The Association of EHR Drug Safety Alerts and Co-prescribing of Opioids and Benzodiazepines

Evaluating implementation of a consult to reduce new combination opioid and benzodiazepine prescriptions at the San Francisco Veterans Affairs Health Care System

“…[22][23][24] A few strategies have been previously described with mixed results for efficacy in reducing concurrent use, including EMR review of current co-prescribed patients with individualized and/or standardized recommendations to prescribers, an electronic EMR alert at the time of prescription entry with information on risks and/or recommended provision of naloxone, and an electronic consult evaluated by CPS prior to prescribing new concurrent treatment. [11][12][13][14][15] This intervention at the SFVAHCS provides further evidence supporting electronic consult interventions as one strategy to reduce new concurrent treatment with opioids and benzodiazepines and may be useful in integrated health care systems that have not yet addressed new concurrent use and/or when reductions in co-prescribing have plateaued.…”

“…A wider variety and range (0:9 vs 0:3) of recommendations were provided by the reviewing CPSs compared with Pardo et al 15 Similar to the EMR review interventions described by Zaman et al and Shayegani et al, these recommendations extended beyond alternative medications and specialty service referrals and also included strategies to enhance safety, such as patient education, medication tapering and withdrawal symptom management, safety monitoring, multimodal therapies, naloxone, further symptom evaluation, and medication disposal bags 11,12 . This differs from the EMR alert intervention described by Smith et al, in which provision of naloxone was the only recommendation made, and by Malte et al, in which no specific or individualized recommendations were made 13,14 …”

“…While Pardo et al demonstrated a higher recommendation implementation rate at 59%, this is likely due to a lower percent of consults with recommendations made (18% vs 79%) 15 . The interventions by Pardo et al and Smith et al did not describe which types of recommendations were most commonly implemented 14,15 . Zaman et al and Shayegani et al described interventions designed to reduce current use of opioids and benzodiazepines, and thus the most common recommendations implemented included tapering one or both medications 11,12 .…”

“…13 However, a similar intervention by Smith et al, evaluated an EMR alert that was flagged at the time of prescription entry, regardless of high risk conditions, and demonstrated little to no effect on concurrent prescribing. 14 Finally, one study by Pardo et al, evaluated outcomes of requiring EMR consultation with a clinical pharmacy specialist (CPS) prior to initiating new concurrent use in 168 patients. 15 Results demonstrated a 34.6% reduction in co-prescribed patients and a 17.6% reduction in opioid overdose-related emergency department/hospitalization visits.…”

“…Reductions in co‐prescribing were noted at 12 months among patients with suicide risk, sleep apnea, and substance use 13 . However, a similar intervention by Smith et al, evaluated an EMR alert that was flagged at the time of prescription entry, regardless of high risk conditions, and demonstrated little to no effect on concurrent prescribing 14 . Finally, one study by Pardo et al, evaluated outcomes of requiring EMR consultation with a clinical pharmacy specialist (CPS) prior to initiating new concurrent use in 168 patients 15 .…”