Letter on Patient’s Fatal Overdose May Curb Benzodiazepine Prescribing

Physicians who received a letter from a medical examiner notifying them of a recent patient’s fatal overdose prescribed fewer benzodiazepines, a secondary analysis of clinical trial data showed.

Daily 2-mg diazepam pill equivalents decreased more in an intervention group that received a medical examiner letter and injunction to prescribe safely compared with a control group (-3.7%, 95% CI -6.9% to -0.5%, P<0.05), reported Jason Doctor, PhD, of the University of Southern California in Los Angeles, and co-authors.

On average, 2.9 fewer 2-mg diazepam pills were dispensed per prescriber per month in the intervention group compared with controls, Doctor and colleagues noted in JAMA Internal Medicine.

“The results of this secondary analysis of a randomized clinical trial suggest that having medical examiners send out letters informing clinicians of a fatal scheduled drug overdose in their practice is a low-cost approach to curtailing the overprescribing of benzodiazepines,” they wrote.

“The observed moderate reductions that were associated with the letter seemed to concentrate among continuing prescriptions, which is what was associated with the increase in benzodiazepine prescribing from 2005 to 2012,” they added.

The report extends the trial’s earlier finding that showed physicians in San Diego County who were informed by the medical examiner of a patient’s fatal overdose from July 2015 to June 2016 prescribed 10% fewer opioids.

These notifications may be effective reminders of the potential harm of opioids and benzodiazepines, observed JAMA Internal Medicine deputy editor Mitchell Katz, MD, of NYC Health and Hospitals, in an editor’s note.

“It is important to understand that the prescribed drugs may have been appropriate and that the patients did not necessarily overdose on the drugs that were prescribed by the physician who received the notification,” Katz pointed out. “Patients who die of overdose may have more than one prescribing physician and may overdose on illicitly obtained drugs.”

“Nonetheless, when we prescribe opioids and benzodiazepines, the risks and benefits to patients should always be weighed,” he continued. “Even appropriately prescribed scheduled drugs may be associated with long-term use and abuse, purchase of illicit drugs, and death owing to overdose.”

In their analysis, Doctor and co-authors assessed the change in benzodiazepines dispensed 3 months before (pre-period) and 1 to 4 months after (post-period) the letters and injunctions were sent. The researchers measured benzodiazepine prescriptions in daily 2-mg diazepam pill equivalents.

Overall, patients of 743 prescribers (353 in the intervention group and 390 in the control group) filled a benzodiazepine prescription during the study period. Alprazolam and lorazepam were the most frequently dispensed benzodiazepines.

In the intervention group, an adjusted average of 76.0 pills monthly were dispensed in the pre-period and 72.3 were dispensed in the post-period. In the control group, adjusted mean monthly pills were 82.9 in the pre-period and 82.0 in the post-period.

There was no significant difference by group in new treatment initiations from pre- to post-period.

One limitation to the study was that it did not evaluate the clinical well-being of patients or physicians in the intervention group, Doctor and colleagues acknowledged.

Other localities, like Los Angeles County and Washington State, have adopted the practice of sending letters to prescribing physicians alerting them of patient overdoses, Katz noted.

“As physicians, we do not always know why patients are no longer coming to see us,” he wrote. “Follow-up information can help us to be better physicians.”