Using the STOPP criteria Several studies demonstrate the effectiveness of STOPP. Campins et al. (2017) reported that the STOPP tool helped pharmacists determine that 27% of the intervention population’s prescriptions were potentially inappropriate. 103 The majority of these prescriptions were then changed, as follows: 43% were discontinued, 33% received a dose adjustment, 14% were substituted for more appropriate medications, and for 10%, the patient received a new prescription. Similarly, Gibert et al. (2018) used STOPP in primary care consultations in France, resulting in a 38% reduction in the number of PIMs across about 45% of patients. 104 Hannou et al.(2017) introduced a part-time ward-based clinical pharmacist to a psychiatric unit’s multidisciplinary team and screened prescriptions for potentially inappropriate drug prescribing (PIDP) using the STOPP/START criteria. 105 The intervention was measured by the acceptance rate of pharmacist interventions (PhIs). The global PhI acceptance rate was 68% and the rate based on STOPP/START was 47%. When two STOPP criteria, the prescription of benzodiazepines or of neuroleptic drugs to patients who had fallen in the last 3 months, were removed from analysis, the acceptance rate for STOPP/START-based PhIs increased to 67%. One potential unfavorable effect of deprescribing interventions is that, while the interventions have reduced medication costs, they do not always lead to a decrease in healthcare utilization, such as hospital admissions and primary care visits. With the exception of longer lengths of stay no other unintended negative consequences were reported in the studies that examined the use of STOPP criteria to reduce ADEs. Barriers to deprescribing In the deprescribing literature, notable barriers to implementation included: 100 • Pharmacists not adhering to study protocols • Inadequate documentation of medication history • Limited communication between pharmacists and physicians • Patients being discouraged from discontinuing medications by individual providers • Patients perceiving deprescribing as contradicting their provider’s recommendations • Scheduling conflicts, competing demands, and general lack of time, which impacted medication review meetings between pharmacists and physicians • Nonprescription medications (i.e., over-the- counter) that were not documented in medical databases, which prevented providers from seeing the full-range of medication use per patient and therefore not being able to accurately identify and include all patients who were at risk of polypharmacy in the study • Lower acceptance rates of pharmacist interventions based on the STOPP criteria due to the lack of discontinuation of benzodiazepines
Conclusions Being able to prevent unnecessary ADEs that are associated with the use of inappropriate medication use or polypharmacy is especially important for older adults who are affected by multiple ailments and who inevitably traverse multiple healthcare settings and providers for treatment. Deprescribing to reduce polypharmacy and use of the STOPP criteria to reduce PIMS are two approaches to consider. Albeit still emerging, studies on deprescribing highlight its potential in helping providers adjust down and/or eliminate medications based on the condition/need of patients. However, more research is needed to assess deprescribing in relation to patient adherence, compliance, and preference, as patients play a key role in a provider’s ability to effectively monitor and adjust medication and treatment plans. With regard to using the STOPP criteria to reduce PIMS, evidence suggests it is the most effective approach, but also note that it often does not—and should not—stand alone. In order to ensure thatolder adults are given the best possible care, in addition to screening their prescriptions for PIMS (i.e., using STOPP), it is equally important to identify more appropriate treatment options, thus also including the START criteria. More appropriate medication selection is also achieved through the use of the Beers Criteria or the Medical Appropriateness Index (MAI), which are other interventions that oftenaccompany the use of STOPP. The field will undoubtedly benefit from more studies that examine the short- and long-term clinical effects of reducing polypharmacy and PIMS through deprescribing and using the STOPP criteria. Harms due to opioids The United States has seen three successive waves of opioid overdose deaths related to both legal and illegal opioids. 106 The first began in the 1990s and was associated with steadily rising rates of prescription opioids. In 2010, deaths from heroin increased sharply, and by 2011 opioid overdose deaths reached “epidemic” levels as described by the Centers for Disease Control and Prevention (CDC). 107 The third wave began in 2013 with a sharp rise in overdose deaths attributed to synthetic opioids, particularly those involving illicitly-manufactured fentanyl. In late 2020, the CDC announced that 81,230 drug overdose deaths occurred in the 12 months ending in May, 2020, which was the highest level of overdose deaths ever reported. 108 The surge was primarily driven by a 34% increase in overdose deaths related to synthetic opioids, primarily fentanyl. 108 Overdose rates appear to have accelerated during the COVID-19 pandemic. 109 Between 1999 and 2019, the CDC estimates that nearly 500,000 people in the United States died from such overdoses. 110 This section reviews two PSPs that aim to mitigate the potential harms of opioids: opioid stewardship and initiation of Medication Assisted Treatment (MAT) for opioid use disorder (OUD)
Opioid stewardship can consist of a range of risk- reduction interventions or strategies often used in combination. Evidence is moderately strong that opioid stewardship interventions can reduce opioid dosages, which is an important intermediate outcome given high MMEs are associated with an increased risk of overdose. MAT can be initiated and provided safely in a variety of healthcare settings. Initiation of MAT in the ED, primary care setting, or outpatient clinics may result in faster access to care and longer retention in or adherence to treatment. MAT’s effectiveness in reducing illicit opioid use and overdose deaths has already been demonstrated in multiple randomized clinical trials, and effective MAT includes a combination of behavioral therapy and medications approved by the Food and Drug Administration (methadone, buprenorphine, and naltrexone). Opioid stewardship Opioid stewardship—similar to antibiotic stewardship—consists of a range of risk- reduction interventions or strategies, often used in combination, to prevent adverse consequences from prescription opioids, including misuse, abuse, and overdose. The range of opioid stewardship interventions or strategies includes the following, several of which are recommended in the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain: 111 • Conduct of an individualized assessment of risks and benefits of opioids, and the appropriateness of a tapering (tapering slowly to minimize withdrawal symptoms) • Avoid and benzodiazepines or other sedative hypnotics (as appropriate) • Use of treatment agreements (also known as controlled substance agreements or pain contracts) • Urine drug screening (UDS) • Checking Prescription Drug Monitoring Programs (PDMPs) • Pain and functional assessment. • Registry of patients with chronic pain or patients on chronic opioid therapy (COT) • Limiting number of days supply for acute pain opioid prescriptions • Pill counts to detect aberrant drug-related behavior • Referrals to nonpharmacologic treatment providers (e.g., physical therapy), pain management, behavioral health, or addiction specialists • Risk assessment Besides recommending these specific interventions, most opioid stewardship initiatives also include implementation strategies to actually change practice. These implementation strategies are not necessarily unique to opioid stewardship efforts and include electronic health record (EHR) tools (e.g., clinical decision support, templates, alerts, integrated PDMP, autopopulated fields), dashboards for monitoring and/or audit and feedback, provider and staff education and training, academic detailing, committee or task force on opioids, telehealth, and nurse care management. coprescribing opioids
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