FEBRUARY 2020 - "It is an art of no little importance to administer medicines properly, but it is an art of much greater and more difficult acquisition to know when to suspend or altogether omit them.” This quote by 18th century family physician Philippe Pinel is often cited by Dr. Barbara Farrell (in fact it’s part of her email signature), and more than 200 years later it remains a clarion call for action. In response, Farrell and her team at the Bruyère Research Institute in Ottawa, and supported by funding from CFP’s Innovation Fund, have been hard at work building frameworks for deprescribing in Canada.
“The whole idea of deprescribing comes from my clinical work in a geriatric day hospital where I see many patients taking many medications, sometimes around 25 or 30. We find that if we can reduce doses and stop the medications that we can often help clear confusion and reduce risk for falls and other negative health impacts,” says Farrell.
|Dr. Barb Farrell
Farrell received $50,000 from CFP’s Innovation Fund in 2016, for her project entitled, “Mobilizing Community Pharmacists as Catalysts for Deprescribing.” Farrell and her team worked with four community pharmacies in Ontario as well as a national advisory group to build and assess community pharmacists’ capacity to integrate deprescribing into their daily practices through training and workflow strategies.
"Pharmacists care about their patients but are sometimes paralyzed by a lack of information about the original reason for the medication; that can make it hard to suggest stopping a medication,” notes Farrell. “We found that community pharmacies can implement workflows that incorporate deprescribing initiatives. That makes me hopeful that in the future, pharmacies can be places where patients have support for deprescribing when their medications are causing more harm than benefit.”
The participating pharmacies tested and adapted different approaches. For example, one concentrated their efforts on patients in retirement homes, one focused on in-store and external advertising, another on staff training, and another on sourcing patients through the pharmacy’s database. For the initial and detailed interactions, one pharmacy offered a free 15-minute initial consult, followed by a more detailed, lengthy paid consultation (by appointment) if the patient wished to proceed with deprescribing. By the end of the study, every pharmacy achieved some level of deprescribing success. The workflow process could be broken down into four main steps: capacity building, preliminary interactions with patients, in-depth medication reviews and follow-up monitoring.
“Each of these four community pharmacies were able to use the deprescribing guidelines in some way. They all used them a little bit differently in terms of which medications they focused on or how they approached it,” says Farrell.
The study's findings were recently published in the Canadian Pharmacists Journal. The article summarizes the barriers and facilitators to deprescribing in community practice. Barriers included competing workload demands, lack of response from prescribers and inadequate compensation; facilitators were onsite education (including training of all staff), increased patient awareness and standard templates. Pharmacy students can also be brought in to share the workload.
The article also includes six tips for the implementation of deprescribing in community practice.
At least two other Canadian deprescribing programs have drawn from the experiences of this project, says Farrell: early in 2019 Newfoundland and Labrador launched SaferMedsNL, and in May 2019 Green Shield Canada launched the Pharmacist Health Coaching – Deprescribing program.
For more on deprescribing
The Bruyère Research Institute has developed deprescribing guidelines and algorithms for five drug classes: proton pump inhibitors, antihyperglycemics, antipsychotics, benzodiazepines receptor agonists and cholinesterase inhibitors and memantine.
To download the guidelines and algorithms, as well as a supporting app, go to www.deprescribing.org.