Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study

Donovan T. Maust; Linda Takamine; Ilse R. Wiechers; Frederic C. Blow; Amy S. B. Bohnert; Julie Strominger; Lillian Min; Sarah L. Krein

doi:10.1370/afm.2825

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RE: Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study
Paolo L Sinopoli, Daniel J Levine, Khaled N Elhassan and Lorraine S Wallace

Published on: 11 October 2022
Study Shows the Impact of Interventions That Reduce Benzodiazepine Prescribing Towards Evidence-Based Levels
Bernard Silvernail

Published on: 22 August 2022

Published on: (11 October 2022)
Page navigation anchor for RE: Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study
RE: Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study
Paolo L Sinopoli, undergraduate, The Ohio State University
Other Contributors:
Daniel J Levine, undergraduate

Khaled N Elhassan, undergraduate

Lorraine S Wallace, Associate Professor--College of Medicine
We read Maust et al.’s study with great interest. In particular, while the mixed-methods—quantitative and qualitative—study design was strong, the authors provided a thoughtful discussion of potential limitations related to generalizability. We particularly appreciate the use of random effect estimates to account for potential variation in average benzodiazepine daily dosage throughout the course of the study. Expectedly, a large portion of older benzodiazepine users were veterans, but nonetheless, 58.1% is a shocking, yet important, majority of this population. Despite the comprehensiveness of this study, we have several questions regarding employed methodology and future applications.

First, benzodiazepine safety risks are outlined in the introduction, and we noticed that both key articles cited were published in the 1980s. Given that four decades have passed since these landmark studies were published, we were left to ponder why more recent population-based studies have not been conducted. As such, is there a need for more recent studies addressing risk to be conducted? And, if so, how would your results potentially be impacted?

Second, Maust and colleagues articulated the necessity to develop and implement multi-component interventions as a means of reducing benzodiazepine prescriptions. Specifically, we found it interesting to learn about successful strategies from high-performing VA facilities. In the future, could these multi-component strategies be e...
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We read Maust et al.’s study with great interest. In particular, while the mixed-methods—quantitative and qualitative—study design was strong, the authors provided a thoughtful discussion of potential limitations related to generalizability. We particularly appreciate the use of random effect estimates to account for potential variation in average benzodiazepine daily dosage throughout the course of the study. Expectedly, a large portion of older benzodiazepine users were veterans, but nonetheless, 58.1% is a shocking, yet important, majority of this population. Despite the comprehensiveness of this study, we have several questions regarding employed methodology and future applications.

First, benzodiazepine safety risks are outlined in the introduction, and we noticed that both key articles cited were published in the 1980s. Given that four decades have passed since these landmark studies were published, we were left to ponder why more recent population-based studies have not been conducted. As such, is there a need for more recent studies addressing risk to be conducted? And, if so, how would your results potentially be impacted?

Second, Maust and colleagues articulated the necessity to develop and implement multi-component interventions as a means of reducing benzodiazepine prescriptions. Specifically, we found it interesting to learn about successful strategies from high-performing VA facilities. In the future, could these multi-component strategies be effectively employed in community health settings beyond VA facilities? Lastly, as highlighted in the limitations section, as this study did not employ randomized controlled trial design, facility performance cannot be attributed to specific strategies used. Does your research team have plans to design a robust randomized trial to clearly delineate how facility performance is tied to the multi-pronged strategies used?
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Competing Interests: None declared.
Published on: (22 August 2022)
Page navigation anchor for Study Shows the Impact of Interventions That Reduce Benzodiazepine Prescribing Towards Evidence-Based Levels
Study Shows the Impact of Interventions That Reduce Benzodiazepine Prescribing Towards Evidence-Based Levels
Bernard Silvernail, President and CEO, The Alliance for Benzodiazepine Best Practices
The study done by Maust et al (Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults - A Mixed Methods Study) shows the effectiveness of intentional measures to reduce benzodiazepine (BZD) over-prescription. It describes a range of innovative interventions by the Veteran’s Administration (VA) that, even in their least intrusive and costly form, significantly reduced BZD prescription. The VA has taken a leadership role in recognizing the dangers of inappropriate BZD prescribing and taking action to improve patient safety. When the VA introduced the VA/DoD 2017 Practice Guideline for the Management of PTSD [1], it was the first large-scale provider group to put the evidence into action and stop prescribing BZDs for PTSD. The VA has again assumed a leadership role with limiting BZD prescription, and this study shows that prescribers can change their practice fairly rapidly to be evidence-based. The interventions implemented are a model that can be replicated nationwide to reduce the high rate of injury among older BZD users.[2] It also gives hope to the thousands of current and former BZD users who suffer painful and debilitating long-term sequelae from using these medications[3]: someone is listening and willing to take action.

Of particular interest is that the interventions labeled by the authors as “passive” appear to be effective. They typically included education, identification of overusing patients, clinicians and clinics, and pr...
Show More

The study done by Maust et al (Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults - A Mixed Methods Study) shows the effectiveness of intentional measures to reduce benzodiazepine (BZD) over-prescription. It describes a range of innovative interventions by the Veteran’s Administration (VA) that, even in their least intrusive and costly form, significantly reduced BZD prescription. The VA has taken a leadership role in recognizing the dangers of inappropriate BZD prescribing and taking action to improve patient safety. When the VA introduced the VA/DoD 2017 Practice Guideline for the Management of PTSD [1], it was the first large-scale provider group to put the evidence into action and stop prescribing BZDs for PTSD. The VA has again assumed a leadership role with limiting BZD prescription, and this study shows that prescribers can change their practice fairly rapidly to be evidence-based. The interventions implemented are a model that can be replicated nationwide to reduce the high rate of injury among older BZD users.[2] It also gives hope to the thousands of current and former BZD users who suffer painful and debilitating long-term sequelae from using these medications[3]: someone is listening and willing to take action.

Of particular interest is that the interventions labeled by the authors as “passive” appear to be effective. They typically included education, identification of overusing patients, clinicians and clinics, and providing tools to facilitate deprescription from BZDs. The “passive” seem to have been chosen from the palette of interventions because they require the minimum time investment by prescribers. Still, even at the sites where reducing BZD was not a priority, they yielded an average annualized reduction in BZDs of −0.26 mg/d. Since BZDs are not recommended for long-term use[4], and this group is particularly at risk, it would have been helpful to know what that reduction translates to in terms of annualized percentage.

Note that, since the subjects were long-term BZD users, there was no opportunity to see the impact of ensuring informed consent prior to the initiation of prescription. As a suggestion for future study, it would be interesting to see some quantification of the impact of the VA discontinuing the use of BZDs for treating PTSD.

[1] https://www.healthquality.va.gov/guidelines/MH/ptsd/
[2] Maust DT, Lin LA, Blow FC. Benzodiazepine use and misuse among adults in the United States. Psychiatr Serv. 2019;70(2):97-106. Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358464/
[3] Finlayson R, Macoubrie J, Huff C, Foster D, Martin P. Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Ther Adv in Psychopharmacology. 2022, Vol. 12: 1–10 Article: https://journals.sagepub.com/doi/pdf/10.1177/20451253221082386
[4] Food and Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class, 2020 Full text: https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-box...
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Competing Interests: None declared.