In an older adult carrying chronic pain, a long medication list is not several separate problems. It is one list, one person, and one fall. Reviewing that list with a view to reducing it has a name — deprescribing — and it is a formal clinical discipline with published tools, not an admission that something was prescribed in error.
Before anything else: do not stop, reduce or change any prescribed medication on your own after reading this. Some medications must be tapered under supervision, and abrupt withdrawal of certain drugs — blood pressure medications among them — can cause rebound effects that are more dangerous than continuing. What follows is intended to inform a conversation with your prescriber, not to replace one.
Deprescribing is a discipline, not a lapse
STOPP/START is a physiological systems-based, explicit set of criteria that defines clinically important prescribing problems: potentially inappropriate medications, which are the STOPP criteria, and potential prescribing omissions, which are the START criteria.1 It matters that both directions are covered — the framework is as concerned with what is missing as with what should come off.
The current version is version 3, published in 2023, following earlier versions in 2008 and 2015.1 It was produced from a system-by-system review of literature published between April 2014 and March 2022, then validated over four rounds of Delphi consensus by a panel of eleven academic physicians with recognized expertise in geriatric pharmacotherapy from eight European countries.1
If you look this up yourself, check which version you are reading. Summaries circulating online frequently describe superseded editions.
The path from an over-tight dose to a broken hip
The sequence worth understanding is specific. A blood pressure dose that is tighter than the person needs can produce orthostatic hypotension — a drop in blood pressure on standing. That causes dizziness or faintness on rising, which causes falls, which cause fractures and head injuries.
The resulting harm has nothing to do with blood pressure. It arrives entirely through the fall. This is why a medication list in an older adult is reviewed as a whole rather than one prescription at a time, and why fall history belongs in a medication review.
The statin trade-off, stated plainly
Statins are associated with a modest increase in new-onset type 2 diabetes, and it is better to know that than to encounter it as a surprise.
A collaborative meta-analysis of 13 randomised statin trials covering 91,140 participants found statin therapy associated with a 9% increased risk of incident diabetes (odds ratio 1.09, 95% CI 1.02–1.17), with little heterogeneity between trials. Over a mean of four years, 4,278 participants developed diabetes. The risk was highest in trials with older participants. In absolute terms, treating 255 patients with a statin for four years resulted in one extra case of diabetes.2
The authors’ own conclusion is the part that must travel with the figure: the risk is low both in absolute terms and compared with the reduction in coronary events, and clinical practice in patients with moderate or high cardiovascular risk or existing cardiovascular disease should not change.2
So this is a trade-off to discuss, never a reason to stop a statin on your own. Both halves of that sentence are load-bearing.
Where a pain practice fits
Older adults living with chronic pain tend to accumulate the longest medication lists, because each symptom attracts its own prescription over time. The contribution an interventional pain practice can make is narrow and specific: treat the pain at its source, using image-guided procedures aimed at a confirmed generator, so that the medication burden has room to come down under the prescriber’s supervision.
That is the whole of it. Your blood pressure and cardiac medications remain the business of the physician who prescribes them. What can change is how much analgesia the pain itself demands — see the range of pain treatments, opioid stewardship, and for the behavioral component delivered in-house, counseling for chronic pain. Where cognition is a concern in the same conversation, cognitive assessment is available.
Frequently asked questions
Is deprescribing an admission that my medications were wrong?
No. It is a recognized clinical discipline with published, validated criteria covering both medications that may no longer be appropriate and treatments that may be missing. A medication that suited you at 60 may not suit you at 80 without anything having been done incorrectly. See lifestyle medicine.
Should I stop a medication if I read that it causes falls?
No. Some medications must be tapered under supervision, and stopping certain drugs abruptly can cause rebound effects more dangerous than continuing. Bring the question to your prescriber. How medication burden is approached alongside pain treatment is described under opioid stewardship.
Do statins cause diabetes?
They are associated with a modest increase in risk — about 9% relative, amounting to one extra case for every 255 people treated for four years. The authors of that meta-analysis concluded the risk is low compared with the reduction in coronary events and that practice should not change for people at moderate or high cardiovascular risk. It is a trade-off to discuss, not a reason to stop. See lifestyle medicine.
How does treating my pain reduce my medication list?
Indirectly. Treating a confirmed pain generator can lower how much analgesia the pain demands, which gives your prescriber room to review the wider list. The procedures are described across the range of pain treatments.
What should I bring to a medication review?
The full list including doses and anything bought without a prescription, plus a record of any falls, dizziness on standing, or near-falls. That history changes how the list is read. To discuss the pain side, use the appointment request form.
To discuss pain treatment that may reduce what your medication list has to carry, request an appointment, call (314) 481-5000, or text (314) 886-5902. Medication changes remain a decision for your prescribing physician.
Sources
- O’Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, Gudmundsson A, Cruz-Jentoft AJ, Knol W, Bahat G, van der Velde N, Petrovic M, Curtin D. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. doi:10.1007/s41999-023-00777-y. Retrieved via PubMed. DOI
- Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. The Lancet. 2010;375(9716):735–742. doi:10.1016/S0140-6736(09)61965-6. Retrieved via PubMed. DOI
Dr. Gurpreet Singh Padda, MD, MBA, MHP
