If you’re a regular follower of this newsletter, you likely aware that I’ve written extensively about psychotropic medication prescribing across all medication classes. I’ve addressed best practices for the first-time psychotropic medication user, techniques for non-responsiveness across all spectrums, as well as augmentation and additive drug strategies. But what about “un-prescribing” psychiatric medication?
Patients are often quick on the draw to wanting to cease taking medication that is causing side effects or other adverse circumstances, and most prescribers will comply with discontinuing the drug or at least lowering the dose. But what about patients continuing with medication(s) that are unnecessary, or may become riskier with advancing age? These are examples of when a patient could benefit significantly from an “un-prescribing” session with their medication prescriber, but I’ll be clear here: most patients won’t ask for this and most prescribers won’t suggest this as a function of routine practice.
When meeting with a patient seeking an evaluation of the medication regimen they’re currently on, I always begin with this question: “what’s the underlying cause for which you were started on this medication in the first place?” This quite often yields a blank stare in my direction, because here’s the way medication management often goes: the patient speaks to a problem with the prescriber, “I’m feeling depressed, anxious or I can’t sleep,” then medication is prescribed, (or people self-medicate with OTC products) with only cursory attention paid to the CAUSE of the problem. Sleeplessness, for example, is not THE problem, what’s responsible for the sleeplessness is the issue. And there’s always something responsible. So instead of going to actual cause, people unwittingly continue with medication as if that’s the solution, which it’s so often not.
A Couple of Examples Identifying Cause
Last week, when describing a sleep problem for which a new patient of mine had sought and received sleep medication, I inquired about his caffeine intake. He commented, “Oh, caffeine doesn’t bother me,” to which I replied, “well, then what’s causing your insomnia to the extent that you are now taking sleeping pills?” He admitted to consuming at least 6 cups of coffee during the workday. I recommended that he cut back one cup per day with a goal of 2 cups per day and no caffeine after 3pm. He complied, is off the sleeping pills and his hand tremors have disappeared. Another patient complaining of insomnia with whom I’m working had taken to drinking two glasses of wine each night to help him get to sleep. He reported that he was routinely awakening at 3am. I explained that alcohol significantly interrupts the sleep-wake cycle and recommended a trial of no alcohol in the evening hours for one week. This then opened the door to our discussing the underlying cause of his difficulty sleeping – his business was failing. He complied with the no alcohol request and has stopped alcohol altogether in the evening during the work week.
Un-Prescribing Related to Advancing Age
With older clients, I’ll use plain, straightforward language when discussing un-prescribing: “A medication that was once appropriate for you might not be so appropriate for you now.” As we age, drug absorption and excretion rates change and we become more susceptible to central nervous system side effects. As such, falls become much more common, as well as excessive sedation, cognitive impairment and dizziness. Thus anyone 65 and older who is taking a benzodiazepine or a “z” drug (zolpidem, eszopiclone, zaleplon) for anxiety or insomnia would be a good candidate for un-prescribing. And it’s worth noting that some older people – through a tapering and eventual discontinuation process designed specifically for them – are able to come off these drugs more easily because they’re now retired, and no longer stressed by the rigors of work.
The single most important consideration for a prescriber in medication management is to conceptualize a reason for each drug choice prescribed to a patient. But when reasons become less apparent or age becomes an issue, it’s time for reexamination, so that unwarranted drugs don’t become unnecessary wingmen.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.