February 19, 2015
As a brand new Consultant Pharmacist many years ago, I welcomed the newly-published CMS regulations for nursing home practice that began to restrict the usage of harmful medications for frail elderly nursing home patients. The medication classes most keenly focused on were anticholinergics, anti-psychotics, and benzodiazepines. While the use of these medications in that setting has been greatly reduced since the early 90s, there is still work to be done. So, surely that medication management trend has carried over to the ambulatory setting correct? Well not so much!
Through the last several months here in The Daily Dose™ we have commented on the links between continued use and potential adverse events from anticholinergics (Feb 2015), anticholinergics and sedative-hypnotics (Oct 2014), benzodiazepines (Sept 2014) and ‘Z-drugs’ for insomnia (July 2014). Throughout we have referred to a succession of evidence based studies and guidelines regarding use of these medications including the original CMS 1987 guidelines for nursing home patients, the initial Beers’ List of inappropriate medications for older adults, with an American Geriatrics Society update in 2012, and another expected in 2015, and the more recent implementation of quality measures regarding the use of high risk medications in older adults by CMS, HEDIS, NQF and others.
Yet, in a study published this week in JAMA Psychiatry, Olfson1 et al. described a retrospective claims data analysis which showed that greater than 5% of the US population of adults 18 to 80 years filled one or more prescriptions for a benzodiazepine annually. More importantly, the OLDER the patient cohort, the HIGHER the prevalence of benzodiazepine use, with 8.7% of adults between 65 and 80 years filling one or more prescriptions, a whopping one third of whom reported ‘long term use’ (greater than 120 days in the year). Benzodiazepine adverse events of dementia, cognitive impairment, falls, impaired activities of daily living, etc. are well documented. The authors conclude “Despite cautions concerning risks associated with long-term benzodiazepine use, especially in older adults…use remains common in this age group. More vigorous clinical interventions supporting judicious benzodiazepine use may be needed.” As a health care professional community, what part of ‘NO’ do we not understand?
In her New York Times blog The New Old Age (http://nyti.ms/1CoF3RS) Paula Span outlines challenges we face in reducing the use and potential adverse events from benzodiazepine medications:
First of all they work really well, and fast. Boom, you were not sleeping well and the first dose first night, you did. More benign treatments such as implementing a sleep hygiene program, eliminating ‘stimulating’ self-medication behaviors and food choices (i.e. caffeine), and antidepressants/behavioral therapy for anxiety all take some time to work.
Secondly, even recognizing the need for short-term therapy, discontinuing therapy may often cause a return of insomnia/anxiety symptoms for which the medications were used in the first place. Patients may be very resistant to returning to the ‘bad old days’ prior to benzo treatment.
Lastly, our health care delivery system is really not aligned to encourage providers to spend the time on general medication management, much less the weeks of routine patient encounters that might be required to taper and discontinue from long term benzodiazepine use. And it’s hard to say “no” when all the patient wants is an Rx refill.
So what can we do? We could push for a repeat of the propoxyphene scenario…just get the FDA to take harmful benzodiazepines off the market. OK, not happening. What about giving the primary care providers a hand…mobilizing the members of the care team with an all hands on deck call to get the numbers going in the opposite direction…reducing benzo use as patients get older. Some evidence (see links below) show that interventions with patients at transitions of care can work.
We need to follow the HEDIS recommendation for full medication reconciliation with each primary care visit. By using the ActualMeds Comprehensive Medication Management System we can make sure we capture all of the patient’s medications and characterize exactly when and how patients are using them. We need to go beyond the ‘one and done’ Medicare Part D MTM Comprehensive Medication Review, and follow patients longitudinally through all transitions of care to make sure that benzodiazepine use is identified and assessed. Most importantly, we need to put the patient at the center of the team, with a clear plan to taper and remove/replace inappropriate medications for our older adult patients, and we need to be able to keep the team up to date on the patient’s progress.
1Olfson, M et al: Benzodiazepine Use in the United States. JAMA Psychiatry 2015;72(2):136-142
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds