I knew about polypharmacy, which is generally understood as the use of five or more medications at a given time, from medical and psychiatric training. However, it was further training in addiction psychiatry and a chance occurrence of working with a few pain specialists that made me appreciate the complexities of medication management and polypharmacy. Further, it has been the stories and experiences of my patients, especially those with chronic pain, that have truly shaped my understanding and develop a keen interest in this field.
I often met individuals who had over time, accumulated numerous medications, including antidepressants, antipsychotics, and anticonvulsants but their symptoms had not improved, and many had side effects and/or become dependent on medications, struggling to reduce it. This led me to the path of deprescribing, which is the planned and supervised process of reducing or stopping a medication that might be causing harm or is no longer providing benefit.
Initially used in the context of elderly care, the importance of deprescribing is being appreciated across the lifespan, and across medical specialities. Antidepressant medication deprescribing has gathered significant interest and debate in recent times. There are a few algorithms to assist reducing or stopping antidepressants, benzodiazepines (e.g., Diazepam), opioid analgesics (e.g., Oxycodone, Codeine) etc. They are useful, but do not consider polypharmacy, which is a complex area not well researched at this stage.
It is in this context that my patients have taught me more, made me think and pull together scientific literature to understand that deprescribing is far more than a simple tapering algorithm. Success hinges on a strong therapeutic alliance, creating a trusting and safe environment, ensuring continuity of care, taking the time to understand the personal meaning a patient attaches to their medications, exploring their recovery goals and remaining flexible in our approach, especially in cases of complex polypharmacy.
There is a place for appropriate polypharmacy, but identifying inappropriate or problematic polypharmacy is also important as it can lead to a cascade of complications I’ve unfortunately witnessed, including debilitating side effects, falls, fractures, worsening mental health, hospitalisation, overdose, and even death.
At times, what begins as a reliance on medications like opioid analgesics and benzodiazepines can evolve into a substance use disorder, commonly known as addiction or dependence. Research and my clinical experience has consistently shown that when we can identify and treat addictions appropriately, a person's functioning and quality of life could improve significantly. For some individuals struggling with opioid dependence, this may mean transitioning to opioid substitution therapy, at least temporarily, with agents such as Buprenorphine (e.g., Suboxone™, Buvidal™, Sublocade™) or Methadone, a step that can be transformative on their path towards rehabilitation and recovery.
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