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

More than 40% of older adults take five or more medications daily. For many, that means more pills than meals. And while those drugs might have helped at one point, today they could be causing more harm than good. Headaches, dizziness, confusion, falls, stomach bleeds, even kidney damage-these aren’t just side effects. They’re warning signs that the medication list needs a serious rethink. This is where deprescribing comes in. It’s not about stopping meds cold turkey. It’s a careful, step-by-step process to remove drugs that no longer serve you-especially when the risks outweigh the benefits.

What Exactly Is Deprescribing?

Deprescribing is the opposite of prescribing. Instead of adding more pills, you’re thoughtfully removing them. It’s not lazy or lazy medicine. It’s the opposite: a deliberate, evidence-based review of every drug on your list. The goal? Reduce side effects, lower the chance of hospital visits, and improve your daily life.

This isn’t new. Canadian researchers Barbara Farrell and Cara Tannenbaum started building the first real frameworks around 2010. By 2015, they launched deprescribing.org, a free resource used by doctors and pharmacists worldwide. Today, it’s the gold standard. Their work showed that cutting back on unnecessary meds doesn’t make people sicker-it often makes them feel better.

Take proton-pump inhibitors (PPIs), for example. These are common acid reflux drugs like omeprazole. Many people take them for years-even decades-long after their symptoms are gone. But long-term use raises the risk of bone fractures, kidney problems, and even infections. Deprescribing guidelines say: if you’ve been on a PPI for more than 8 weeks with no clear reason, it’s time to try tapering off. Slowly. With monitoring.

The Big Problem: Polypharmacy

Polypharmacy isn’t just a fancy word. It’s the reality for millions. When someone takes five or more medications, the chance of harmful interactions jumps. A 2023 study from the American Geriatrics Society found that inappropriate polypharmacy leads to 30% of hospital admissions in adults over 65. That’s not a small number. That’s one in three.

Why does this happen? Often, it’s because each doctor treats one condition-high blood pressure, diabetes, arthritis-and doesn’t know what the others have prescribed. Pills pile up. No one steps back to ask: “Is this still helping?”

Some meds were meant for short-term use but became permanent. A benzodiazepine for anxiety after surgery. An antipsychotic for sleep. An opioid for back pain that never went away. These drugs don’t always get re-evaluated. And that’s dangerous.

Five Medication Classes That Are Prime Targets

Not all meds are equal when it comes to deprescribing. Some have clearer evidence that stopping them improves safety. The top five classes, according to deprescribing.org, are:

• Proton-pump inhibitors (PPIs) - Often taken way too long. Tapering reduces risk of kidney and bone damage.
• Benzodiazepines and sleep aids (BZRAs) - Like lorazepam or zolpidem. These increase fall risk and memory problems in older adults.
• Antipsychotics - Sometimes used for agitation in dementia. But they raise stroke risk and cause stiffness, tremors, and sedation.
• Antihyperglycemics (diabetes drugs) - Especially in frail older adults. Too-low blood sugar can be deadly.
• Opioid painkillers - Long-term use leads to tolerance, dependence, and overdose risk-even at low doses.

Each of these has a published, step-by-step deprescribing protocol. For example, the PPI guideline says: identify patients using STOPP/START criteria, check if the original reason still exists, reduce the dose slowly over 4-8 weeks, then monitor for rebound symptoms. No rush. No guesswork.

The Shed-MEDS Framework: A Proven Method

One of the most tested frameworks is called Shed-MEDS. It stands for:

1. Best Possible Medication History - Get the full list. Not what the patient remembers. Not what the chart says. What’s actually being taken.
2. Evaluate - Use tools like the Beers Criteria (updated in 2023) to flag potentially inappropriate drugs.
3. Deprescribing Recommendations - Prioritize which meds to cut first based on risk, benefit, and patient goals.
4. Synthesis - Create a clear plan with the patient, including tapering schedule and follow-up.

A 2023 JAMA Internal Medicine trial with 372 older adults showed this method worked. Patients on the Shed-MEDS plan dropped an average of 1.8 medications-and stayed just as safe. Hospitalizations didn’t go up. Side effects didn’t spike. Quality of life improved.

Who Should Be Doing This?

Deprescribing isn’t something a doctor can do in a 7-minute visit. It needs time. Collaboration. And expertise.

Pharmacists are key. In settings where pharmacists lead the process, deprescribing success rates jump by 35-40%. Why? They’re trained in drug interactions, tapering schedules, and patient counseling. They have the time to sit down, review the full list, and talk through concerns.

But in most U.S. primary care offices, pharmacists aren’t part of the team. Doctors are stretched thin. A 2022 Canadian study found only 15% of primary care practices have any formal deprescribing process. That’s not because doctors don’t care. It’s because the system doesn’t support it.

That’s changing. The American Medical Association issued its first deprescribing policy in June 2024, saying doctors should “routinely assess the continuing appropriateness of all medications.” Medicare is also moving forward-starting in 2026, deprescribing metrics will count toward doctor pay under the Merit-Based Incentive Payment System.

What Patients Say

Patients aren’t just passive recipients here. Their input matters.

A 2022 study found 65% of older adults felt relieved when they reduced their pill count. “I stopped feeling like a pharmacy,” one woman said. Another reported better sleep and less confusion after stopping a long-term sleep aid.

But 22% felt anxious. “I’ve taken this pill for 15 years,” one man told researchers. “What if I get sick again?” That fear is real. And it’s why shared decision-making is non-negotiable.

Successful deprescribing doesn’t happen with a note on the chart. It happens with a conversation: “Why did we start this? Is it still helping? What happens if we stop? What would you like your life to look like in six months?”

Barriers and Real-World Challenges

Even with strong evidence, deprescribing still faces big hurdles.

First, most clinical guidelines don’t include deprescribing. A 2024 analysis of 3,569 recommendations found only 7% addressed stopping meds. The rest are about starting them. That creates a blind spot.

Second, electronic health records (EHRs) aren’t built for it. Most systems still default to auto-renewing prescriptions. If a doctor doesn’t actively cancel a refill, the pharmacy sends it again. No one checks.

Third, there’s a lack of case examples. Clinicians say they need more real-world stories: “How do I taper this opioid in someone with chronic pain and depression?” “What if the patient’s family pushes back?”

And then there’s the fear of backlash. Some worry that stopping a med will be blamed if something goes wrong-even if the med was the problem.

Dr. Joseph Teno from Brown University warns against indiscriminate deprescribing. “Some older adults with advanced dementia need certain meds for comfort,” he says. “Taking away a sedative that helps them sleep peacefully isn’t progress-it’s neglect.”

That’s why deprescribing isn’t about cutting meds for the sake of cutting. It’s about aligning treatment with personal goals.

How to Get Started

If you’re a patient or caregiver wondering where to begin:

• Make a complete list of every pill, patch, inhaler, and supplement you take. Include over-the-counter drugs and herbal products.
• Ask your doctor: “Which of these are still necessary? Which might be doing more harm than good?”
• Request a medication review with a pharmacist. Many insurance plans now cover this.
• Don’t stop anything on your own. Tapering is critical for safety.
• Use deprescribing.org’s free tools to prepare for your visit. They have printable checklists and guides for common drugs.

If you’re a clinician:

• Start with one high-risk class-like benzodiazepines or PPIs.
• Use STOPP/START criteria or the Beers Criteria to flag candidates.
• Partner with your pharmacy team. Even one pharmacist can transform your practice.
• Document your decisions clearly: “Deprescribed lorazepam due to fall risk. Tapered over 6 weeks. No withdrawal symptoms.”
• Track outcomes. Did the patient sleep better? Fall less? Feel clearer-headed?

The Future of Deprescribing

The numbers are clear. By 2030, 1 in 6 people worldwide will be over 65. More meds. More side effects. More hospital stays.

But the tools are here. The evidence is strong. The systems are starting to change.

The NIH is funding research to create deprescribing guidelines for antidepressants, anticoagulants, and other complex drugs. AI tools are being built to scan EHRs and flag patients who might benefit from deprescribing. In Canada, the national DIGE program has made deprescribing routine. In the U.S., it’s catching up.

By 2030, experts predict deprescribing assessments will be as common as checking blood pressure. That’s not a dream. It’s a necessity.

Medication isn’t always the answer. Sometimes, less is more. And knowing when to stop is just as important as knowing when to start.