Winter 2018

Choosing Wisely: Recommendations for Pharmacists to Help Patients Avoid Unnecessary Medications

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By: Karen Born, PhD

Knowledge Translation Lead, Choosing Wisely Canada & Assistant Professor, Institute of Health Policy, Management & Evaluation


Choosing Wisely joined the lexicon of health care just five short years ago with the launch of the campaign in the United States in 2012. Since that time, over 20 countries have created their own national campaigns, including the launch of Choosing Wisely Canada in 2014.

Choosing Wisely has become synonymous with thinking twice about whether that test, treatment and procedure is necessary. It has also encouraged having conversations with patients and colleagues about why more is not always better when it comes to health care. Unnecessary medical tests, treatments and procedures cause harm to patients, and waste precious resources.


Pharmacists play a critical role in avoiding harms associated with medications. There are ever increasing and powerful medications that pharmacists dispense to patients, which can offer tremendous healing and benefits, but can also lead to significant harm if used inappropriately or unnecessarily. There are also social harms of unnecessary medications.

For example, the problem of antimicrobial resistance is directly tied to unnecessary use of antibiotics. Over 50% of antibiotic prescriptions in Canada are unnecessary, and overuse of these powerful medications makes them less effective when our patients really need them to treat bacterial infections.

Choosing Wisely campaigns offer health care professionals the evidence and information needed to think twice, and question whether that test or treatment is really necessary.


In December 2017, the Canadian Pharmacists Association (CPhA) released their list of ‘Six Things Pharmacists and Patients Should Question’. This list is the first pharmacy list in the Choosing Wisely Canada campaign, which launched in 2014 in partnership with the Canadian Medical Association. There are over 280 recommendations from medical specialty societies, and a growing number of other clinician societies (such as the Canadian Nurses Association). Recommendations are developed by societies and identify tests and treatments that are commonly used in each specialty, but are not supported by evidence and can expose patients to harm. In addition, Choosing Wisely Canada has materials for patients and the public which explain why more is not always better and offer plain language information about the harms of unnecessary care.

The CPhA list was developed with the input of members, including practicing pharmacists and pharmacy researchers from coast to coast. This list of six recommendations addresses common problems in pharmacy around unnecessary care and offers an opportunity for pharmacists to question, and engage in conversation with patients and their colleagues.

Recommendation 1.

Don’t use a medication to treat the side effects of another medication unless absolutely necessary.

This recommendation addresses the problem of prescribing cascades, which lead to polypharmacy, which has several associated risks, such as drug interactions, increased frequency or severity of side effects and poor medication adherence. This recommendation reminds pharmacists to question whether a new symptom is an adverse drug reaction, and avoid prescribing additional drug treatment until this possibility has been thoroughly investigated.

Recommendation 2.

Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain. Counsel patients against their use and recommend safe alternatives.

There is no evidence to support the use of low-dose codeine pain medication over non-opioid pain relieving medications. In addition, codeine can cause harm as it is an addictive opioid with potential for abuse. Further, harms from high doses of OTC medications with codeine are significant and include liver toxicity, gastric perforation, haemorrhage and peptic ulcer, renal failure, chronic blood loss anaemia and low blood potassium (with potential fatal heart and neurological complications).

Recommendation 3.

Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient.

Data from Canadian Institute of Health Information (CIHI) has found that two-thirds of Canadians over the age of 65 take five or more different medications and more than 40% of seniors 85 and older take 10 or more drugs. As the number of drugs patients take increases, so too do risks for drug reactions. This recommendation is a reminder to clinicians that before adding an additional medication to a patient’s regimen, especially an elderly patient, it is wise to ask whether the benefit of this medication outweighs potential harms.

Recommendation 4.

Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.

This recommendation adds to the Choosing Wisely Canada lists for Gastroenterology which includes a recommendation questioning long-term use of Proton Pump Inhibitors (PPIs) and supporting patients to taper this medication. PPIs are among the most commonly prescribed drugs in Canada and many are becoming available as over-the-counter medications. While generally safe and well-tolerated for short-term use as needed in the treatment of gastro-esophageal reflux disease (GERD), PPIs can cause harm when used for long term, and in older patients.

Recommendation 5.

Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.

There has been a sharp and alarming increase in the off-label prescribing of atypical antipsychotics for insomnia, especially in young people. This recommendation joins those from Psychiatry which questions this off-label use and suggests to use nonpharmacological measures before a prescription. These include behavioural modifications, and good sleep hygiene as well as short-term use of melatonin.

Recommendation 6.

Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).

A recent CIHI report found that 1 in 10 Canadian seniors regularly takes a benzodiazepines for anxiety disorders and insomnia. Long-term use of benzodiazepines is harmful. Alternatives should be explored prior to prescribing benzodiazepines, and if determined that they are beneficial, it should be for short term use. It is important to discuss discontinuation or tapering strategies to avoid long-term use.

Choosing Wisely Conversations to Avoid Harm

Pharmacists have joined the Choosing Wisely Canada campaign with the release of the above six recommendations. In addition to using these recommendations in practice, Choosing Wisely means having a conversation with patients and your colleagues about when more is not always better.

Check out all of the Choosing Wisely Canada Recommendations.

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