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.