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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes
Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
Precision Medicine and Sharing Medical Data in Real Time: Opportunities and Barriers
Y. Tony Yang, ScD, and Brian Chen, PhD, JD
Levers to Reduce Use of Unnecessary Services: Creating Needed Headroom to Enhance Spending on Evidence-Based Care
Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
From the Editorial Board: Michael E. Chernew, PhD
Michael E. Chernew, PhD
Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility
David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
Baseline and Postfusion Opioid Burden for Patients With Low Back Pain
Kevin L. Ong, PhD; Kirsten E. Stoner, PhD; B. Min Yun, PhD; Edmund Lau, MS; and Avram A. Edidin, PhD
Patient and Physician Predictors of Hyperlipidemia Screening and Statin Prescription
Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
Evaluating HCV Screening, Linkage to Care, and Treatment Across Insurers
Karen Mulligan, PhD; Jeffrey Sullivan, MS; Lara Yoon, MPH; Jacki Chou, MPP, MPL; and Karen Van Nuys, PhD
Currently Reading
Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population
Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD

Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population

Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD
This study evaluated a passive clinical pharmacist intervention to reduce the coprescribing of benzodiazepines and opioid analgesics by using chart review notes to alert providers.

Objectives: Combination opioid and benzodiazepine (BZD) therapy is associated with poor treatment outcomes and increased risk of overdose death. There is currently limited literature detailing well-implemented strategies to minimize dual prescribing of these agents. The following describes the implementation processes and outcomes of a health system quality improvement project that aimed to reduce combination BZD and opioid therapy. 

Study Design: A retrospective chart review–based quality improvement project.

Methods: All patients within a single healthcare system of the Department of Veterans Affairs treated with long-term (>90 days) combination therapy were identified. A psychiatric pharmacist submitted a 1-time chart review note for each patient, which briefly outlined patient-specific considerations and recommendations for alternatives to BZD treatment. After a 30-day period following entry of the chart review notes, data were collected regarding the number of providers who (1) acknowledged the chart review notes by providing their additional signature and (2) committed to the recommended interventions by initiating taper schedules. 

Results: During the 30-day follow-up period, 47.5% (n = 29) of chart review notes were acknowledged and 11.5% (n = 7) of prescriptions were tapered by providers. Mental health providers were less likely to provide their additional signature to the chart review notes (χ2 = 4.62, df = 1, P = .0316; Fisher exact test, P = .0215) and to initiate taper schedules (χ2 = 5.51, df = 1, P = .0189; Fisher exact test, = .0410) compared with primary care providers. 

Conclusions: Chart review note recommendations were frequently disregarded by providers and are likely insufficient as a primary intervention tool for reducing long-term combination BZD and opioid therapy.

Am J Manag Care. 2018;24(8):e265-e269
Takeaway Points
  • When prescribing controlled substances, systematic risk assessment and mitigation strategies to prevent abuse and overdose, such as controlled substance agreements and urine drug screening, are suboptimally implemented in routine clinical practice.
  • Compared with primary care providers, mental health providers were less likely to acknowledge or act upon pharmacists’ recommendations to taper benzodiazepines.
  • Chart review note recommendations are likely insufficient as a primary intervention tool for reducing long-term combination benzodiazepine and opioid therapy.
The reality of America’s prescription drug overdose epidemic has been well established.1 Benzodiazepines (BZDs) and opioids are the 2 most common prescription medication classes associated with the overdose epidemic.1,2 Although there are serious risks related to the use of these medication classes individually, such as tolerance, dependence, and abuse, concurrent use can further increase the risk of overdose death due to potentiation of respiratory depressant effects.3 These risks are particularly concerning in vulnerable patient populations, such as those with posttraumatic stress disorder (PTSD), in which chronic symptoms of anxiety and pain commonly overlap.4

National data from 2004 to 2011 indicate that emergency department visits and drug overdose deaths involving nonmedical coingestion of opioids and BZDs have increased 3-fold.5 Nevertheless, high-risk prescribing practices are common, and many overdose victims are prescribed these agents by their healthcare providers.6,7 It should be noted that nearly half of all opioid prescriptions are written by primary care practitioners, who report inadequate formal training in safe opioid prescribing.8,9 Fragmented patient care can also contribute to inadvertent coprescribing due to the involvement of multiple providers in the treatment of medical and psychiatric comorbidities.10

In recent years, several systematic risk assessment and mitigation strategies have been suggested to enhance the safe prescribing of opioids and BZDs. These include controlled substance agreements, regular follow-ups, urine drug screenings, using prescription drug monitoring programs, and offering emergency naloxone kits to first responders and patients at high risk of opioid-related overdose.11 The adoption of these strategies has been limited, partly due to several provider-related barriers, such as lack of resources, time, and training.11 One option recommended by treatment guidelines is deployment of clinical pharmacists as part of interdisciplinary teams to optimize medication safety.11 A recent study identified the instrumental role of clinical pharmacists in the successful reduction of high-dose opioid prescribing practices by providing education and case management of taper plans.12 However, no study to our knowledge has evaluated the use of interventions that include clinical pharmacists for reducing the coprescribing of BZDs and opioid analgesics. To determine if passive clinical pharmacist involvement would reduce combination opioid and BZD therapy, we developed a quality improvement activity (QIA) that incorporated a single pharmacist without the need for additional resources or dedicated office visits. Herein, we describe the processes and outcomes of this health system QIA designed to reduce combination opioid and BZD therapy.



This project was a retrospective chart review–based investigation conducted within a small Department of Veterans Affairs (VA) healthcare system, which consisted of 5 community-based outpatient clinics in suburban and rural areas throughout the Southwest United States. A board-certified psychiatric pharmacist was assigned the task of assessing BZD prescribing practices that resulted in coprescription with opioids from both primary and specialty care (ie, mental health) clinical settings. The psychiatric pharmacist’s clinical responsibilities included the provision of comprehensive medication and disease management under a collaborative practice agreement at 1 of the 5 outpatient clinics. In addition to routine clinical duties, the psychiatric pharmacist dedicated time to remotely review dual prescribing and execute the project’s intervention. Prescribers included physicians and midlevel providers (eg, nurse practitioners, physician assistants), who were classified based on their areas of practice in primary care versus mental health clinical settings. Because the project was conducted as part of a VA QIA, institutional review board approval was not required.


Our inclusion criteria consisted of any veterans receiving long-term (≥90 days in 3 consecutive months or longer) combination opioid and BZD prescriptions from 1 of the 5 outpatient clinics. An analysis was conducted to identify a baseline list of patients on combination opioid and BZD prescriptions using the Veterans Integrated Service Network Datamart database. Datamart is an online real-time user interface that extracts data from electronic health records (EHRs) using Structured Query Language. Various databases are developed within Datamart with a specific VA clinical and safety initiative in mind. The database used for this project generated a list of patients who were actively receiving an opioid prescription for chronic noncancer pain and were coprescribed a BZD for at least 90 days. This patient list was generated in January 2015. Upon chart review, patients were excluded if they had discontinued, initiated tapering, or failed to renew expired prescriptions. Patients were also excluded if their only opioid prescribed was tramadol, due to a lower risk of respiratory depression in comparison with equianalgesic doses of other opioid agonists.13

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