Regular MedShadow readers are likely familiar with the idea of deprescribing—the process of reducing the number or dose of drugs a person is taking. MedShadow has written about the phenomenon before. But, while the idea of taking fewer medications is simple, the process of deprescribing while balancing risks versus benefits is complicated. Some medications have withdrawal symptoms, and tapering may take time.
The Therapeutics Initiative at the University of British Columbia is hosting a series of webinars with healthcare professionals sharing real-life stories of their own patients whose medications they were able to reduce, and what happened when they did. To bring deprescribing to life, here is the first patient story the team shared.
A Little About ‘Patient X’
The first BC Provincial Deprescribing Series webinar took place on Feb. 8, 2023 and Jill Norris, MD, a family care practitioner in Victoria, BC, and Alison Gregson, MD, a psychiatrist at Royal Jubilee Hospital in Victoria, BC, told the story of their patient, a woman in her 50s with a history of Post-Traumatic Stress Disorder (PTSD), worsened by a difficult childhood and experiences of racism. She was also in remission from an alcohol use disorder and had survived a suicide attempt. Norris is the woman’s primary care physician. The woman also had a psychiatrist doctor who managed her psychiatric treatment. One day, she came to Norris for her refills, because her psychiatrist was no longer able to manage her care (for whatever reason).
The woman had been prescribed quetiapine (an antipsychotic sometimes used to treat anxiety), zopiclone (a sleeping pill), clonazepam (an antiepileptic sometimes used to treat panic disorders), gabapentin (antiepileptic sometimes used to treat anxiety), citalopram (an antidepressant), bupropion XL (an antidepressant), pantoprazole (a proton pump inhibitor that treats acid reflux) and a statin (for high cholesterol). Norris was immediately concerned, by both the number of drugs she was taking, but also by what she described as particularly high doses of them.
Norris says, “I’m a family doctor. And I’m thinking that these medications were prescribed by her specialist for a reason.”
Still, the more Norris spoke with her patient, the more she realized the medications didn’t seem to be improving her life. She seemed sedated. She had tremors. When she stood up, her blood pressure dropped so dramatically that she sometimes fell. Her cholesterol was high and she had risk factors for a serious arrhythmia (a heart rhythm disorder). Perhaps most importantly, she still had depressive symptoms. She spent most of her time home alone in bed.
The Start of Deprescribing and A New Opportunity
Both Norris and her patient were worried about decreasing her medications.
“She’s really concerned that if I decrease her doses that she is going to go to that dark place,” referring to the time she tried to end her own life, says Norris. Of course, that is a major risk when reducing antidepressant medications.
After thoroughly discussing it with the patient, Norris started lowering the doses of some of her medications very slowly.
“I imagined the deprescribing journey with her to end up taking many months and years,” says Norris. “But an opportunity came up.”
The woman had been admitted to the hospital for an elective cardiac surgery, unrelated to her mental health. While she was recovering from her surgery in the intensive care unit (ICU), the woman was sedated, disoriented, and hallucinating. Her symptoms made it difficult for other healthcare professionals to provide post-operative care. Norris reached out to the psychiatrist at the hospital, Gregson, for help with deprescribing. Together, they made drastic cuts to her doses.
The next day, Gregson says the woman’s mental state had cleared. She was attentive, and there were no signs of benzodiazepine withdrawal or an immediate relapse of PTSD symptoms. The team would still need to monitor these signs over time. She left the hospital eight days later, taking far fewer medications.
The Lessons Norris and Her Patient Learned with Fewer Drugs
“We spent some time talking about discharge, and she expressed anxiety about ‘well what happens if I get worse when I go home? What if I can’t sleep?’ And we reviewed how to manage these things that didn’t include unnecessarily re-prescribing or increasing medication doses,” says Norris.
And some of those things did happen. A few weeks after she went home, she did experience insomnia again. She thought she might need to start taking zopiclone again. But, Norris took a look at the list of medications she was still being prescribed and realized that insomnia can be a side effect of bupropion, so they decided to lower the dose of that drug further. Norris also recommended melatonin, a supplement that helps some people sleep better. And the woman said, following these changes, she was sleeping much better.
“In those first few weeks, I was really quite astounded by the differences I saw in her. She was making jokes,” says Norris. “It was the most future-oriented and engaged with life that I’d ever seen her.”
When she spent time with family, she connected with them in a way she hadn’t for years.
“We both came to the recognition that the most important intervention at this point was human connection,” says Norris.
But the process hasn’t been without challenges. In the past few months, the woman’s mood did start to decline again, and the two have had to discuss whether it made sense to increase her doses slightly. She values the connections she’s making with friends and family that she wasn’t really able to feel before, and she doesn’t want to be sedated.
Still, she wants to make sure depression and anxiety don’t take her to dark places. The most important thing healthcare providers should know, the woman told Norris, is that “it’s important to know who you’re dealing with: what’s important to them, and what their goals are.”
Check out the other articles in this series:
Cutting Down on Medications for Time with the Great Grandkids
Deprescribing to Be a Better Dad
To learn more about deprescribing, check out our articles:
Too Many Prescriptions? How to Talk to Your Doctor About It
Can I Cut Down the Number of Drugs I Take?
