Deprescribing Frameworks: How to Safely Reduce Medications and Cut Side Effects

Every year, millions of older adults take more medications than they need. Some have been on the same pills for decades-antacids for heartburn, sleeping pills for insomnia, statins for cholesterol-even when their health has changed, their symptoms are gone, or the risks now outweigh the benefits. This isn’t laziness or poor care. It’s the quiet crisis of polypharmacy: taking five or more medications at once. And it’s leading to falls, confusion, hospital stays, and even early death.

Deprescribing isn’t about stopping meds cold turkey. It’s not cutting pills because they’re expensive or inconvenient. It’s a deliberate, evidence-based process to remove drugs that no longer serve the patient-and do it safely. The goal? Fewer pills, fewer side effects, better quality of life.

What Is Deprescribing, Really?

Deprescribing means reviewing every medication a person takes and asking: Is this still helping? It’s the flip side of prescribing. Just as doctors carefully choose drugs to treat illness, they should also carefully stop drugs that no longer fit.

It started gaining real traction around 2012, led by researchers in Canada like Barbara Farrell and Cara Tannenbaum. Their work created the first practical tools doctors could use-not just theory, but step-by-step guides. Today, deprescribing.org is the go-to resource, offering free, evidence-backed protocols for five major drug classes: proton-pump inhibitors (PPIs), benzodiazepines, antipsychotics, diabetes meds, and opioids.

For example, many older adults take PPIs like omeprazole for heartburn. But long-term use raises the risk of bone fractures, kidney damage, and infections. Studies show that up to 70% of these patients can safely stop or reduce the dose with a slow taper over 4-8 weeks, and their symptoms don’t return.

Why Do So Many People Take Too Many Pills?

It’s not one mistake. It’s a cascade.

Someone goes to the doctor for high blood pressure and gets a pill. Then they develop acid reflux from that pill, so they get a PPI. The PPI causes low magnesium, so they get a supplement. The supplement interacts with their heart medication, so they get another drug to fix that. Before long, they’re on eight pills. Each one was prescribed with good intent. But no one ever stepped back to look at the whole picture.

Time is the biggest enemy. A typical primary care visit lasts 7-10 minutes. That’s barely enough to check blood pressure, refill a prescription, and ask about knee pain. There’s no room to ask, Why are you still taking this sleeping pill from 2012?

And then there’s inertia. Patients are afraid to stop. They think, If my doctor gave me this, it must be necessary. Or they worry symptoms will come back worse. One study found 22% of older adults felt anxious about stopping even one medication-even when their doctor said it was safe.

The Science Behind Safe Deprescribing

Deprescribing isn’t guesswork. It’s built on clear frameworks that have been tested in real patients.

The Shed-MEDS framework-validated in a 2023 JAMA Internal Medicine trial-shows how it works in practice. Researchers worked with 372 older adults in nursing homes and rehab centers. Using a structured process-reviewing each med, checking for duplication, assessing risk vs. benefit-they reduced the average number of medications from 11.3 to 9.5 at discharge. At 90 days, it was still down by 1.6 drugs.

And here’s the kicker: There was no increase in hospitalizations or deaths. The group that had meds pulled had the same safety outcomes as the group that kept everything. That’s huge. It proves you don’t need to keep every pill to stay safe.

Another win: pharmacist-led deprescribing. When pharmacists are part of the team, success rates jump 35-40%. Why? They spend hours reviewing med lists. They spot interactions doctors miss. They know how to taper benzodiazepines without causing seizures or rebound insomnia.

How Deprescribing Works: The 4-Step Process

It’s not random. Here’s how it’s done right:

1. Identify candidates. Look for drugs with known risks in older adults. The Beers Criteria (updated in 2023) lists 34 potentially inappropriate meds for seniors-like long-acting benzodiazepines, anticholinergics, and certain diabetes drugs that cause low blood sugar.
2. Assess the need. Is this med still treating a real problem? Has the condition improved? Is the patient still alive long enough to benefit? For someone with advanced dementia, an Alzheimer’s drug might not add years-but it might cause nausea and confusion.
3. Plan the taper. Don’t quit cold turkey. Benzodiazepines? Reduce by 10-25% every 1-2 weeks. Antidepressants? Slow drops over months. Use tools from deprescribing.org for exact schedules.
4. Monitor closely. Watch for withdrawal symptoms, return of original symptoms, or new problems. Keep a log. Talk to the patient weekly. Involve family.

This isn’t a one-time event. It’s an ongoing conversation. A patient might stop a sleep med and feel better for months-then start having trouble again. That’s when you reassess. Maybe it’s not the med-it’s their room, their routine, their anxiety.

Where It’s Working-and Where It’s Not

Canada leads the world in deprescribing. Since 2018, the national DIGE program has trained thousands of providers. Sixty-three percent of Canadian clinics now have formal protocols. In the U.S., it’s only 28%.

Why the gap? Resources. In Canada, pharmacists are embedded in primary care teams. In many U.S. clinics, pharmacists aren’t even on staff. And electronic health records (EHRs) don’t help. Most systems flag drugs to add-not to remove. One doctor told researchers: “My EHR pops up 12 alerts when I try to prescribe a statin. But nothing tells me to stop the sleeping pill I wrote in 2015.”

Even when tools exist, time kills them. A 2022 study found only 15% of U.S. primary care doctors regularly do full deprescribing reviews. The average visit is too short. Documentation is too clunky. There’s no reimbursement for the time it takes.

But change is coming. In 2024, the American Medical Association officially recognized deprescribing as a core part of responsible prescribing. Medicare will start measuring deprescribing performance in 2026. The FDA has funded over $8 million in research since 2020 to build better tools.

What’s Missing-and What’s Next

Right now, we have solid guidelines for five drug classes. But older adults often take 10-15 medications. What about anticoagulants? Antidepressants? Muscle relaxants? There’s almost no guidance for these.

A 2024 analysis of 3,569 clinical guidelines found only 248 (7%) even mentioned deprescribing. The rest? All about adding drugs. That’s like having a manual for how to turn on the oven-but no instructions for turning it off.

AI is starting to help. New tools are being built to scan EHRs and flag patients who might benefit from deprescribing. One prototype in Minnesota looks for people on three or more high-risk meds, with no recent lab tests or clinic visits. It auto-generates a deprescribing checklist for the doctor. Early results show it cuts review time by 60%.

By 2030, experts predict deprescribing checks will be as routine as checking blood pressure. But we’re not there yet. The biggest barrier isn’t science. It’s culture.

What Patients Need to Know

If you or a loved one is on five or more meds, ask:

• Which of these are still necessary?
• Is there a risk I don’t know about?
• Can we try stopping one-and see what happens?
• Who will monitor me if I do?

Don’t be afraid to say: “I’m tired of all these pills. Can we take some away?”

Most patients who’ve gone through deprescribing report feeling clearer-headed, more energetic, and less afraid of falling. One woman in her 80s stopped her nighttime antipsychotic and slept better-not because she was sleeping more, but because she wasn’t waking up confused, disoriented, and scared.

It’s not about taking less. It’s about taking only what matters.

Where to Start

Start here:

• Go to deprescribing.org and download the free algorithms for PPIs, benzodiazepines, or antipsychotics.
• Ask your pharmacist to do a full med review. Most offer this for free.
• Use the Beers Criteria (2023 edition) to check if any of your meds are flagged for older adults.
• Write down every pill, supplement, and patch you take. Bring it to your next appointment.

Deprescribing isn’t a last resort. It’s a smart, safe, necessary part of good care. And it’s happening-slowly, but surely.