The key challenges of deprescribing

Abstract

Doctors have prescribed medicines for thousands of years. The ancient Greek physician Dioscorides authored De Materia Medica, one of the first pharmacopoeias, in the first century AD, and it was used to guide therapeutics for over a millennium. Fast forward to the 20th century: the tome had changed to the British National Formulary, and the Medicines Act of 1968 introduced legislation governing prescription-only medicines – but the prescriber remained the doctor. Indeed, the fundamental skills necessary to prescribe medicines have always been a core part of medical school teaching – the basic principles of pharmacology, the diagnostic and therapeutic process, the essentials of evidence-based clinical practice. The significance of prescribing is even reflected in doctors’ notorious reputation for illegible handwriting, which owes itself to writing scrips in Latin. The prescription is a tool not just with pharmacological purpose, but one that impacts patient trust and confidence in the doctor, that influences health-seeking behaviour, and can even act as a symbol that signifies the end of the consultation. As prescribing has grown, however, there have been increasing concerns about the overuse of medicines. Perhaps all those medicines we are handing out aren't always the best thing for the patient? The concept of deprescribing is now well established, yet there are no clear strategies for its implementation in practice; barriers include a lack of education and training, an absence of robust evidence, a tendency towards defensive practice, and pressure to adhere to single-disease evidence-based guidelines that frequently promote adding more medications. Shifting doctors away from a culture of prescribing that has been established for so long is not an easy thing to do. Although this is something the medical profession is only just getting to grips with, there are, of course, many other professionals who can now prescribe – and as a result, need also to consider the challenges of deprescribing. Although this might come more readily to pharmacists, given their expertise in reducing potentially unsafe medication use, the experiences of nurses are not well understood; Emma Crowe discusses this perspective on page 29 of this month's Prescriber. Non-medical prescribing only began in the 1990s, and so the weight of history may be somewhat easier to deal with when it comes to pharmacist and nurse deprescribing. But there are other key challenges, including overcoming inter-professional boundaries (it's still doctors who initiate most medicines, after all), and dealing with the clinical uncertainty deprescribing is often associated with but that many non-medical prescribers feel inadequately prepared for. Deprescribing is not going to go away any time soon. For all health professions involved in prescribing, medical or otherwise, there is a growing need to foster strategies – whether those are grounded in training, guidelines, policy, or something else – to help clinicians deliver this core aspect of good therapeutic management in the most effective and safe manner possible.