Where We Stand
Section: Pharmaceuticals
Policy: Polypharmacy and Deprescribing
Appendix P

Polypharmacy and Deprescribing 

The Policy Committee was tasked with assembling a small workgroup to tackle polypharmacy and deprescribing, based on a resolution from two members in 2019 that called for the Policy Committee to make recommendations on a process to identify and mobilize best practices around deprescribing.

Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes.¹ According to a study on the trends in prescription drug use among adults from 1999-2012, 39% of patients over 65 take 5 or more prescription medications..."²   The number of medications is the strongest predictor of potentially inappropriate medication use.³

According to a report by the Centers for Disease Control and Prevention from 2019, 83% of U.S. adults in their 60s and 70s had used at least one prescription drug in the previous 30 days and about one-third used five or more prescription drugs. The most commonly used drugs were cholesterol, high blood pressure, and diabetes medications.

Inappropriate polypharmacy - the use of excessive or unnecessary medications - increases the risk of adverse drug effects, including falls and cognitive impairment, harmful drug interactions, and drug-disease interactions, in which a medication prescribed to treat one condition worsens another or causes a new one. Patients may be prescribed medicines that are unlikely to help, potentially harmful, or misaligned with the person’s health goals. Polypharmacy also creates a tremendous burden for patients and their families, who need to understand the purpose of the many prescriptions written by multiple providers, get refills, take each medication at the correct time of day, and recognize side effects.⁴

The members of the workgroup, worked with other clinical advisors from the Oregon Chapter American College of Physicians who provided input.  Because of the complexity of the polypharmacy issue, there is no one single protocol, algorithm, or guideline for deprescribing, that can be applied to all patients and each physician and physician assistant must determine with their own clinical approach how to address this problem. 

The Oregon ACP and the Oregon Geriatrics Society recently developed continuing medical education; a 4-part series to help clinicians design a plan for deprescribing. That series is titled “Tackling Prescription Overload.”  But more is needed for awareness and resources.

The recommendations set the stage for collaboration between the Oregon Medical Association and other stakeholder organizations who are already involved in polypharmacy and to introduce, educate and advocate effectively for patients through this collaboration.

References
AAFP - Polypharmacy – Evaluating Risks and Deprescribing 
AAFP - Deprescribing Unnecessary Medications
AAFP - Geriatric Assessment: An Office-Based Approach
American Geriatrics Society - Trends in Prevalence and Determinants of Potentially Inappropriate Prescribing in the United States: 2007 to 2012
US Task Force of Deprescribing
https://jamanetwork.com/journals/jama/fullarticle/2661582
https://www.acponline.org/system/files/documents/clinical_information/high_value_care/clinician_resources/hvcc_toolkit/data_sets/polypharmacy.pdf
¹ Quato DM et al; Changes in prescription and over the counter medication and dietary supplementation use among older adults in the US 2005-2011; JAMA Intern Med 2016; 176(4): 473-82.  https://pubmed.ncbi.nlm.nih.gov/26998708/
² Kantor Ed et al; Trends in prescription drug use among older adults in the US 1999-2012; JAMA 2015:314(17):1818-1830.
https://jamanetwork.com/journals/jama/fullarticle/2467552
³ Steinman MA et al; Prescribing quality in older veterans in a multifocal approach; J gen Intern Med 2014:29(10): 1379-86
https://pubmed.ncbi.nlm.nih.gov/25002159/
⁴ National Institute of Aging; The dangers of polypharmacy and the case for deprescribing in older adults; 2021
https://www.nia.nih.gov/news/dangers-polypharmacy-and-case-deprescribing-older-adults

Policy Committee Polypharmacy and Deprescribing Workgroup
Harry Krulewitch, MD, Family Practice, Portland
Preston Peterson, MD, Internal Medicine, Portland

Workgroup Advisors:
Jenny Silberger, MD
Marianne Parshley, MD