American Society of Consultant Pharmacists
View all recommendations from this societyReleased June 8, 2022
Don’t combine opioids with benzodiazepines or gabapentinoids to treat pain in older adults and re-evaluate routinely for deprescribing during chronic use.
Co-prescribing of benzodiazepines or gabapentinoids (gabapentin, pregabalin) with opioids is increasingly utilized in the multimodal treatment of acute
and chronic pain despite limited evidence to support the effectiveness of this practice. Population studies have demonstrated that these combinations are associated with increased risk of serious adverse outcomes such as excessive sedation, overdose events, and death. In 2019, The FDA required new warnings about the risk of serious breathing difficulties that can lead to death in patients who use gabapentanoids with opioid pain medicines or other drugs that depress the central nervous system, or those who have underlying respiratory impairment, such as patients with chronic obstructive pulmonary disease, or the elderly.
Older adults may be particularly vulnerable due to age-related changes in pharmacokinetics, pharmacodynamics, and medical comorbidity. Initiation of combination therapy should be avoided whenever possible; older patients who require chronic concurrent use of these medication classes should be closely monitored and periodically evaluated for deprescribing.
Choosing Wisely Canada (Canadian Pharmacists Association) spells out an important consideration for prescribing benzodiazepines that includes discontinuation strategies, except for patients with valid indications requiring long-term use of these medications.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
(1–5)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis is on older adults no matter where they reside in step with ASCP’s mission.
Definition wise, deprescribing is a stepwise reduction of unnecessary or potentially inappropriate medications in concert with patient and family goals and wishes. We recognize that even with the best of intentions, many older adults are left on unnecessary and potentially dangerous or duplicative medications that might precipitate adverse events and other negative outcomes.
The task force prioritized formulation of the Choosing Wisely (CW) List, since the goals of CW intersect and overlap with deprescribing initiatives. The list was created to address general medication regimen review statements, and more importantly to address the paucity of statements that address DDIs with several incriminating medication therapeutic classes prescribed for older adults. After a review of published CW statements on www.choosingwisely.org and also a review of CW statements published by international countries, it was decided by consensus to have a strong emphasis on DDIs.
After several virtual meetings, the CW workgroup was divided into subgroups to formulate DDIs that have a strong evidence base in the literature and those that focus on CNS therapeutic classes, anticholinergic burden, heightened bleeding risk, and other pivotal pharmacokinetic and pharmacodynamic DDIs. For each statement the group formulated a rationale that was evidence-based accompanied with several recent, pertinent references. The compiled list (after several virtual meetings and email discussion) was further reduced to top ten statements with the strongest evidence base and practice trends on medication management in older adults.
The top five list was selected by consensus for initial submission.
Attached is a recently published guest editorial in ASCP’s journal that highlights the emphasis on DDIs.
Beier MT. Vigilance of Drug-Drug Interactions to Mitigate ADRs: Front and Center for Pharmacists (Guest Editorial). Sr Care Pharm 2020; 35:336-7.
(6–10)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis for all our statements is on older adults no matter where they reside in step with ASCP’s mission. Our first 5 CW statements were published in May 2021.
As previously addressed, the rationale for the new 2022 list (statements 6–10) includes one medication review statement in older adults with limited life expectancy, and three statements emphasizing the adverse combination of CNS medications that have a strong evidence base in the literature including tramadol’s potential for greater harm than benefit for pain relief, especially in older adults. We had previously highlighted pharmacodynamic DDIs for heightened bleeding risk, and this time our statement addresses the complexity of pharmacokinetic DDIs with Direct Oral Anticoagulants (DOACs).
Sources
Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. Tsai AC, ed. PLoS Med. 2017;14(10):e1002396.
Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert AS. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ 2015; 350:h2698.
Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review. Addiction 2016;111:1160–74.
Goodman CW, Brett AS. A clinical overview of off-label use of gabapentinoid drugs. JAMA Intern Med 2019;179:695-701.
FDA In Brief: FDA requires new warnings for gabapentinoids about risk of respiratory depression. Food and Drug Administration. December 19, 2019. Accessed March 28, 2022.https://www.fda.gov/news-events/fda-brief/fda-brief-fda-requires-new-warnings-gabapentinoids-about-risk-respiratory-depression
Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent use of prescription opioids and gabapentinoids in older adults. American Journal of Preventive Medicine. 2022;62(4):519-528.
Canadian Pharmacist Association. Six test and treatments to question. August 2020. Accessed March 09, 2022. https://choosingwiselycanada.org/pharmacist/
