Improving Training to Reduce Co-Prescribing of Benzodiazepines and Opiates

Concomitant use of prescription benzodiazepines and opiates is a current public health crisis, especially among veterans (Jones & McAninch, 2015). Approximately 27% of veterans who have an opiate prescription are also taking a benzodiazepine (Park et al, 2015). The combination of these medications increases the risk of respiratory depression, coma, death, and other adverse outcomes (Jann, Kennedy, & Lopez, 2014). Moreover, half of all intentional and unintentional opiate overdose deaths among veterans involved a benzodiazepine prescription (Park et al, 2015). The purpose of this project was to decrease the amount of concurrent opiate and benzodiazepine prescriptions by: (1) training providers on proper benzodiazepine taper guidelines and (2) providing a quick guide flowchart for how to access various resources for tapering a benzodiazepine. Methods: This was a quality improvement project at an outpatient mental health clinic for veterans in the Intermountain West. We presented a training to providers that outlined Veteran Affairs guidelines and recommendations for decreasing concurrent opiate and benzodiazepine prescriptions. During this presentation, we explained how to access and use different VA resources available for addressing this problem. We provided every prescriber with a flowchart to show the correct process for identifying high risk patients and helping them decrease their opiate or benzodiazepine use. On the back of the flowchart, we outlined examples of motivational interviewing techniques for decreasing benzodiazepines and opiates. At the end of the presentation, we administered a post presentation questionnaire assessing provider knowledge and practices. Prior to the intervention and at three month follow up we collected electronic health record data to assess (via a paired t-test) if the number of concurrent prescriptions had decreased. A total of 16 providers attended the presentation and 10 of them completed the questionnaire. Providers scored an average of 85% on the portion of the questionnaire testing knowledge of guidelines for reducing concurrent prescriptions. All the providers agreed that they were more likely to utilize the online taper tool or pharmacy referral because of the presentation. Nine of the providers agreed that they were more likely to use motivational interviewing techniques because of the training. Six of the providers reported that they felt more familiar with effective benzodiazepine tapering strategies. There was no significant change in the number of concurrent prescriptions three months after the presentation. Conclusion: Our results demonstrate that providers' knowledge and intentions were positively affected by the presentation. The elements of the presentation that were most effective were the section on motivational interviewing and the online benzo taper tool. The benefit of the training did not translate into fewer concurrent prescriptions. Additional research is necessary to directly pair individual providers with their own number of concurrent prescriptions in comparison with providers who did not attend the training as a control. More follow up training interventions and a longer sampling interval may be necessary to see improved patient outcomes.