New recommendations for deprescribing and tapering antidepressants, benzodiazepines, z-drugs, gabapentinoids, and opioids have been made based on input from service users and a global survey.
These recommendations were recently published in the scientific journal PLOS ONE by a team of authors from the United Kingdom, including Ruth E. Cooper, Michael Ashman, Jo Lomani, Joanna Moncrieff, Anne Guy, James Davies, Nicola Morant, and Mark Horowitz.
The authors not only documented the current state of deprescribing and tapering but also aimed to identify factors that contribute to successful outcomes for service users who go through the deprescribing and tapering process.
“In the UK, a recent Public Health England (PHE) Report identified the scale of the prescribing of drugs that can cause dependence and withdrawal as a significant public health issue. It found that one in four adults in England were prescribed at least one prescription of a benzodiazepine, z-drug, gabapentinoid, opioid or antidepressant in 2017–2018,” the authors write.
“In the USA, it is estimated that 10.4% of people are using benzodiazepines, and benzodiazepine-related deaths have risen, which has generated concern. The US Food and Drug Administration (FDA) updated a boxed warning for benzodiazepine medications to add information about the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions…In Norway, due to dissatisfaction with aspects of mental healthcare, including high rates of prescribing of psychiatric medication, service user groups successfully campaigned for the introduction (from 2015) of medication-free mental health services into national policy.”
As websites like SurvivingAntidepressants.org grow in popularity, the need for shared-decision making in the prescribing and deprescribing process between patients and their practitioners grows, too. However, barriers on the prescribers’ end can create friction that may leave service users feeling disempowered and unheard. Thus, the UK-based authors crafted a research question designed to document the current state of deprescribing practices and to draft recommendations to improve them:
“In deprescribing services, what are the common practices to support patients to withdraw from prescribed medicines of dependence?”
To answer this question, the study’s authors surveyed 13 deprescribing services across various countries, including 8 in the UK, 1 in the USA, 1 in Norway, 1 in Italy, 1 in Sweden, and 1 in Denmark. Each of the included deprescribing services had to meet the following criteria: 1) the service was specifically designed to support patients withdrawing from prescribed psychotropic medications, and 2) at least one staff member could conduct interviews in English.
A researcher with lived experience conducted structured interviews, and the study lasted only three months. The qualitative analysis of the structured interviews was performed using a rapid qualitative analytical framework.
Most of the service users at the deprescribing centers were prescribed various psychotropic medications, with four centers targeting a specific combination of z-drugs, benzodiazepines, antidepressants, and antipsychotics. The interviews revealed the difficulties and complexities of tapering and discontinuing psychotropic drugs.
“It’s maybe hard to start a benzodiazepine taper if you haven’t got somewhere to live or money struggles.”
“People still are very much told that they need, for instance, antidepressants because there is some imbalance in their brain. . .and then I typically used to say that the imbalance theory is very much of a myth which actually has not been possible to. . .validate.”
“…if I’ve got a client who’s struggling, which I do quite often, I’ll ask them [peer volunteers] if they’ll join us in a Zoom session to give their experience, people want to hear it from the horse’s mouth, as it were, rather than some professional, it can sort of motivate them to make changes. . ..it works really well.”
After coding, the results revealed that the most efficacious way to discontinue psychotropic drugs was to taper the medication slowly with patient preference and lived experience as the driver of the taper. The author’s direct recommendations for services are:
- Drugs should be tapered gradually using hyperbolic strategies. “This means that the steps by which the dose is lowered are made smaller and smaller as the dose decreases, for example, reducing the medication by 10% of the prior dose.”
- Tapering should be individualized, flexible, and use shared decision-making.
- Psychosocial support should be provided to patients during and, if required, after withdrawal.
- Lived experience should be integrated at all levels: people with lived experience of successfully and unsuccessfully withdrawing from prescribed drugs of dependence must be involved in the conception, development, and running of services.
- The broader context of a patient’s life should be taken into account.
- Dedicated deprescribing services for prescribed medications of dependence are necessary.
The authors end their recommendations by substantiating their qualitative findings with quantitative findings:
“Tapering medications gradually and slower at lower dosages is in line with the existing limited evidence and guidance on withdrawal strategies for a range of medications, including antidepressants, benzodiazepines, antipsychotics, opioids, and z-drugs. A systematic review found one trial demonstrated a 6-fold increased chance of stopping benzodiazepines for gradual dose reduction compared with routine care.”
Cooper RE, Ashman M, Lomani J, Moncrieff J, Guy A, Davies J, et al. (2023) “Stabilise-reduce, stabilise-reduce”: A survey of the common practices of deprescribing services and recommendations for future services. PLoS ONE 18(3): e0282988. https://doi.org/10.1371/journal. pone.0282988 (Link)