A recent article on deprescribing best practices in The Pharmaceutical Journal, the official publication of Great Britain’s Royal College of Pharmacy, shows growing awareness among pharmacists of psychotropic deprescribing. But clear guidelines are is still lacking.
In August, a brief article, “Best practice for prescribing drugs with dependence potential,” appeared in The Pharmaceutical Journal, the official publication of Great Britain’s Royal College of Pharmacy, which has more than 44,000 members. While lacking in fine detail, the article is a welcome sign that awareness of psychotropic deprescribing is growing.
The Royal College of Pharmacy is the leadership body for pharmacists and pharmaceutical scientists across Great Britain. About a third of registered Great Britain pharmacists are independent prescribers, who directly manage primary patient care through the strategic prescribing and deprescribing of medications.
All Great Britain pharmacists can conduct medication reviews, where they systematically evaluate a patient’s entire drug regimen, identifying necessary treatments while reducing or discontinuing redundant, inappropriate, or high-risk medications.
Patient care by pharmacists saves an estimated 38 million primary care physician appointments annually, as well as potentially enhancing patient safety by reducing the risks of dangerous drug interactions, polypharmacy, and overmedication.
Great Britain’s pharmacists are well placed to support the tapering processes necessary for safe reduction or discontinuation of psychotropic drugs.
The readers of The Pharmaceutical Journal are therefore well placed to support the tapering process that is necessary for safe reduction or discontinuation of psychotropic drugs.
Several core concepts about prescribed psychotropics that have historically been misunderstood by doctors are well articulated by the article’s authors, pharmacists Namita Bhuta and Matthew Ayre. The piece opens by explaining the critical distinctions between physical dependence and addiction, highlighting that “withdrawal reactions may occur in patients who have taken medications as prescribed and do not necessarily indicate misuse.” Likewise, Bhuta and Ayre emphasize that properly informed consent requires that patients are advised of a drug’s physiological dependence potential at the point of prescription. The authors repeat throughout that deprescribing should be “individualized” and “person-centered.”
Touching on opioids, benzodiazepines, z-drugs, gabapentinoids, antidepressants and stimulants, the article provides a concise overview of efficacy, adverse effects and key withdrawal symptoms for each drug class.
Clinicians are left to decide for themselves what is meant by terms like “slow” and “gradual,” with no clear indication of whether this means tapering over weeks, months, or years.
The utility of the Horowitz-Taylor method of hyperbolic tapering receives only one mention, in relation to antidepressants, though the law of mass action, which underpins the logic of hyperbolic tapering and its efficacy in reducing withdrawal symptoms, applies equally to all classes of dependence-forming drugs. A clearer recognition that hyperbolic or proportional reductions are appropriate for tapering all prescribed psychotropics would have been welcome, or a reference to the more detailed 2023 article on the topic in The Pharmaceutical Journal by Drs. Horowitz and Taylor themselves.
Like much mainstream professional discourse on deprescribing, this article fails to provide this kind of detailed technical information. Clinicians are left to decide for themselves what is meant by terms like “slow” and “gradual,” with no clear indication of whether this means tapering over weeks, months, or years. The need to provide patients with very small doses is hinted at, but no instructions are given about how available formulations can be used to achieve this goal.
This lack of specificity leads to a high degree of variability in the way that deprescribing is practiced by individual providers, to the detriment of patient care. Patients seeking safe, supported deprescribing are often obliged to search hard for a withdrawal-informed practitioner, rather than being able to trust that their regular clinician will have the requisite skill set.
Generic calls for “individualized,” “patient-centered” deprescribing must be supported by clinical guidance that specifies the technical skills needed to implement a safe taper. Nonetheless, given the historical absence of professional discourse about deprescribing, it is good to see health authorities like the Royal College of Pharmacy engaging with this important topic.
