Emergency Department Provider Perspectives on Benzodiazepine–Opioid Coprescribing: A Qualitative Study

Kim, Howard; McCarthy, Danielle M.; Hoppe, Jason; Courtney, D. Mark; Lambert, Bruce L.

doi:10.1111/acem.13273

Cited by 52 publications

(21 citation statements)

References 23 publications

(30 reference statements)

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“…The emotional burden of opioid prescribing and challenging patient conversations are felt across physician specialties. 22,28,29 Opioid prescribing represents a significant proportion of specialist prescribing, with 56% of newly initiated opioid treatments attributed to non-primary care specialties. 30 Although prescriptions are often initiated elsewhere in the system, the prevailing sentiment is that the care of these patients is "dumped" on FPs.…”

Section: Discussionmentioning

confidence: 99%

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

et al. 2019

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PURPOSE We examined the perspectives of family physicians (FPs) on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care and differences in perspectives that may be potential drivers of practice variation. METHODS We used an exploratory qualitative study design. Semistructured interviews were conducted in June and July 2017 with 22 FPs in Ontario and coded inductively. Thematic analysis was used to identify themes, and a framework analysis explored the influence of physician demographics on prescribing experience. RESULTS Three key themes emerged: the discrepancy between FPs' training and current practice, the tension between the FP's role and patient and system expectations, and the influence of length of time in practice and strength of therapeutic relationships on perspectives on opioid prescribing. There was an overarching sentiment among participants that FPs are unsupported in their efforts to manage chronic pain. More years in practice (≥15 years) seems to influence practice patterns by increasing trust in therapeutic relationships and decreasing reliance on emergent guidelines (vs clinical experience). CONCLUSION Number of years in practice influences FPs' response to emergent evidence, requiring initiatives to include strategies tailored to individual beliefs. Initiatives must move beyond dissemination and education to equip FPs with the skills they need to navigate emotionally charged conversations. External pressures and misaligned system and patient expectations place FPs at the center of a challenging situation, which may result in a higher risk of burnout compared with that of their specialist colleagues.

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Section: Discussionmentioning

confidence: 99%

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

et al. 2019

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“…Medications of interest were determined a priori by evaluating the 2015 Beers Criteria for medications commonly prescribed from the ED setting. We determined the final medication list by a consensus technique, triangulating the study team members’ clinical experience, published literature on common analgesic prescribing practices among ED prescribers, and national survey data on the most frequent ED discharge prescriptions . The final medication classes included NSAIDs, benzodiazepines, skeletal muscle relaxants, opioids, and acetaminophen.…”

Section: Methodsmentioning

confidence: 99%

“…We determined the final medication list by a consensus technique, triangulating the study team members' clinical experience, published literature on common analgesic prescribing practices among ED prescribers, and national survey data on the most frequent ED discharge prescriptions. 10,23 The final medication classes included NSAIDs, benzodiazepines, skeletal muscle relaxants, opioids, and acetaminophen. Although acetaminophen is not listed as a potentially inappropriate medication on the 2015 Beers Criteria, it was included for comparison given its relatively low side-effect profile and expected null effect on ED revisits.…”

Section: Variables Of Interestmentioning

confidence: 99%

“…They also strongly recommend avoiding benzodiazepine use except in specific clinical scenarios (eg, seizure, ethanol withdrawal), due to the risk of cognitive impairment, delirium, and falls, and they strongly recommend avoiding skeletal muscle relaxants due to the risk of anticholinergic side effects and sedation. Although not typically considered analgesics, benzodiazepines are frequently used as a muscle relaxant in both ED and outpatient settings . ED prescription patterns of NSAIDs and benzodiazepines were identified as key research opportunities to develop future quality indicators by the Society for Academic Emergency Medicine's Geriatric Task Force …”

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confidence: 99%

“…Although not typically considered analgesics, benzodiazepines are frequently used as a muscle relaxant in both ED and outpatient settings. [10][11][12] ED prescription patterns of NSAIDs and benzodiazepines were identified as key research opportunities to develop future quality indicators by the Society for Academic Emergency Medicine's Geriatric Task Force. 13 The Beers Criteria were updated in 2015 to include a conditional warning against the use of opioid analgesics in older adults with a history of falls or fractures.…”

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confidence: 99%

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Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits

Chukwulebe

Kim

McCarthy

et al. 2019

J American Geriatrics Society

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Objectives To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED. Design Retrospective cohort study. Setting Large urban academic ED from January 1, 2013, to December 31, 2015. Participants Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits). Measurements Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti‐inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return. Results Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9‐day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54‐0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10‐3.70). Conclusions These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient‐centered outcomes. J Am Geriatr Soc 67:719–725, 2019.

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Hospitalizations for opioid‐related overdose and timing of concurrent opioid and benzodiazepine use: A nested case‐control study

et al. 2021

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Background Concurrent opioid and benzodiazepine (BZD) use is a prevalent high‐risk prescribing behavior that increases the risk of opioid overdose. However, there is limited evidence on the relationship between timing of concurrent use and risk of opioid overdose. Objective To evaluate the likelihood of opioid‐related overdose across levels of duration, recency, and daily dose of concurrent use. Design A nested case‐control study was conducted using Truven MarketScan claims data (2009–2018). Participants Commercially insured adults (age 18–64 years old) with a new opioid dispensing in 2010–2018. Main Measures Cases of opioid‐related overdose were identified based on hospitalization diagnosis codes. Controls were matched to cases in a 10:1 ratio by age, sex, opioid start date, and cancer history. Concurrent use was classified based on duration, timing, and daily dose of overlapping opioids and BZDs during 90 days before the event. Conditional logistic regression models were used to evaluate the relationship between concurrent use and opioid‐related overdose. Key Results Among 11,137,866 dispensed a new opioid, a total of 3388 patients experienced opioid‐related overdose and were matched to 33,893 controls. Cases and controls were 34 years old on average and 54% female. Patients with concurrent use were significantly more likely to have opioid‐related overdose compared to patients receiving opioids, BZDs, or neither (OR 9.28; 95% CI 7.87, 10.93). Longer concurrent use of 1–7, 8–30, and 31–90 days was associated with 4.6, 12.1, and 26.7‐fold higher likelihood of opioid‐related overdose (p < 0.01). Patients with overlapping prescriptions during previous 0–30, 31–60, and 61–90 days were 13.2, 6.0, and 3.2‐times more likely to experience an overdose (p < 0.01). Conclusions Patients with an opioid‐related overdose were more likely to be prescribed concurrent opioid and BZD across all levels of duration, timing, and daily dose. Future policies and quality measures should be pursued to prevent concurrent use unless medically necessary.

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Emergency Department Provider Perspectives on Benzodiazepine–Opioid Coprescribing: A Qualitative Study

Cited by 52 publications

References 23 publications

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits

Hospitalizations for opioid‐related overdose and timing of concurrent opioid and benzodiazepine use: A nested case‐control study

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