Beyond Prescriptions Monitoring Programs: The Importance of Having the Conversation about Benzodiazepine Use

Abstract

Internationally there is an escalation of prescription-related overdose deaths, particularly related to benzodiazepine use. As a result, many countries have implemented prescription monitoring programs (PMPs) to increase the regulation of benzodiazepine medications. PMPs centralize prescription data for prescribers and pharmacists and generate alerts to high-doses, risky combinations, or multiple prescribers with the aim to reduce inappropriate prescribing and subsequently the potential of patient harm. However, it has become clear that prescribers have been provided with minimal guidance and insufficient training to effectively integrate PMP information into their decision making around prescribing these medications. Accordingly, this paper discusses how PMPs have given rise to a range of unintended consequences in those who have been prescribed benzodiazepines (BDZs). Given that a gradual taper is generally required to mitigate withdrawal from BDZs, there are concerns that alerts from PMPs have resulted in BDZs being ceased abruptly, resulting in a range of unintended harms to patients. It is argued that best practice guidelines based upon a patient-centered framework of decision-making, need to be developed and implemented, in order to curtail the unintended consequences of PMPs. This paper outlines some key considerations when starting the conversation with patients about their BDZ use.

Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study

“…Lastly, the potential for PMPs to be an impetus for deprescribing BZDs was evident in the current sample, as a small number of participants reported increased government regulation prompted their decision to discontinue use. Although able to access support to guide their cessation, these individuals experienced either stigma or reproach in how the prescriber communicated these new regulations, re-iterating the need for patient-centred principles to be adopted alongside the implementation of PMPs (15) .…”

“…general practitioners; GPs) and pharmacists to more effectively monitor and manage BZDs and other high-risk medications. Evidence shows that PMPs do reduce the prescribing of monitored medications, but have also given rise to unintended consequences (15,16).…”

“…While PMPs provide GPs with new information about patient risk they offer little guidance on how to manage this risk, so GPs are more likely to respond in a risk-averse and reflexive manner (see Oldenhof et al, 2019 for discussion), leading many patients to have their BZD prescription ceased inappropriately (i.e. prescription abruptly terminated without exploration of indicated use) (17,18).…”

Different Attitudes of Patients and Psychiatrists Toward Benzodiazepine Treatment

“…In addition, a patient-centered framework with prescriber-patient conversations is believed to reduce the dose of BDZs and prevent unintended abrupt cessation. 31 Communication and interpersonal skills, such as warmth, trust, active listening and exploration of patient experiences, enhance prescriber-patient conversations. Patients must be involved in the decision-making process and should take time to prevent withdrawal.…”

Mandates are not magic bullets: Leveraging context, meaning and relationships to increase meaningful use of prescription monitoring programs

“…We need to think about how the PMP might change a clinicians relationship with their patient, coworkers, practice site administration, local community, state licensing board, and others in their specialty or professional group. Clinicians report that they have concerns about the way their use of information from the PMP might impact their relationship with patients, 27 discomfort with perceived blurring between the role of care giver and disciplinarian given the PMP's law enforcement purpose, 3,28 and lack of knowledge about how to best communicate with patients about the information contained in the PMP 29,30 …”