In early 2013, Penobscot Community Health Care (PCHC) in Bangor, Maine, created an interdisciplinary group to review cases of patients who were new to the practice and seeking controlled substances. Though the group’s work initially focused on reducing opioid prescriptions, the Chief of the Psychiatry Department expressed equal concerns about prescriptions for benzodiazepines.
Several medical societies’ Choosing Wisely recommendations advise caution when prescribing benzodiazepines as these sedative drugs can also be abused. PCHC is a partner of Choosing Wisely grantee Maine Quality Counts, a regional health improvement collaborative, currently advocating for reduction of benzodiazepines.
Noah Nesin, MD, FAAFP, Vice President of Medical Affairs for Penobscot, said benzodiazepines should not be the first choice of treatment for insomnia, anxiety or muscle pain, but they are still prescribed for those conditions.
While working to discern patient expectation for prescriptions and provider prescribing patterns for opioids and benzodiaopines, PCHC looked to reduce people on chronic prescriptions through:
- Weekly case reviews and prescriber education about the risks associated with the drugs;
- Patient education using Choosing Wisely materials developed by Consumer Reports;
- Monitoring and reporting prescriber rates and providing case-by-case feedback to all prescribers;
- Including counselors, psychiatric nurse practitioners, psychiatrists and clinical pharmacists on the team; and
- Working across the community with a standard approach of treatment and monitoring prescriptions.
The first thing the team looks at when they review cases is the primary indication for the prescription, if the issue was diagnosed properly and whether other treatments were used first, including lifestyle changes and alternative medications and physical therapy for chronic pain. Dr. Nesin said it is also important to assess childhood trauma and past substance abuse, which can indicate future abuse.
Dr. Nesin said that these interventions led to a 70 percent decrease in the number of chronic benzodiazepine prescriptions.
“This is based on a population of more than 60,000 people,” Dr. Nesin said. “We should really only have a handful of people on it chronically and they should have gone through all other options first. We still have work to do.”
In addition, PCHC tracks patient retention to determine if patients who aren’t prescribed the drugs turn to another practice. While it’s difficult to collect the data, Penobscot seems to be retaining patients with what Dr. Nesin said is taking the time for “sustained compassionate engagement.”
“It’s difficult to talk about, and the conversations don’t always go smoothly,” Dr. Nesin said about conversations with patients who expect a prescription. “I tell patients that I really care about them and they are safer and will have a better quality of life without the medication. Through the Choosing Wisely materials, you can show them that it’s not just your opinion. Patients are more willing to talk with you.”
Since there is overlap with efforts to reduce unneeded opioid and benzodiazepine prescriptions, PCHC also shares prescriber data for those under the age of 60 who died while on chronic controlled substance prescriptions with no terminal illness.
“We saw a steep decline in those deaths in the last four years,” he said. “We also hear anecdotal feedback that patients are functioning at higher level when they are not on the medications. They tell us the fog has lifted and they can enjoy life more. This is what helps sustain our efforts – clinicians get to see how much patients benefit.”