Part 1 and 2 of this series on Managing the Monster have outlined the evidence that supports the extreme risk posed by co-prescribing benzodiazepines and opioids. This blog outlines the initiative that Partnership HealthPlan of California is undertaking to reduce this risk, starting with provider education.

Where are we going?

As Partnership dives in to our last phase of the Managing Pain Safely initiative, we are expanding its focus to include co-prescribing of benzodiazepines (BZD).  For the last two and a half years, Partnership has been actively working to reduce the number of members prescribed high dose opioids.  Since the start of the project in January 2014, we have seen a 74% reduction in the proportion of members on high dose opioids (>120 mg MED), PMPM, plan-wide.  This is only 1% away from our initial goal of 75% reduction!    As the project begins to accomplish the goals we initially set out to tackle, it is apparent that there is one crucial area that we have yet to focus on- co-prescribing BZD and opioids.

Why is it important?

As detailed in the last two blogs, the risks of severe complications, including overdose and death, are significantly higher when a patient uses a combination of opioids and benzodiazepines.  While the dangers of opioids alone are significant, they drastically increase when combined with BZD. It has been shown that as much as 80% of unintentional opioid overdoses deaths also involve BZD ¹.  In the past five years, the U.S. has seen a fivefold increase in the number of unintentional BZD associated deaths¹.  Studies have shown that the adjusted hazard ratio for risk from drug overdose for patients currently taking both opioids and BZD for is 3.86.³ This is especially concerning when keeping in mind that compared with opioid abusers, those taking both opioids and BZD are more likely to take the medications for longer periods of time and at higher doses.²

What are we doing?

Given the evidence of the dangers of co-prescribing, PHC leadership has designated this as a priority within this next year.  The MPS team has convened to determine a new goal for the initiative- to reduce the number of members with co-prescriptions of both opioids and benzodiazepines, PMPM.  While final plans and anticipated targets are still being defined, the top strategy of the health plan as of now is to provide education for our providers and our members.  The Plan intends on creating educational material for both providers and members, host a webinar to discuss how to manage patients taking both opioids and BZD, and share provider-site level data detailing who in the practice has prescriptions for both.  PHC is also promoting the CDC guidelines which recommend avoiding co-prescribing. PHC will also be working with community coalitions currently developing and implementing county-wide safe prescribing guidelines acknowledge the dangers of co-prescribing and recommend against the practice.

How will it impact you?

As mentioned, as of now the primary strategy to address co-prescribing will be to create educational materials for the provider and member, share best practices, share provider-site level data, and have 1:1 provider level academic detailing sessions with select provider sites.   PHC is dedicated to support our providers in continuing to grow a knowledge base and develop and utilize tools on safe prescribing.  Throughout the fall of 2016, expect to see more material and discussions on the use of BZD in conjunction of opioids.

Webinar on Co-Prescribing

Managing the Monster: Strategies in Managing Opioid and Benzodiazepine Co-Prescribing

Tuesday October 25, 2016

Noon-1pm

Registration: https://attendee.gotowebinar.com/register/8210921216123819778

References

• Gudin JA; Mogal S; Jones JD; Comer SD. “Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use”. Post Graduate Medicine, 2013, 125 (4) 0032-5481
• Jann M; Kennedy WK; Lopez G. “Benzodiazepines: A Major Component in Unintentional Prescription Drug Overdoses with Opioid Analgesics”. Journal of Pharmacy Practice, 2014, 27(1) 5-16
• Park TW; Saitz R; Ganoczy D; Ilgen MA; Bohnert ASB. “Benzodiazepine prescribing patters and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study”. BMJ Open Access, 2015, 350:h2698