Deprescribing means reducing or stopping medications that may no longer benefit or may harm a patient. In other words, by definition, it means taking something away that has previously been given. In the middle of the opioid epidemic, deprescribing now may arguably be more complicated than ever.
For example, many providers assume that prescribing fewer opioid medications for acute pain in the emergency department (ED) will lead to patients experiencing prolonged pain. Or more complaints. Or requests for more medications. Maybe we fear that we — and our colleagues, our teams, or our health systems — will not be able to handle these responses. Maybe we fear our patients will not be able to handle their pain without the opioids.
And, so, we do not deprescribe. But maybe it doesn’t have to be this way. Maybe some of our fears are unfounded. The experience of a team of ED physicians in Jacksonville, Florida, may surprise many.
According to Travis Smith, DO, of Ascension St. Vincent’s, “We started using a multimodal approach [in the ED] that involved prescribing opioids only as a last resort to help reduce the incidence of adverse events.” An early champion of deprescribing, Smith reports, “I received many thank you notes from my patients in the weeks and months following my first tests of deprescribing opioids, which validated our approach. This was, most likely, because I spent time with patients and their families explaining the reasons for deprescribing opioids and assuring them that our focus was on treating pain safely and effectively.”
Smith’s efforts were part of a targeted, patient-focused analgesic approach that supports utilization of non-opioid medication combinations. It involved a more judicious use of opioids to achieve better pain control, fewer side effects, and reduced dosing of individual medications.
Prior to developing their opioid deprescribing protocol, Ascension St. Vincent’s participated in community discussions about the opioid crisis. They administered Naloxone, the opioid reversal agent, when someone needed it. And they were like just about every other hospital using opioids as the main modality to manage pain.
“We knew we had to do our part to address the national opioid crisis,” said Florian Daragjati, PharmD, BCPS, then the pharmacy clinical manager at Ascension St. Vincent’s. “But, quite honestly, we did not know where to begin. In addition to being a national crisis, it was an issue that was truly affecting our own patients on a daily basis.”
Then, in 2017, Ascension St. Vincent joined the IHI International Innovations Network, funded by the Commonwealth Fund, and tested an approach to deprescribing that originated in Ottawa, Canada (deprescribing.org). “We were motivated by the [results of the] innovation from Canada and joined a network of US health systems to apply the Model for Improvement to test the innovation in their systems,” Daragjati reported. “The results were dramatic enough to lead Ascension to spread the practice across all its 150+ hospitals nationwide.”
Ascension St. Vincent reduced their use of opioids significantly over time with incrementally broader tests of change and involving more and more physicians as their belief in their results increased.
Ascension St. Vincent’s pain scores help to explain the thank you notes from patients. Pain scores improved as opioid use declined.
To learn more about how you might implement this approach in your health system, review the IHI Evidence-Based Medication Deprescribing Innovation Case Study.
Leslie Pelton is Senior Director for IHI Innovation and leads IHI’s Age-Friendly Health Systems initiative.
Editor’s Note: Representatives from Ascension shared their story on the September 13, 2018, audio program, WIHI: The How and Why of Deprescribing.
You might also be interested in learning more about effective approaches to deprescribing at sessions offered at the IHI National Forum (December 9-12, 2018).