3.2 Facilitators of Guideline-Concordant Benzodiazepine Use in Veterans with PTSD
3.2.1. Organizational facilitators. Organizational factors that contributed to decreased prescribing of benzodiazepines for PTSD include consistent facility treatment practices and research presentations such as in journal clubs that present up to date findings.
Fortunately, the other psychiatrists in this clinic, we’re all on the same page regarding that, so there is consistency throughout the clinics which makes it easier when we have substance-seeking. [Psychiatrist, MH]
Some clinicians reported that flexibility with their schedules to have time to use shared decision making practices and discuss safer options is critical; they rarely write initial benzodiazepine prescriptions. Another organizational factor that helped decrease benzodiazepine prescribing was integrated MH clinical teams that include psychologists and geriatric specialists who facilitated safer treatments for veterans.
I feel very lucky to work as closely as I do with the psychologists here and to have an integrated team so that when these treatment questions come up, the patient can talk about it with the psychologist and me, discuss cognitive behavioral therapy, and formulate a treatment plan. [Psychiatrist, MH]
3.2.2 . Provider facilitators. Clinicians discussed strategies they use including psychoeducation with the patient to discuss potential harms and working to build rapport. For example, a prescribing clinician in Primary Care noted “A lot of this involves educating the veteran about medications and how they work. With benzodiazepines I discuss the risks of how they can be habit-forming and things like that.”
The funny thing about the VA is, while your patient can fire you, you really can’t fire your patient. And so…meaning, you just create another problem for somebody else if that person walks out of that meeting with you…So, I guess I just keep trying to build that trust. [Psychiatrist, MH]
Prescribing clinicians in both PC and MH were aware of the CPG recommendation against chronic benzodiazepine use in patients with PTSD and felt supported by it.
I think that it is helpful that the PTSD Clinical Practice Guideline is so clear about benzodiazepines and it’s nice to be able to provide that with certain providers that have had a difficult time understanding that. [Psychiatrist, MH] Obviously being a prescriber, I will talk to them about the medication options and be very frank about the limitations of medications, in the sense that they can help with some depression and anxiety, but at least in the context of starting an SSRI as a first-line agent. But I’m always planting the seed of how helpful psychotherapy can be, and then we can get more into that discussion, so I’m always pushing that. [Psychiatrist, MH]
3.2.3. Patient facilitators. The most often cited patient facilitator was established rapport and trust in the prescriber.
…you need to spend time with them to keep them engaged because on the first visit if the impression they have is not good, they’re not coming back, they go back to alcohol. [Psychiatrist, MH, Medical Director for PTSD].
Patients’ reports of unwanted symptoms can provide an entrée for providers to being discussions about reducing dosages.
It depends on what they complain about as far as symptoms that allows me to get that hook – if they’re complaining of attention, concentration and memory, which they usually do, that is usually sometimes an appeal to try a lower dose. [Psychiatrist, MH].
DISCUSSION
This national qualitative study of VA prescribing clinician examined perspectives regarding the use of chronic benzodiazepines in veterans with PTSD. It is encouraging that compared to work done with community physicians,13 VA clinicians acknowledge problems associated with benzodiazepine overuse. Judging from the VA’s decreased utilization rate, progress has been made.4 However we still see veterans with PTSD at increased risk of the harmful effects chronically prescribed these medications.4 In this study, we identified factors that contribute to new prescriptions as well as maintenance among both MH and PC clinicians that can help us understand how not just VA but community healthcare systems might design future efforts to promote change.
Unfortunately, many clinicians and patients have found benzodiazepines effective, are unaware of harmful side effects and have not attributed adverse impacts to them. Caseloads of patients on benzodiazepines get passed on to new providers when a prescribing clinician leaves, and the new provider doesn’t have time to taper these patients. Specific protocols that address how to handle inherited caseloads and education about complicated PTSD with multiple comorbidities will help providers make safer, informed decisions. Enlisting the help of clinical pharmacists to support patient tapers through these protocols can ease the burden on busy clinicians. Some providers, however, are still not convinced that benzodiazepines pose risks and, in some cases, believe there are continued benefits, particularly among older veterans who appear stable. Outreach education to these providers, to facility leadership and directly to the veterans and families to share recent research findings can improve this knowledge gap. Finally, several providers mentioned prescribing benzodiazepines to decrease suicidality. Suicide is indeed a significant risk for this population especially among older veterans; the majority of suicides in 2016 in VA occurred in those over 55.17 Evidence suggests, however, that rather than reduce suicide, there is an almost 3-fold increase in suicide risk in PTSD patients prescribed benzodiazepines.18 Including this information in educational materials for prescribing clinicians and sharing through direct mail with patients and families is critical.
Fortunately, the practice guideline recommends treatments that offer several safer effective alternatives. One solution to the benzodiazepine problem is to increase the use of SSRIs and/or trauma-focused psychotherapies that help target anxiety and insomnia while reducing overall PTSD symptoms. SSRIs are the recommended first-line treatment for anxiety and there are effective cognitive-behavioral therapy (CBT) protocols.19 The efficacy of brief CBT for insomnia, CBT-I , continues to grow and favors its use over many pharmacotherapies.20 Clinicians in this study reported they often do not offer psychotherapy as an option because they are unaware of its availability in their facility and because of administrative difficulties in access and consult processes.21 If providers are to benefit from effective psychotherapy alternatives, then administrative solutions such as a consult direct to a CBT-I provider could ease access problems. It is also critical that specialty care clinicians communicate with prescribing clinicians about the treatments available and encourage referrals.
We heard from clinicians that consistent care across services regarding the use of benzodiazepines made it easier for them to turn down requests for renewals or new prescriptions. Collaboration between prescribing providers can foster a consistent guideline concordant standard of care. Currently, although MH specialists who best understand the risks of benzodiazepines, prescribe the majority (70-80%) of these drugs,22 there has been an alarming increase in benzodiazepine prescriptions by PC providers who may be less knowledgeable of the CPG.12 Coordinated care can help to avoid problems such as a patient successfully tapering only to see a different provider in another clinic or in the community to start the medication again.
Clinicians identified other organizational changes that can foster guideline concordant prescribing. For example, providers can ensure the sharing of psychoeducational strategies and brochures including direct-to-patient educational materials that highlight potential harms,23,24,25 methods to engage patients and build trust, tapering clinics and success stories of patients who have lowered their dose, switched to a safer, long-acting agent, or tapered from benzodiazepines.26 Instituting journal clubs and online courses that share new knowledge about PTSD psychopharmacology including SSRIs can help change the prescribing culture in a facility as well as sharing team approaches to assist with deprescribing. Finally, reducing benzodiazepines in veterans with PTSD aligns with national VA suicide prevention efforts. It is therefore critical that clinicians make appropriate clinical risk-benefit decisions concerning prescribing of these medications.