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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.
DISCUSSION

This study evaluated a passive clinical pharmacist intervention to reduce the coprescribing of BZDs and opioid analgesics by using chart review notes to notify providers of potentially problematic prescribing. Using this approach, we found that less than half (48%) of the chart review notes were acknowledged and the vast majority (89%) of recommendations were not acted upon by providers within the observation period. These results have implications for the future development of tailored interventions to overcome coprescribing.

Based on national data from 2004 to 2009, 27% of US veterans on chronic opioid therapy received a concurrent BZD prescription, and patients who received this combination accounted for nearly half of all veteran deaths from a drug overdose while taking opioid analgesics.6 Our findings that 61 patients were coprescribed opioids and BZDs in the presence of underlying risk factors, such as age greater than 55 years (79%), high-dose opioid prescriptions (18%), PTSD diagnosis (46%), and sleep apnea (28%), suggest that educational outreaches to both clinicians and patients may be warranted. Recent evidence from the EMPOWER trial demonstrated that basic patient counseling and a shared decision-making process can be highly effective in discontinuation of inappropriate BZD therapy.17 Targeted educational programs should use these data to drive provider development and improve practice-based policies.

The recent advent of VA clinical dashboards has created an impetus for efficient patient monitoring and real-time clinical decision making. By using these clinical tools, VA providers can now identify patients on high-risk opioid and BZD therapies, access risk estimates for overdose and respiratory depression, and track attempted risk mitigation strategies.18 According to a recent study, the national implementation of the Opioid Safety Initiative (OSI) dashboard has significantly improved the rates of high-risk prescribing, including an overall 21% reduction in opioid and BZD coprescriptions.19 However, the authors noted a wide variation in implementation of the OSI and prescribing patterns across VA facilities.19 In spite of providing clinical information similar to that in the OSI dashboards, we found that chart review notes did not demonstrate meaningful change in provider prescribing. This could be due to alert fatigue, as clinicians can receive up to an average of 77 EHR inbox notifications daily.20 Although specialists typically receive a lower number of notifications,20 we found that mental health providers were less likely to provide their additional signature or initiate taper schedules than primary care clinicians. Alternative passive approaches, such as the use of electronic consults or clinical reminders, may be more effective at getting the attention of the prescribers. However, interventions that address not only providers’ knowledge or awareness but also motivation and attitudes have been found to be most effective.21 Consequently, academic detailing programs have been established throughout the VA and several other large healthcare systems to promote safe prescribing via multifaceted interventions that include one-on-one interactive discussions with providers.

Perhaps among our most striking findings was that most patients receiving coprescriptions were white (79%), despite the patient population within our healthcare system being predominantly Hispanic. It has previously been reported that providers, within both the VA and non-VA clinical settings, are more cautious when prescribing opioid analgesics for minority patients compared with whites.22 Minority patients are also less likely to be screened for pain symptoms but more closely monitored once opioid therapy has been initiated.23,24 This racial disparity is thought to be due to a lack of adequate training in evidence-based opioid prescribing, leading some providers to make clinical decisions based on heuristics and stereotypes.25 In addition, barriers to communication play an important role, because the experience of pain differs considerably among ethnic groups.22 Multicultural integrated approaches, as well as standardized monitoring procedures, are crucial to improve both the quality and equity of current pain management practices.

Limitations

This report represents a novel discussion on methods for reducing opioid and BZD combination therapy. Although our work presents several noteworthy findings, we acknowledge important limitations. First, the patient sample was small and selected from a single VA healthcare system, which may limit the external validity of our findings. Additionally, we used an arbitrary follow-up period of 30 days despite the lack of current standards on what constitutes a timely response when using note-based messaging. Although the chart review notes outlined risks specific to opioid therapy, taper recommendations were limited to BZDs, given the purview of psychiatric pharmacy. Nevertheless, provider review of the chart review notes resulted in taper initiation of opioid prescriptions for 4 patients. It is possible that the overall poor response to chart review notes was partly due to lack of a personal working relationship between the prescribers and the psychiatric pharmacist. Finally, we did not examine clinical outcomes—namely, symptom severity, quality of life, or functional status—and as a result, we cannot determine the impact of these factors on clinician judgment and risk–benefit assessment. Since the completion of this study, several policy initiatives have emerged in response to the prescription drug epidemic, including measures to increase access to evidence-based treatment for mental health and substance use disorders, as well as alternative therapies and interventional pain treatment options. Future research is needed to examine the potential implications of these regulatory changes on accidental drug overdose trends and overall quality of patient care.

CONCLUSIONS

Despite electronic chart review notes being the primary method of communication between clinical pharmacists and other clinicians, this study found that they were frequently disregarded by providers and are likely insufficient as a primary intervention tool for reducing long-term combination BZD and opioid therapy. This observation underscores the importance of evaluating current electronic communication methods to ensure optimal treatment outcomes and patient safety. Our findings can inform the development of future clinical initiatives and quality improvement strategies to reduce coprescribing. 

Acknowledgments

The authors would like to thank the following individuals: Dr Joy Miller, who contributed to the project design, implementation, and management; Dr Ian Pace and Dr Tessa Rife for their assistance with data acquisition and project design; and Dr Kangwon Song for technical editing of the manuscript.

The content of this article is solely the responsibility of the authors and does not necessarily represent the position or policy of the Department of Veterans Affairs or the United States government.

Author Affiliations: VA Southern Nevada Healthcare System (RS), Las Vegas, NV; VA Salt Lake City Health Care System (MJP), Salt Lake City, UT; University of Utah Health, Department of Medicine (MJP), Salt Lake City, UT; South Texas Veterans Healthcare System (WK), San Antonio, TX; University of Texas Health Science Center at San Antonio (WK), San Antonio, TX; University of the Incarnate Word, Feik School of Pharmacy (GLW), San Antonio, TX.

Source of Funding: None.

Author Disclosures: Dr Pugh has received VA grants unrelated to this study. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RS); acquisition of data (RS); analysis and interpretation of data (RS, MJP, WK, GLW); drafting of the manuscript (RS, MJP, GLW); critical revision of the manuscript for important intellectual content (RS, MJP, WK, GLW); statistical analysis (RS, WK); and supervision (MJP, GLW).

Address Correspondence to: Ramona Shayegani, PharmD, VA Southern Nevada Healthcare System, 6900 N Pecos Rd, North Las Vegas, NV 89086. Email: ramona.shayegani@va.gov.
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