflected in guidance from NICE and other specialist national guidelines. (REF/REF)

Diazepam equivalence can be calculated using online resources including the BNF, the Specialist Pharmacy Service and The Ashton Manual Online. It's important to apply caution when using these tables due to inter-patient variability, differing half-lives and sedative properties between drugs and then titrating any prescribed doses against patient responses.

NICE guidelines recommend a slow taper of benzodiazepines by 5-10% of the total daily dose every 1-4 weeks. Practically, it may be useful to cover all prescribed benzodiazepines to the longer-acting diazepam in the first instance, to mitigate symptoms of withdrawal from any prescribed shorter acting drugs, and to facilitate a simpler weaning plan.

Published deprescribing schedules are published by NICE and The Ashton Manual Online. Non-medication-based interventions, such as psychological therapies and sleep hygiene, may need to be considered as supplementary support measures as part of the deprescribing programme.

Concluding remarks

Whilst deprescribing dependency forming medication is challenging, stopping these medications can be openly approached with the same care for the risk and benefits as the decision to prescribe them, supported by scheduled medication reviews.

While doctors have a responsibility to prescribe medications that are safe and in the patient's best interest, they must also consider the potential for conflict when discontinuing a medication that a patient may have become dependent on. Non-medication support may also be required to sustain the weaning plan, including psychological support and physiotherapy.

Further reading:

Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care.

The views expressed in this article are those of the author and do not necessarily reflect those of the MDU.