Effect of Pharmacist Email Alerts on Concurrent Prescribing of Opioids and Benzodiazepines by Prescribers and Primary Care Managers

Abstract

ImportancePolicy makers have sought to discourage concurrent prescribing of opioids and benzodiazepines (coprescribing) because it is associated with overdose. Email alerts sent by pharmacists may reduce coprescribing, but this intervention lacks randomized evidence.ObjectiveTo investigate whether pharmacist emails to practitioners caring for patients who recently received opioids and benzodiazepines reduce coprescribing of these medications.Design, Setting, and ParticipantsRandomized clinical trial (intention to treat) conducted in 2019-2021 of patients and their practitioners (prescribers and primary care managers) in the National Capital Region of the Military Health System. Participants were 2237 patients who were recently coprescribed opioids and benzodiazepines. These patients had 789 practitioners eligible for emails.InterventionsPatients were randomized to email alerts to their practitioners or as-usual care. Clinical pharmacists sent the email alert. Messages were standardized and designed to facilitate coordination between practitioners, increase awareness of guidelines, and provide action steps and resources.Main Outcomes and MeasuresThe primary outcomes were patients’ days received of opioids, benzodiazepines, and concurrent opioids and benzodiazepines during the 90 days following enrollment evaluated using 1-sided hypothesis tests. Secondary outcomes included total prescribing of opioids and benzodiazepines by patients’ practitioners, including to patients outside the study, to test for broader outcomes on their prescribing.ResultsOf 2237 patients, 1187 were assigned to treatment and 1050 to control; 1275 (57%) were women. Patients received a mean (SD) of 31 (44) days of opioids and 33 (34) days of benzodiazepines in the 90 days before enrollment. There were no detected differences in the primary end points, including patients’ receipt of opioids (adjusted difference, 1.1 days; 95% CI, -∞ to 3.0; P = .81), benzodiazepines (adjusted difference, −0.6 days; 95% CI, -∞ to 1.4; P = .30), and opioids and benzodiazepines together (adjusted difference, −0.1 days; 95% CI, -∞ to 0.7; P = .41). Of 789 practitioners, 429 were considered the treatment group, 325 were considered controls, and 35 were excluded. There were no detected differences in practitioners’ total prescribing of opioids, benzodiazepines, or both drug classes together.Conclusions and RelevanceIn this randomized clinical trial of pharmacist emails to practitioners, email alerts failed to detectably reduce coprescribing, highlighting the value of alternative approaches. Combining randomization with quality improvement activities may help stakeholders seeking evidence-based interventions to encourage guideline-concordant care.Trial RegistrationClinicalTrials.gov Identifier: NCT03887247

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

“…Prior efforts to change postoperative prescribing with behavioral interventions have used pretest-posttest designs and have shown reductions in the number of tablets prescribed. 15 , 35 , 36 , 37 , 38 , 39 The present work is consistent with trials testing clinician feedback interventions on opioid prescribing in emergency department, primary care, and urgent care sites, 14 , 17 , 40 , 41 , 42 , 43 although 2 other trials examining clinician feedback on concurrent prescribing of opioids and benzodiazepines did not show reductions 40 , 44 in concurrent prescribing. The finding that both the peer-based descriptive norm and guideline-based injunctive norm treatment conditions were equally effective contributes to an ongoing debate from the broader norms literature about which type of norm—descriptive or injunctive—is more likely to exert an effect in a fast-paced environment in which there is a great deal of cognitive depletion.…”

“…15,[35][36][37][38][39] The present work is consistent with trials testing clinician feedback interventions on opioid prescribing in emergency department, primary care, and urgent care sites,14,17,[40][41][42][43] although 2 other trials examining clinician feedback on concurrent prescribing of opioids and benzodiazepines did not show reductions40,44 in concurrent prescribing. The finding JAMA Health Forum | Original Investigation…”

Best Practice Alerts: A Poke in the Eye or an Efficient Method for Safer Prescribing?

“…11 However, email alerts to primary care physicians about their recent risky opioid prescribing did not change prescribing. 11 The current study by Rolfzen and colleagues adds to this evidence and highlights that best practice alerts need to be well tailored and that their effectiveness is context dependent. For example, the effectiveness of feedback interventions may be influenced not only by alert fatigue but also the time in which a provider can cognitively absorb the information and decide to change their practice at the point of care.…”