High Benzodiazepine Rx Tied to PCP Characteristics, Geography

Troy Brown, RN

October 25, 2018

Where a patient lives and "nonpatient characteristics" such those of their primary care provider (PCP) are significantly associated with the intensity of benzodiazepine (BZD) prescribing to Medicare beneficiaries, even after adjusting for the availability of mental health treatment resources, new data show. Moreover, BZD prescribing rates were more than three-fold higher in the top quartile counties versus the lowest and shared an overlap with high-opioid prescribing counties.

"Counties with lower educational attainment and lower median income had high-intensity prescribing. In the final model, several other concerning county-level health status characteristics were associated with high-intensity BZD prescribing, including more days of poor mental health, a higher proportion of disability-eligible Medicare beneficiaries, and a higher suicide rate," the authors write. They note that their findings are consistent with previous suggestions that BZD prescribing increases "in response to distress in socioeconomically disadvantaged counties."

Donovan T. Maust, MD, Department of Psychiatry, University of Michigan in Ann Arbor, and colleagues published their findings online September 24 in the Journal of General Internal Medicine.

The researchers analyzed data from the 2015 Medicare Part D Public Use Files (PUF) to look at county and PCP characteristics associated with high-intensity BZD prescribing to Medicare beneficiaries. The data included 122,054 PCPs who prescribed 37.3 billion medication-days

Asked what prompted the study, Maust told Medscape Medical News, "Based on some prior research and discussions with clinician colleagues, it has always seemed like whether or not a patient receives a BZD is partly determined by the provider they happen to see. Also, we know that there is wide geographic variation in things like opioid prescribing or life expectancy, so it seemed possible that there might also be location-based variation in prescribing."

Medicare Part D beneficiaries received more than 1.2 billion total days of BZDs at a cost of more than US$374 million, which accounted for 2.3% of all Part D medication days. PCPs prescribed 61.9% of all BZDs overall, or more than 728 million of all BZD days.

Short-acting BZDs were prescribed for 91.1% of BZD days, with alprazolam accounting for 38.2% of all BZD days, followed by lorazepam (24.3%), clonazepam (18.3%), temazepam (9.8%), triazolam (0.2%), oxazepam (0.2%), and estazolam (0.1%).

Long-acting BZDs were prescribed for 8.9% of BZD days: diazepam (8.2%), clorazepate (0.6%), and chlordiazepoxide (0.1%).

"I was disappointed [but] not entirely surprised that alprazolam is the most wide-prescribed BZD. Because it is short acting and high potency, it is potentially more likely to be misused — though this paper did not look specifically at misuse," Maust said.

Persistent County-Level Variability

Benzodiazepines made up 2.1% (standard deviation, 0.9; interquartile range, 1.5 - 2.6) of drugs prescribed on average in a county. When stratified into quartiles, the mean intensity of BZD prescribing was 3.1-times higher in the highest-intensity counties (3.4%) compared with the low-intensity ones (1.1%; P < .001).

States that had the highest county-level prescribing were all located in the South. The five states with the highest county-level prescribing were Louisiana, Florida, West Virginia, Tennessee, and Alabama.

High-intensity counties were located mostly in Appalachia and south-central states, though occurred sporadically across the country. High-intensity counties were more likely to be rural, have fewer primary care providers per 100,000 population, or have a psychiatrist. Socioeconomic status was lower in high-intensity counties and residents had lower results for every health status indicator except binge alcohol use.

"A clear outlier is New York, which initiated a restrictive BZD triplicate prescription policy 30 years ago that does not permit refills: all but three counties were in the lowest-intensity quartile," the researchers explain. "This cannot be because patients in New York are uniquely free from anxiety or insomnia, or that they have distress-free lives. It is most likely due to the restrictive policy in place, further suggesting that patient diagnosis is not the only factor to determine BZD prescribing. However, initiation of the New York policy also demonstrated that, in the face of pressure to reduce BZD prescribing, physicians may simply shift to even less desirable sedating medications."

Adults with higher income and higher education were less likely to live in a high-intensity county in the first model; however, education and income were no longer significant in the final model, which also considered county-level health status. "However, most characteristics suggesting worse health status was associated with increased odds of high-intensity prescribing, including the proportion of disability-eligible Medicare beneficiaries, days of poor mental health in the past, and suicide rate. Higher binge drinking, however, was still associated with lower odds of high-intensity BZD prescribing in the final model," the researchers write.

"Our county-level analysis does suggest that there is more prescribing in socioeconomically distressed areas. Of course, no medication is a treatment for challenging life circumstances," Maust told Medscape Medical News.

"A clinician should always be mindful of the potential for nonclinical factors to influence their prescribing — which patient gets what treatment. For BZDs in particular, if some use does in fact reflect distress — a clinician’s relationship with their patient is an important part of the treatment, and good listening and communication are important parts of the therapeutic relationship (not just for a psychiatrist like me)," Maust explained.

Differences Among Physicians

Among PCPs, prescribing intensity was more than six-times higher in the highest quartile (3.9%) than the lowest quartile (0.6%; P < .001). After adjusting for local availability of mental health services, women were significantly less likely to be high-intensity prescribers, whereas those with additional years in practice were more likely to be high prescribers.

The strongest link to high-intensity BZD prescribing was being a high-intensity opioid prescriber. Being a high-intensity prescriber of any type was associated with high-volume prescribing, as was being a high prescriber in general.

"I did not expect to find that female primary care physicians were less likely to be a high-intensity [prescriber] and also did not expect to find that there would be a link between high antibiotic prescribing and high BZD prescribing," Maust said.

Physicians who had an older patient panel were less likely to be high prescribers, whereas those who saw higher proportions of white patients or those whose patients received a low-income subsidy were more likely to be high prescribers of BZDs.

"The high-intensity counties share a striking overlap with county opioid use. The Part D PUF cannot determine whether a PCP is prescribing opioids and BZDs to the same patient. However, the fact that the same PCPs appear to be high-intensity prescribers of both medications is potential cause for concern," the researchers write.

One author has reported receiving consulting fees from Alkermes, Allergan, Sage Therapeutics, Sunovion Pharmaceuticals, and Ortho-McNeil Janssen. Maust and the remaining authors have reported no relevant financial relationships.

J Gen Int Med. Published online September 24, 2018. Abstract

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