Reduce BZD prescriptions from community providers

Benzodiazepines are a class of drug used to treat certain conditions, such as anxiety, with medications like Xanax and Ativan. Risk of these medications for older adults include falls, confusion, or contributing to lethal overdoses.

This reduction is part of the Psychotropic Drug Safety Initiative, which began in 2013.

“It would be wrong to say, ‘No one should be on benzodiazepines.’ However, you want to minimize use as much as possible, in particular for older adults because of the risks,” said Dr. Donovan Maust.

From 2013 to 2017, one study noted that BZD prescribing in VA to older Veterans was cut in half.

Veterans over 65 also use Medicare Part D for prescriptions

However, Veterans who are at least 65 years in age also qualify for Medicare Part D and can use this program to have prescriptions filled outside of VA sources. These Veterans are considered to be dually enrolled – in VA and Part D.

Researchers began to consider if there was a true decline in the BZD prescriptions to older Veterans or if these Veterans were using their Part D prescription plan to acquire BZDs from outside sources, making up for the difference in VA’s decline.

A recently published study examined this exact issue. The study is called Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study.

The study was led by Dr. Maust of the Center for Clinical Management Research at the VA Ann Arbor Healthcare System. The study examined nearly two million Veterans aged 65 or older who were enrolled in VA and Medicare Part D from 2013 to 2017.

Study showed prescription numbers dropped

Overall, the study results showed positive improvements. Looking at just prescriptions from VA, BZD prescriptions dropped from about 5% of the age-65+ population to just 3%. When Medicare Part D prescriptions were also included, Veterans receiving BZD prescriptions declined from 10% of age-65+ population to just under 8%.

“This is good news. The drop that seemed to be happening based on VA prescribing alone really did happen,” Maust said. “Community prescribers didn’t just replace them.”

The study also examined the source of BZD at each individual VA facility. The study will determine whether they were prescribed by VA, by Part D community providers, or both.

At most VA facilities, older Veterans were more likely to receive their BZDs through Part D than from VA.

For example, from July 2016 to June 2017, 37% of Veterans acquired their medications from VA only. Almost 11% received prescriptions from VA and Part D, and the remaining 52% used Part D only.

Community providers primary source of BZDs

“If you really want to address prescribing these medications to Veterans, you have to start thinking about what’s happening in the community,” Maust added. “It appears that the primary sources of BZDs are community providers.”

These findings are especially critical after the implementation of the VA MISSION Act of 2018. That act expanded criteria that allowed Veterans to access community health care providers outside VA.

The study notes that, “While the ability to access non-VA care ideally would improve the quality of care Veterans receive, dual-system use increases the potential for poorly coordinated care and has been associated with potentially inappropriate prescribing.”

Need to engage community providers to minimize use of BZDs

There’s positive news that BZD prescriptions are on a true decline between VA and community sources. Still, it’s vitally important that clinicians seeing Veteran patients continue to check state prescription drug monitoring program databases and complete a thorough medication review.

“This effort VA has done to improve prescribing to older Veterans and minimize use of these medications looks like it has worked,” Maust said. “They’re not just driving people out into the community. Overall, the goal was to reduce prescribing to Veterans and that has succeeded. But it is also true that a lot of Veterans are receiving benzodiazepines prescriptions through community sources. As VA continues to promote high-quality prescribing, it will be important to think about how to engage community providers in that effort.”