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A low-carb diet can get many people off some of their medication, mainly insulin, diabetes pills and blood pressure drugs. The 2026 guideline from the Society of Metabolic Health Practitioners says some of those doses must come down on the first day, before any weight is lost. That is why the cuts belong to a prescriber.

Most deprescribing is slow. A drug is reviewed, a taper is planned, and the dose steps down over weeks. Low-carb eating flips that order. The food changes on Monday, and by Wednesday the old doses can be too strong. The medicine list has to move first, or the diet itself becomes the danger.

Which medicines come down when carbs come down?

The guideline, published October 2, 2026, gives a drug-by-drug summary. It was adapted from earlier work by Dr. Mark Cucuzzella and colleagues. Here it is in plain words.

Medicine	What the guideline says	Why
Insulin	Cut by about half right away. Stop mealtime insulin on a very low-carb diet.	Less carbohydrate means less insulin is needed. Lows are the risk.
Sulfonylureas and meglitinides	Stop right away.	They can drive blood sugar too low.
SGLT2 inhibitors	Stop, or use with caution. The effect lasts up to a week.	They add to fluid loss and need ketone checks.
Thiazolidinediones	Usually stop.	The prescriber weighs risks and benefits.
Metformin, DPP-4 inhibitors, GLP-1 drugs	Safe to keep.	Listed as safe to use.
Blood pressure drugs	Review at the start, then every 2 to 4 weeks.	Salt and water loss lowers blood pressure.

Diuretics and other drugs that move potassium need extra monitoring. So does anyone on many medicines at once. The guideline puts polypharmacy on its list of situations that call for specialist supervision.

Why does the dose have to drop on day one?

Because the body responds in hours, not months. When carbs drop, blood sugar drops and insulin falls with it. Lower insulin tells the kidneys to release sodium and water. Blood pressure falls. A pill that was holding pressure down is now pushing it too low.

Insulin is the sharpest edge. The guideline says the first two to three days carry the greatest risk of a severe low. In an older adult, a low or a dizzy stand-up is how a fall starts. Our page on blood pressure drugs, orthostatic hypotension and falls covers that chain.

Every dose change is made by the prescriber, never by the patient or family alone. That is most true for insulin, sulfonylureas, SGLT2 inhibitors and blood pressure drugs.

Dr. Padda knows the other side of this from the inside. For years he told patients with prediabetes that their A1C was “not too bad.” The care he had been trained to give treated each reading with a pill. Nothing treated the insulin resistance underneath, so the list kept growing.

That is the engine behind many long medication lists. High insulin and the metabolic inflammation it feeds push up sugar, blood pressure and triglycerides together. A food supply full of cheap starch keeps insulin high. Then a care system paid per visit and per prescription answers each number with a drug. Carbohydrate reduction works on the first link of that chain, which is why several drugs can come off at once.

Can I stop insulin completely?

Many adults with type 2 diabetes can. The guideline says adults with stable blood sugar can often stop insulin once they need less than 10 units a day. A blood test called C-peptide confirms the body still makes its own insulin.

Some people labeled type 2 actually make too little insulin. The guideline lists warning signs to check first:

• diagnosis at a younger age, or needing insulin within five years
• still needing insulin after weight loss or weight-loss surgery
• blood sugar that swings widely, or a past episode of ketoacidosis
• not overweight at diagnosis, or normal triglycerides with high HDL
• a personal or family history of autoimmune disease, or pancreatitis

Any of these means the insulin may need to stay.

Can medications kick you out of ketosis?

Some can. The guideline lists drugs that may raise blood sugar or interfere with ketosis. They include corticosteroids, statins, beta blockers, thiazide diuretics, antipsychotics, lactulose and inulin. A second group may block fat breakdown: niacin, beta blockers, fluoxetine, and some antipsychotics such as olanzapine and quetiapine.

None of this is a reason to stop a drug on your own. It is a reason for the prescriber to look at the whole list together. A few drugs need blood levels checked when the diet changes: lithium, valproic acid and warfarin. People with bipolar disorder or other mental health diagnoses may do better with a gradual start, because mood can shift during the change. The guideline also notes that reflux, joint pain and migraine can improve as metabolic health improves, so those drugs deserve a second look later.

How do you track it at home?

With a cuff, a meter and a notebook. The guideline asks patients to check blood pressure every day. People with diabetes also check blood sugar daily, including some readings one to two hours after a meal. A continuous glucose monitor is not required. One study found it no better than fingersticks.

Write every reading down, with the date and any symptom. Light-headedness, cramps and headache are common in the first two to three days and can last two to four weeks. Most come from salt and water loss. The guideline suggests 2 to 3 grams of sodium a day for most people, plus potassium-rich greens and vegetables. Family members can help keep the log, and the guideline encourages including them. Bring it to every review. It is how the prescriber decides which dose comes down next.

How much weight does a consensus guideline carry?

It is expert agreement, not a trial. Twenty-six of 28 participants voted in the final round, and all 18 statements cleared a 70% bar. The literature review was not systematic, and the evidence was not formally graded. Several authors have paid ties to the society or its conference business.

The core claim, though, is already mainstream. The American Diabetes Association’s 2025 Standards of Care say low-carb eating reduces A1C and the need for glucose-lowering medication. Dr. Padda holds this society’s Metabolic Health Practitioner credential. He was not an author or panelist.

A shorter list, on purpose

A medication list usually grows by accident, one reading at a time. Carbohydrate reduction lets it shrink by design. Lower insulin first. Then the drugs that were chasing high sugar and high pressure come off in order, with a plan for each.

Ask the prescriber three questions before the first low-carb meal. Which doses change today? What readings should I log? When is the next review? Ask about fasting insulin too. Dr. Padda treats a fasting insulin above 10 µIU/mL as high risk, because insulin rises years before blood sugar does.

Frequently asked questions

What are the symptoms of carbohydrate withdrawal?

Headache, tiredness, light-headedness, poor focus, mood changes, cravings, muscle cramps and constipation are common. They usually start within two to three days and pass in a few days, sometimes two to four weeks. Most come from salt and water loss, so enough sodium and at least 2 liters of fluid a day help.

Do I have to stop metformin on a low-carb diet?

No. The guideline lists metformin as safe to keep, along with DPP-4 inhibitors and GLP-1 drugs. Whether you still need it later is a question for your prescriber.

Is a low-carb diet safe with kidney disease?

It can be, with a doctor’s plan. The guideline aims for about 0.8 grams of protein per kilogram of body weight a day in kidney disease. Magnesium for cramps is not used in kidney disease without the doctor’s say, and the whole list needs review.

References

1. Rice SM, Buchanan LA, Calkins MW, Cucuzzella MT, Cywes R, Devine PL, Kalamian M, Kalayjian T, Reynolds DB, Westman EC. A Delphi consensus-based guideline for the implementation of therapeutic carbohydrate reduction in metabolic disorders. Journal of Metabolic Health. 2026;9(1):a152. DOI 10.4102/jmh.v9i1.152.

Opioid tapering carries measurable risk: in a cohort of 113,618 adults on long-term opioids, tapering was associated with more overdose, withdrawal and mental health crisis events, and faster reductions raised both. The lever that is not the dose is treating the pain generator, so the dose falls because the input fell.

A dose reduction is not a treatment. It is a change to one number, and whether it helps or harms depends entirely on what else was changed at the same time.

Is opioid tapering dangerous?

This site’s tapering principles hold that a taper and a withdrawal differ by four things: agreement, rate, monitoring, and a way back. The opioid literature is where that claim has been most expensively tested.

In a retrospective cohort of 113,618 adults on stable long-term therapy at 50 morphine milligram equivalents a day or more, tapering was associated with an adjusted 9.3 overdose or withdrawal events per 100 person-years against 5.5 in non-tapered periods (aIRR 1.68), and 7.6 mental health crisis events against 3.3 (aIRR 2.28). Rate mattered independently: each 10% increase in maximum monthly dose-reduction velocity carried an aIRR of 1.09 for overdose and 1.18 for mental health crisis.

A companion analysis followed the same population further out and found the elevated rates persisting into the second year after taper initiation — 1.57 for overdose or withdrawal and 1.52 for mental health crisis, comparing post-induction with pre-taper periods.

Both are observational, and the authors say so. Sicker patients get tapered, and that confounding cannot be fully removed. But the direction is consistent, the dose-response on velocity is what you would predict if the mechanism were real, and nothing in the deprescribing literature suggests the opposite.

What lowers an opioid dose besides a taper?

The policy response of the last fifteen years treated quantity as the only available variable. It is not the only one, and the alternative is not a slower version of the same maneuver.

Sustained opioid exposure produces tolerance, in which the drug still works but more is required, and can produce opioid-induced hyperalgesia, in which the nervous system is recalibrated toward pain and additional drug makes it worse. The mechanisms proposed for the latter center on the central glutamatergic system and NMDA receptor activation, spinal dynorphin, and descending facilitation. Where hyperalgesia is operating, one review states plainly that further opioid prescribing is largely futile.

The clinically useful consequence is the one that gets least attention: a 2019 review notes that interventional techniques which reduce pain input can permit a dose decrease and, in doing so, revert the mechanisms producing tolerance and hyperalgesia. The dose falls because the input fell. That is a different event from a taper, and it is the event the four conditions above are trying to approximate when no such option exists.

Can treating the pain source get patients off opioids?

On International Overdose Awareness Day in August 2026, Dr. Gurpreet Singh Padda — who directs the clinical positions this site is built on — published the opioid figures from his interventional pain practice.

• Average arrival: more than 90 MME per day, after more than two and a half years in pain.
• 21% completely off opioid pain medication within 90 days of active interventional treatment; 34% within one year.
• Of those not fully weaned, the large majority held below 30 MME per day.

These are practice-reported figures from a single population, not trial outcomes, and individual results vary. There is no control arm, no independent adjudication and no randomization; they cannot be read as evidence that this approach outperforms another. What they do illustrate is the mechanism — a population in which the dose fell as a downstream consequence of treating pain generators, rather than as the primary intervention. Reported by AP News; full release.

For contrast on what dose reduction achieves without that: a randomized trial of a group-based self-management program in 608 primary-care patients on strong opioids produced a large increase in discontinuation at 12 months (29% versus 7%) and no improvement in pain interference. Getting people off the drug and improving their lives are two different endpoints, and they can move independently.

Is opioid tapering different for older adults?

The patients this site concerns are rarely on opioids alone. They are on opioids inside a list, frequently with sedatives, and the interaction risk is what turns a modest dose into a fall or a delirium. That argues for reduction. The tapering data argue for reducing carefully, with monitoring and a way back — and for asking, before starting, what is generating the pain and whether anything can be done about it directly. See opioids in older adults and the deprescribing framework.

The summary a prescriber can act on: a taper is arithmetic, and arithmetic performed on a patient whose pain generator is untreated is the scenario the cohort studies were measuring.

Frequently asked questions

Do opioids need to be tapered instead of stopped all at once?

Yes. Opioids cause a withdrawal syndrome when they are stopped abruptly, so they have to be reduced gradually under a prescriber’s supervision. Never stop or change a prescribed opioid on your own. A taper done well rests on four things: your agreement, a sensible rate, monitoring along the way, and a way back if the reduction goes badly.

Is it dangerous to taper opioids too fast?

Speed matters. In a study of 113,618 adults on long-term opioids, tapering was linked to more overdose, withdrawal and mental health crisis events, and each 10% increase in how fast the monthly dose dropped raised those risks further. The higher rates lasted into the second year. The study was observational, but the pattern points the same way throughout.

Why can long-term opioids make pain worse?

Two things happen with sustained use. Tolerance means the drug still works, but more is needed. Opioid-induced hyperalgesia goes further: the nervous system is reset toward pain, and more of the drug makes pain worse. Where hyperalgesia is at work, one review states that prescribing more opioids is largely futile. Lowering the pain input is what lets that process reverse.

Does getting off opioids make pain better?

Not on its own. In a randomized trial of 608 primary-care patients on strong opioids, a group self-management program raised the share who stopped opioids at 12 months from 7% to 29%, yet pain interference did not improve. Coming off the drug and feeling better are separate goals. The answer here is to treat what is generating the pain, so the dose falls because the pain input fell.

How many patients come off opioids when the pain source is treated?

In Dr. Padda’s interventional pain practice, arriving patients average more than 90 MME per day after more than two and a half years in pain. With active interventional treatment, 21% are completely off opioid pain medication within 90 days and 34% within one year. These are practice-reported figures from his own population, not trial outcomes, and individual results vary.

References

1. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. JAMA. 2021;326(5):411–419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
2. Fenton JJ, Magnan E, Tseregounis IE, Xing G, Agnoli AL, Tancredi DJ. Long-term risk of overdose or mental health crisis after opioid dose tapering. JAMA Network Open. 2022;5(6):e2216726. PMID 35696163 · DOI 10.1001/jamanetworkopen.2022.16726.
3. Mercadante S, Arcuri E, Santoni A. Opioid-induced tolerance and hyperalgesia. CNS Drugs. 2019;33(10):943–955. PMID 31578704 · DOI 10.1007/s40263-019-00660-0.
4. Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia — when is enough too much? A review of opioid-induced tolerance and hyperalgesia. The Lancet. 2019;393(10180):1558–1568. PMID 30983591 · DOI 10.1016/S0140-6736(19)30430-1.
5. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145–161. PMID 21412369.
6. Sandhu HK, Booth K, Furlan AD, et al. Reducing opioid use for chronic pain with a group-based intervention: a randomized clinical trial. JAMA. 2023;329(20):1745–1756. PMID 37219554 · DOI 10.1001/jama.2023.6454.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its PubMed record and DOI.

The most quoted number in this field is that adverse drug events cause roughly 100,000 emergency hospitalizations a year among older Americans. The number is real. The argument that usually follows it is not.

How many older adults are hospitalized for adverse drug events each year?

National active surveillance data for adults aged 65 and over produced an estimate of 99,628 emergency hospitalizations per year for adverse drug events (95% CI 55,531 to 143,724), with 48.1% of those in adults aged 80 and over. That is a sound figure from a sound study.

Which drugs cause the most adverse drug event hospitalizations?

Four drugs or classes accounted for 67.0% of those hospitalizations: warfarin 33.3%, insulins 13.9%, oral antiplatelets 13.3% and oral hypoglycemics 10.7%.

And the sentence that almost never travels with the headline figure: “High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations.” A 2016 update using the same surveillance system put medications on the Beers “always avoid” list at 1.8% of emergency department visits for adverse drug events.

Why this matters for a deprescribing program

The argument usually built on the 100,000 figure runs: adverse drug events cause enormous harm, therefore we should reduce potentially inappropriate prescribing. The first half is true. The second does not follow from it, because the drugs causing that harm are overwhelmingly anticoagulants and diabetes agents — drugs that in most cases should not be stopped.

What those drugs need is better dosing, better monitoring, better follow-up on renal function and on hypoglycemia. That is a different program from a Beers-list review, it requires different work, and pointing the 100,000 figure at the Beers list actively directs attention away from where the harm is.

The honest version

There are strong reasons to review and reduce potentially inappropriate prescribing in older adults. The best of them is that a large share of long-term care prescriptions are treating nothing at all — 65.3% of proton pump inhibitor prescriptions in one US skilled-nursing study had no supporting diagnostic code. A drug treating nothing carries only risk, and that argument does not need to borrow a statistic that is about something else.

Read more: The AGS Beers Criteria — what it is and what it is not.

Frequently asked questions

What medications cause the most serious side effects in older adults?

In national surveillance of adults 65 and older, four drugs or classes accounted for 67.0% of emergency hospitalizations for adverse drug events: warfarin (33.3%), insulins (13.9%), oral antiplatelets (13.3%) and oral hypoglycemics (10.7%). Those are blood thinners and diabetes medicines. The drugs labeled high-risk were implicated in only 1.2% of the same hospitalizations.

Which older adults are most often hospitalized for a drug reaction?

The oldest. Of the roughly 100,000 emergency hospitalizations for adverse drug events each year among Americans 65 and older, 48.1% were in adults aged 80 and over. Most of those admissions trace back to blood thinners and diabetes medicines, so better dosing, monitoring and follow-up for those drugs aim at where the harm actually is.

Are Beers list drugs the main cause of adverse drug event hospitalizations?

No. The study behind the 100,000 figure found high-risk medications in only 1.2% of those hospitalizations. A 2016 update using the same surveillance system put drugs on the Beers “always avoid” list at 1.8% of emergency department visits for adverse drug events. The harm sits mainly with anticoagulants and diabetes agents, not with the Beers list.

Should blood thinners and diabetes medicines be stopped to prevent adverse drug events?

In most cases, no. Warfarin, insulins, oral antiplatelets and oral hypoglycemics cause most of these hospitalizations, yet they are drugs that usually should not be stopped. What they need is better dosing, closer monitoring, and follow-up on kidney function and low blood sugar. That is a different program from a Beers-list review, and it takes different work.

References

1. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. The New England Journal of Medicine. 2011;365(21):2002–2012. PMID 22111719 · DOI 10.1056/NEJMsa1103053.
2. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115–2125. PMID 27893129 · DOI 10.1001/jama.2016.16201.
3. Patterson Burdsall D, Flores HC, Krueger J, et al. Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities. Journal of the American Medical Directors Association. 2013;14(6):429–432. PMID 23583000 · DOI 10.1016/j.jamda.2013.01.021.
4. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.

If you have seen something called “The 2026 AGS Beers Criteria,” it is not an American Geriatrics Society publication. There is no 2026 edition.

What is the latest version of the Beers Criteria?

The current edition is the 2023 update, published in the Journal of the American Geriatrics Society. Before it, 2019. The Society publishes on a multi-year cycle and has not issued a 2026 edition.

What did appear in 2025 is a separate document: an Alternatives List, offering pharmacologic and non-pharmacologic substitutes for medications the criteria flag. It is a companion to the 2023 criteria, not a replacement for them, and citing it as a new edition is an error.

Why it matters more than a citation nitpick

Because these criteria get embedded in policies, order sets and audit tools, and a policy citing a version that does not exist cannot be traced back to anything. On a clinical page or in a facility protocol, the version and year are the load-bearing part of the citation.

The same caution applies to STOPP/START, where criteria counts from superseded versions circulate widely and get attached to the wrong version. Version 3 was published in 2023, and it has a published correction that should be cited alongside it.

How should the Beers Criteria be used?

Worth repeating whenever the list is quoted: the criteria “should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.” They also explicitly exclude hospice and end-of-life care, an exclusion that is routinely ignored.

Read more: The AGS Beers Criteria · STOPP/START.

Frequently asked questions

What medications are included in the 2026 AGS Beers Criteria?

None, because there is no 2026 AGS Beers Criteria. The American Geriatrics Society has not published a 2026 edition. The current edition is the 2023 update in the Journal of the American Geriatrics Society. A document titled “The 2026 AGS Beers Criteria” is not a Society publication, and a policy that cites it cannot be traced back to anything.

Is there a 2025 Beers Criteria?

No new edition came out in 2025. What the American Geriatrics Society published in 2025 is a separate Alternatives List, which offers drug and non-drug substitutes for medications the criteria flag. It is a companion to the 2023 criteria, not a replacement for them, so citing it as a new edition is an error.

What are the limitations of the Beers Criteria?

The Society itself says the criteria should be applied thoughtfully and in a way that supports, rather than replaces, shared clinical decision-making. They also explicitly exclude hospice and end-of-life care, an exclusion that is routinely ignored when the list is quoted.

Why does the Beers Criteria version year matter?

Because the criteria get built into facility policies, order sets and audit tools. A policy that cites a version that does not exist cannot be traced back to anything. On a clinical page or in a facility protocol, the version and year carry the citation. The same caution applies to STOPP/START, whose version 3 was published in 2023 with a published correction.

References

1. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
2. By the 2025 AGS Alternative Treatments Panel. Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria. Journal of the American Geriatrics Society. 2025;73(9):2657–2677. PMID 40697073 · DOI 10.1111/jgs.19500.
3. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. PMID 37256475 · DOI 10.1007/s41999-023-00777-y. See also the published correction, Eur Geriatr Med. 2023;14(4):633, PMID 37326916.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.

In its 2022 opioid guideline, the CDC said policies drawn from its 2016 guideline had been misapplied through rapid tapers, abrupt discontinuation, rigid dose thresholds and patient abandonment, and that this contributed to patient harm.

The CDC did something unusual in 2022. It published a guideline that described, in its own text, how its previous guideline had been misapplied and what that misapplication cost patients.

What did the CDC say about misapplication of its 2016 opioid guideline?

From the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain:

“Of particular concern, some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations. Such misapplication includes extension to patient populations not covered in the 2016 CDC Opioid Prescribing Guideline (e.g., cancer and palliative care patients), rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment, duration limits by insurers and pharmacies, and patient dismissal and abandonment. These actions are not consistent with the 2016 CDC Opioid Prescribing Guideline and have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

What changed in the 2022 CDC opioid guideline?

• Dosage thresholds were removed from the recommendation statements, deliberately, “to discourage the misapplication of opioid pain medication dosage thresholds as inflexible standards.”
• Tapering recommendations were substantially expanded.
• The recommendation on not stopping abruptly is explicit: “Unless there are indications of a life-threatening issue such as warning signs of impending overdose… opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.”
• The guideline states its own status: it “should not be applied as inflexible standards of care” by health systems, pharmacies, payers, or any level of government.

Why this belongs on a long-term care site

Because the mechanism that produced the harm is not specific to opioids. It was a number applied to a population, without the individual entering the calculation, by people who had never met them. A nursing home pursuing a percentage reduction on any drug class is running the same mechanism, in a population less able to object.

The withdrawal evidence for antipsychotics illustrates the point precisely: most residents can come off safely, and a specific, identifiable minority — those who responded well to the drug, and those with more severe baseline symptoms — are likelier to relapse. A program chasing the number finds them the hard way, and their relapse does not appear in the measure.

Read more: Opioids in older adults · Measuring what changed.

Frequently asked questions

Did the 2022 CDC guideline remove opioid dose limits?

It removed dosage thresholds from its recommendation statements, and it says it did so deliberately, to discourage the misapplication of those thresholds as inflexible standards. The guideline also states that it should not be applied as an inflexible standard of care by health systems, pharmacies, payers or any level of government.

Should opioids be stopped abruptly?

Not under the 2022 CDC guideline. Unless there are signs of a life-threatening issue, such as warning signs of an impending overdose, opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce doses from higher dosages. The same guideline substantially expanded its tapering recommendations.

What harm came from misapplying the 2016 CDC opioid guideline?

In its own words, the CDC listed untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior. It tied that harm to rapid tapers and abrupt discontinuation, rigid dose thresholds, insurer and pharmacy duration limits, and patient dismissal and abandonment.

Did the 2016 CDC opioid guideline apply to cancer and palliative care patients?

No. The 2022 guideline names the extension of the 2016 recommendations to cancer and palliative care patients as one form of misapplication. It lists that alongside rapid tapers, rigid dose thresholds and applying pain-prescribing rules to medications for opioid use disorder, and says these actions were not consistent with the 2016 guideline.

References

1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
2. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411–419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
3. Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283. PMID 32131996 · DOI 10.1136/bmj.m283.
4. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Sort the medication list by start date. That is the whole technique, and it takes about five minutes.

Why sort a medication list by start date?

A list sorted alphabetically, or grouped by drug class, is optimized for finding a drug you already have in mind. A list sorted by the date it was started is optimized for finding a pattern — and the two most consequential patterns in a long medication list are both patterns in time.

What is a prescribing cascade?

A drug causes a symptom. The symptom is read as a new condition. The new condition is treated. Every step is defensible; nobody made an error; and the sequence is invisible unless somebody looks at the order.

What you are looking for is a medication started within weeks to a few months of another, treating a recognized effect of the earlier one, with no note recording that the earlier drug was reconsidered first. That last part is the diagnostic bit. “Reviewed X, symptom persisted, adding Y” is not a cascade. Silence is.

What is a drug substitution?

The other pattern is a drug appearing as another one is reduced. It is easy to miss because it looks like success on the class you were watching.

The clearest documented example: among Ontario nursing home residents dispensed an opioid between 2009 and 2020, concurrent benzodiazepine use fell by 53.2% in relative terms while concurrent gabapentinoid use rose by 505.4%. In US nursing homes in 2021, gabapentin was the agent most frequently involved in central nervous system polypharmacy. A class was reduced and the burden reappeared under a different heading.

How do you find a prescribing cascade in a medication list?

For every drug started in the past two years, ask what happened in the eight weeks before it. That is it. It is the highest-yield five minutes available in a medication review, and it requires no tool.

Read more: Prescribing cascades · The medication review.

Frequently asked questions

How can you tell a prescribing cascade from a justified new prescription?

Read the notes. A cascade is a medication started within weeks to a few months of another, treating a recognized effect of the earlier drug, with no record that the earlier drug was reconsidered first. A note that says the earlier drug was reviewed, the symptom persisted, and a new drug was added is not a cascade. Silence is.

Why is a prescribing cascade so hard to spot?

Every step looks reasonable on its own. A drug causes a symptom, the symptom is read as a new condition, and the new condition is treated. Nobody made an error, so nothing gets flagged. The sequence only shows up when someone looks at the order in which the drugs were started.

What does it mean when a new drug appears as another is reduced?

That is a substitution, and it can look like success on the drug class being watched. Among Ontario nursing home residents dispensed an opioid from 2009 to 2020, concurrent benzodiazepine use fell 53.2% in relative terms while concurrent gabapentinoid use rose 505.4%. The class was reduced, and the burden reappeared under a different heading.

How long does a medication list review for cascades take?

The date-order check takes about five minutes and needs no special tool. Sort the list by start date. For every drug started in the past two years, ask what happened in the eight weeks before it. It is the highest-yield five minutes available in a medication review.

References

1. Hogan DB, Campitelli MA, Bronskill SE, et al. Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents. Journal of the American Geriatrics Society. 2023;71(8):2462–2475. PMID 36942992 · DOI 10.1111/jgs.18320.
2. Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
3. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.

On January 1, 2026, CMS respecified the long-stay nursing home antipsychotic measure: the numerator now draws on pharmacy claims, and the schizophrenia, Tourette and Huntington’s exclusions now require a matching diagnosis in claims and encounter data. Rates under the new specification run higher for a methodological reason, not because prescribing rose.

If you track the national nursing home antipsychotic rate, the number you are looking at after January 1, 2026 is not measuring the same thing as the number before it.

What changed in the CMS antipsychotic measure in 2026?

The long-stay antipsychotic quality measure was respecified effective January 1, 2026. Two changes matter.

• The numerator now draws on pharmacy claims as well as the resident assessment item.
• The diagnosis exclusions now require corroboration. Under the previous specification, a coded diagnosis of schizophrenia, Tourette syndrome or Huntington’s disease on the assessment excluded a resident from the measure. Under the current one, the exclusion requires both the assessment item and a matching diagnosis in claims and encounter data.

Why did CMS change the antipsychotic measure?

In January 2023 CMS announced audits of schizophrenia coding, stating that it “is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use,” and that “when nursing home residents are given erroneous schizophrenia diagnoses, they are subject to poor care and unnecessary antipsychotic medications, both of which can be very dangerous.” Its pilot audit found “an absence of comprehensive psychiatric evaluations and behavior documentation,” with recorded behaviors “related to dementia, rather than schizophrenia.”

Can old and new nursing home antipsychotic rates be compared?

Do not plot figures from the two specifications on one line. The internally consistent national series is the one CMS reports for the Partnership: 23.9% in the fourth quarter of 2011 falling to 14.2% in the second quarter of 2025, a relative decrease of 40.6%. Figures produced under the new specification are higher for a methodological reason and not because prescribing rose.

CMS states plainly, and it is worth quoting when a facility feels pressure from this number, that circumstances exist where clinical indications for antipsychotics are present and that it “does not expect that the national prevalence of antipsychotic medication use will decrease to zero.”

The larger point

A measure creates pressure toward the measured number, and the pressure lands on whoever is closest to it. The coding problem CMS describes is what that pressure produced last time. A measure that is harder to game is an improvement; it is not a substitute for reviewing each resident individually, and the withdrawal evidence is specific about who relapses when a program stops doing that.

Read more: Antipsychotics and mortality in dementia · Measuring what changed.

Frequently asked questions

What is the new CMS antipsychotic measure for nursing homes?

Since January 1, 2026, the long-stay nursing home antipsychotic quality measure counts antipsychotic use from pharmacy claims as well as the resident assessment. Its exclusions for schizophrenia, Tourette syndrome and Huntington’s disease now require both the assessment item and a matching diagnosis in claims and encounter data. A coded diagnosis on the assessment alone no longer excludes a resident.

Why are nursing homes being audited for schizophrenia diagnoses?

In January 2023 CMS announced audits of schizophrenia coding. It said some nursing homes had erroneously coded residents as having schizophrenia, which can mask a facility’s true rate of antipsychotic use and expose residents to unnecessary antipsychotics. Its pilot audit found missing psychiatric evaluations and recorded behaviors that related to dementia rather than schizophrenia.

Did antipsychotic use in nursing homes go up in 2026?

Rates reported under the new specification run higher, but for a methodological reason, not because prescribing rose. The measure now counts pharmacy claims and makes the diagnosis exclusions harder to meet. On the consistent national series CMS reports for its dementia-care Partnership, use fell from 23.9% in late 2011 to 14.2% in the second quarter of 2025.

Does CMS expect antipsychotic use in nursing homes to reach zero?

No. CMS states that circumstances exist where clinical indications for antipsychotics are present, and that it does not expect the national prevalence of antipsychotic use to decrease to zero. A measure that is harder to game is an improvement, but it is not a substitute for reviewing each resident individually.

References

1. Centers for Medicare & Medicaid Services. Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute. Memorandum QSO-23-05-NH, January 18, 2023. cms.gov. 2023. https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf.
2. Centers for Medicare & Medicaid Services. National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report. cms.gov. 2026. https://www.cms.gov/files/document/data-report-national-partnership-improve-dementia-care-nursing-homes-antipsychotic-medication-use.pdf.
3. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.