Durham University's Institute for Medical Humanities (https://www.durham.ac.uk/research/institutes-and-centres/medical-humanities/) organized a 1-workshop on Deprescribing in UK primary care practices. This interdisciplinary workshop brought together general practitioners, pharmacists, mental health practitioners, medical anthropologists, harm reduction advocates, and public health researchers to examine deprescribing as both clinical practice and ethnographic object. Focused on clinicians’ experiences at one of Newcastle’s “deep-end” practices, serving one of the most deprived populations in the country, the event explored why withdrawing medications proves so difficult in practice.
The workshop opened with a stark presentation of prescribing data. Practices serving the most deprived populations prescribe the most opioids and gabapentinoids, with deprivation levels strongly predicting prescription rates. This correlation has multiple interpretations: patients in deprived areas experience more pain and harder lives; alternatively, prescribers facing intense suffering reach for the only tool available. The evidence suggests both dynamics operate simultaneously.
Newer NICE guidance is unambiguous: opioids should not be prescribed for chronic primary pain due to lack of long-term effectiveness and significant harm. Similarly, antidepressants rank ninth among eleven recommended treatments for mild-to-moderate depression, with placebo accounting for the majority of measured improvement. Yet prescribing continues, often against clinicians' better judgment - what one clinician termed "killing with kindness," where the prescription becomes the available medium for expressing compassion toward suffering that has no other institutional response.
The workshop discussions demonstrated that prescriptions are never merely pharmacological. Every prescription simultaneously performs multiple functions: clinical work (managing symptoms), symbolic work (acknowledging suffering as legitimate), economic work (securing welfare benefits), relational work (maintaining therapeutic alliance), and identity work (providing explanatory frameworks for selfhood).
This overdetermination explains why deprescribing can feel threatening. Patients don't simply lose a medication; they risk losing an entire scaffolding of acknowledgment, recognition, and material support built around that prescription over years or decades. The prescription has become load-bearing for structures far beyond symptom management.
Ethnographic research presented at the workshop illustrated this vividly. Patients stockpile medications they never take because benefit assessment forms focus heavily on what is prescribed. The medication isn't treating their condition - it's a bureaucratic resource securing their welfare entitlements, enabling part-time work, and funding survival strategies. Deprescribing in such contexts potentially severs someone's connection to the welfare state entirely independently of any clinical consideration.
At the workshop, I introduced two concepts from Living Value Theory that I found helpful for conceptualizing multimorbidity and polyiatrogenesis: "recursivity levels" and "legibility."
At the most primary level, people live in a flow state of being-in-the-world - not thinking about their bodies, their pain, their temperature. This is L1, primary recursivity. Chronic pain disrupts this, constantly pulling attention back to the body. This is L2, felt misalignment. This is presymbolic, and can be entirely nonsymbolic when it resists articulation. Chronic pain lives on L2 and is notoriously difficult to put into language or numerical scales. Medical practice operates by moving patients up to third-level recursivity: symbolization. Felt misalignment goes to "I am in pain" to diagnostic categories to treatment protocols. Yet this process of making suffering legible has severe limitations. Pain notoriously resists linguistic capture. Numerical rating scales are poor proxies for experiences that cannot properly be made legible.
This creates an impossible position for clinicians. They face enormous pressure for legibility at every level - to patients, to institutions, to potential legal scrutiny - but the legibility demanded simply cannot be achieved. There is no microscope image or biomarker that shows pain. Physicians must show efficacious intervention in domains where the tools for clear evidence of efficacy are ontologically unavailable.
Harm reduction perspectives reframed the deprescribing calculation entirely. For many patients, the actual choice isn't between taking prescribed medications or taking nothing - it's between prescribed supply and illicit market access. When a clinician deprescribes to avoid carrying overdose risk, they make a professionally defensible decision. But if that patient subsequently dies from contaminated street supply, the connection to that clinical decision goes uninvestigated.
Accountability structures render certain deaths visible and others invisible. Prescribed overdoses trigger coroner scrutiny and drug-related death reviews. Post-deprescribing deaths from illicit supply generate no such institutional attention. This asymmetry shapes clinical decision-making in ways that may produce worse aggregate outcomes while appearing individually defensible.
Patients who experience being bounced between systems - told by their GP that their problem belongs to specialist services, told by specialists it's a primary care matter, told by mental health services they're excluded because they use substances - can come to see all clinicians as gatekeepers who put them in danger. The therapeutic relationship becomes defined by dishonesty and strategic presentation of whatever the patient believes each gatekeeper wants to hear.
This dynamic corrupts clinical encounters even for patients who haven't personally experienced such exclusion. The norm of navigating gatekeepers teaches everyone that honest disclosure is risky, that you speak differently to different clinicians, that the system rewards strategic self-presentation over genuine engagement.
The workshop challenged key assumptions underlying much contemporary mental health practice. The presumption that awareness, articulation, and embodiment are inherently healing was contested. Some domains of experience are actively damaged by reflection - athletic performance degrades when overthought; certain psychological states are disrupted by attempts at linguistic capture.
Testimony from people who use dissociative substances suggested an emerging resistance to therapeutic cultures demanding symbolic articulation and clearer awareness. People in genuinely intolerable circumstances may even say that a reflexive insight into their situation and fuller awareness just makes them feel even more miserable. Illicit drugs may be used precisely to not have to sit with the pain. Dissociation in such cases may represent coping rather than pathology requiring correction.
The workshop demonstrated that deprescribing cannot be understood as the simple inverse of prescribing. Because prescriptions have accumulated functions far beyond their pharmacological action - serving as tokens of recognition, bridges to welfare systems, and scaffolding for identity - their withdrawal requires attending to everything that became attached to them.
This suggests that effective deprescribing requires not just clinical protocols but rebuilding alternative structures of acknowledgment, care, and material support. The prescription swelled to carry weight it was never designed to bear because other institutions capable of bearing that weight were dismantled or defunded. Deprescribing responsibly may ultimately require political and social reconstruction as much as clinical intervention.