What do pharmacists actually do? Ask anyone about what a pharmacist does and you will likely hear a number of responses.
The Role of the Pharmacist
Here are a few of the more common replies:
- Counsel patients on potential side effects….true
- Count pills… wrong!
- Look for drug-drug interactions….true
I am willing to bet though, that not many people will say “get people off of unnecessary medications”. That, though is 90% of what I do in our Geriatric Pharmacy clinic, and it is not easy work. Imagine you are playing with your kid or niece or nephew and you have some brand new stickers. The young child is having a blast putting these colorful stickers all over a blank sheet of paper. It is so easy to do…. Peel it off and stick it on… that’s it. Finally there are no stickers left. A few weeks later, the toddler returns to that sticker sheet and is no longer satisfied. Once a perfect collection of stickers on a sheet, they are now inappropriate and must come off. The only problem is, it is not so easy to peel those stickers off. There is lots of frustration, tears and angst and finally the toddler gives up and leaves the stickers as is.
The Challenges of Deprescribing
Just as it is so much easier to put a sticker on a piece of paper than to pull it off, the same is true about placing a patient on a medication. For a number of reasons, it is hard to stop or “deprescribe” medications especially as we get older. Even in the case where a medication is no longer appropriate or necessary to be on, prescribers and patients often do not want to “rock the boat” and take a medication off the list. Much of what I do is to put in the effort (like a human goo be gone) to take that sticker cleanly off the page when they don’t belong there anymore (ie. the medication benefit no longer outweighs the risk).
Persistence + Patience = Results
This task takes a strong baseline knowledge of medications as well lots of effort and persistence to overcome the “sticky” barriers of deprescribing. The pharmacist must first fully understand the reason why a patient was initially prescribed the medication. They must gather information related to all the dose changes that have occurred in the past in addition to any details related to past deprescribing attempts and then use this information to make sound clinical judgement (with supporting rationale) to determine whether that medication is still appropriate for that patient. Just as those stickers were once appropriate but now need to be peeled off, medications, once absolutely appropriate, may now hold more risk than potential benefit and also need some goo-be-gone.
Finally, the pharmacist must be persistent in following up (with both provider and patient) to provide encouragement and offer support to sustain the deprescribing plan. Some medications are “stickier” than others and will need more of this. For example, benzodiazepines, a common class of medications often misused in the elderly, require slow dose reductions over a long period of time in order to achieve successful deprescribing.
Leading the deprescribing effort is difficult work, but pharmacists are trained in a way that allows them to look at a patient’s medication regimen in a proactive way and from all possible angles. They can identify possible risks before they occur and are the perfect professional to intervene before those, once pretty but now ugly stickers, cause unnecessary tears.
At CUW, we not only train our students on the intricacies of medications and their place in therapy, but also on where they generally DO NOT belong. When CUW grads enter the pharmacy workforce, they can be confident in their ability to holistically manage the medication regimens of their patients. This will often involve proudly serving as the necessary “goo be gone” to “unstick” medications that are no longer appropriate.
—Travis W. Suss, PharmD, BCGP
Assistant Professor, Pharmacy Practice
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