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Rationalising medications through deprescribing

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l570 (Published 07 February 2019) Cite this as: BMJ 2019;364:l570

Re: Rationalising medications through deprescribing

We read with interest the excellent article by Professor Avery and colleagues on the value and benefit of deprescribing. 1 Deprescribing should be integral to every clinician’s practice, and as such in 2013, the General Medical Council highlighted the importance of regular review of a patient's medication. Deprescribing should be undertaken by anaesthetists and intensivists, 3 and as such we are in a position to advise on the deprescribing of drugs that may have been commenced during critical illness eg amiodarone for atrial fibrillation or opioids for the management of post-surgical pain (PSP).

Poor deprescribing is pivotal in the the global prescribed opioid crisis, which is a well documented phenomenon.4 Research from the US has emerged that following surgery the risk of subsequent opioid dependency in opioid naïve patients may be as high as 6.5%5 . Interestingly, the 3 biggest risk factors for subsequent opioid dependence in the US have been identified as the use of modified release opioid preparations eg Oxycontin ®; drugs going onto repeat prescriptions; and the duration of the prescription. 6,7

We therefore advocate that as well as deprescribing, we need to reflect on prescribing habits. Specifically in view of the opioid crisis that is beginning to be appreciated in the UK,8 we need to avoid the use of modified release opioid preparations for acute pain, which is in line with North American and Antipodean recommendations, 9 we need to avoid opioids prescribed for acute pain continuing onto repeat prescriptions and we need to limit the size and duration of our prescriptions.

References
1. Avery AJ, Bell BG. Rationalising medications through deprescribing. BMJ 2019;364 :l570
2. General |Medical Council . Good practice in prescribing and managing medicines and devices (2013). Available from https://www.gmc-uk.org/-/media/documents/prescribing-guidance_pdf-590552...
3. Hermanowski J, Levy N, Mills P, Penfold N. Deprescribing: implications for the anaesthetist. Anaesthesia. 2017 ;72:565-9.
4. Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ 2017;359:j4792
5. Brummett CM, Waljee JF, Goesling J et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504-.
6. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use-United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66:265-9
7. Brat GA, Agniel D, Beam A et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790
8. Curtis HJ, Croker R, Walker AJ, Richards GC, Quinlan J, Goldacre B. Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database study. The Lancet Psychiatry 2018 Dec 20 [Epub ahead of print].
9. Levy N, Mills P. Controlled-release opioids cause harm and should be avoided in the management of post-operative pain in opioid naïve patients. Br J Anaesth. 2018. Doi https://doi.org/10.1016/j.bja.2018.09.005

Competing interests: No competing interests

20 February 2019
Nicholas Levy
Consultant Anaesthetist
Dr Patricia Mills ; Professor William J Fawcett
West Suffolk Hospital
Hardwick Lane