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. Going over that list to cut it down has a name: deprescribing. It is a formal medical discipline with published tools. It is not an admission that something was prescribed by mistake.
Before anything else: do not stop, reduce or change any prescribed medication on your own after reading this. Some medicines must be tapered under a doctor’s care. Stopping certain drugs suddenly — blood pressure medicines among them — can cause rebound effects more dangerous than staying on them. What follows is meant to inform a talk with your prescriber, not to replace one.
Deprescribing is a discipline, not a lapse
STOPP/START is a set of clear rules, organized by body system, that defines important prescribing problems. The STOPP rules flag medicines that may no longer be appropriate. The START rules flag treatments that may be missing.1 It matters that both directions are covered. The framework cares as much about what is missing as about what should come off.
The current version is version 3, published in 2023. Earlier versions came out in 2008 and 2015.1 It was built from a review, system by system, of research published between April 2014 and March 2022. Then it was checked over four rounds of expert voting. The panel had eleven academic doctors from eight European countries, all known experts in medicines for older people.1
If you look this up yourself, check which version you are reading. Summaries online often describe outdated editions.
The path from an over-tight dose to a broken hip
The chain of events worth knowing is specific. A blood pressure dose that is tighter than the person needs can cause orthostatic hypotension. That is a drop in blood pressure when you stand up. It causes dizziness or faintness on rising. That causes falls, and falls cause broken bones and head injuries.
The harm that results has nothing to do with blood pressure. It comes entirely through the fall. That is why an older adult’s medicine list is reviewed as a whole, not one prescription at a time. And it is why fall history belongs in a medicine review.
The statin trade-off, stated plainly
Statins are linked to a modest rise in new type 2 diabetes. It is better to know that than to be surprised by it.
A pooled analysis of 13 randomized statin trials covered 91,140 people. It found statins linked to a 9% higher risk of new diabetes (odds ratio 1.09, 95% CI 1.02–1.17), with little difference between trials. Over about four years on average, 4,278 people developed diabetes. The risk was highest in trials with older people. In real terms, treating 255 patients with a statin for four years caused one extra case of diabetes.2
The authors’ own conclusion must travel with the figure. The risk is low, both in real terms and compared with the drop in coronary events (heart attacks and other heart artery problems). 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 matter.
Where a pain practice fits
Older adults with chronic pain tend to build up the longest medicine lists, because each symptom picks up its own prescription over time. An interventional pain practice can help in one narrow, specific way. It treats the pain at its source, using image-guided procedures aimed at a confirmed pain source. That gives room for the medicine load to come down under the prescriber’s care.
That is all of it. Your blood pressure and heart medicines stay the business of the doctor who prescribes them. What can change is how much pain medicine the pain itself demands. See the range of pain treatments and opioid stewardship. For the behavior part, done in-house, see counseling for chronic pain. When memory or thinking is a concern in the same talk, cognitive assessment is available.
Frequently asked questions
Is deprescribing an admission that my medications were wrong?
No. It is a recognized medical discipline with published, tested rules. They cover both medicines that may no longer fit and treatments that may be missing. A medicine that suited you at 60 may not suit you at 80, without anything having been done wrong. See lifestyle medicine.
Should I stop a medication if I read that it causes falls?
No. Some medicines must be tapered under a doctor’s care. Stopping certain drugs suddenly can cause rebound effects more dangerous than staying on them. Bring the question to your prescriber. How the medicine load is handled alongside pain treatment is described under opioid stewardship.
Do statins cause diabetes?
They are linked to a modest rise in risk — about 9% relative. That works out to one extra case for every 255 people treated for four years. The authors of that analysis concluded the risk is low compared with the drop in coronary events (heart attacks and other heart artery problems). They said practice should not change for people at moderate or high heart 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 source can lower how much pain medicine the pain demands. That 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?
Bring the full list, including doses and anything bought without a prescription. Bring 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 lighten your medicine list, request an appointment, call (314) 481-5000, or text (314) 886-5902. Medicine changes stay a decision for your prescribing doctor.
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
