Can’t sleep? Feeling anxious or stressed?
Benzodiazepines, benzos for short, are often used to treat these common conditions. These sedating drugs are among the most prescribed medications in the U.S. and include familiar names like Xanax, Valium and Ativan.
The medications put patients at higher risk for falls, fractures, car accidents and even death, especially when they are used in combination with opioids, which is commonly the case. And despite being intended for short-term use, many patients, particularly older adults, are staying on them for months if not years or even decades.
USC Leonard Davis School of Gerontology Assistant Professor Michelle Keller is working to change that. She sent brochures about why these drugs are dangerous and how to taper off them directly to patients at home.
The snail mail delivered results.
“We found that for every 10 brochures we sent — a very low-cost intervention — one person completely stopped these medications [while] working closely with their doctor,” says Keller. “This is a neat intervention because it is so simple. All it requires is sending patient-education materials to a patient via mail. Sometimes health care is so complicated that it is nice to see such a simple intervention work.”
In an age of instant messaging, Keller’s work is one in a trio of studies from USC researchers showing that low-tech letters can lead to better practices around high-risk medications. Patients who received brochures about risks, alternatives and tapering recommendations were more likely to successfully quit taking benzodiazepines, while letters sent to clinicians successfully encouraged them to check patients’ records before prescribing opioids or to write fewer prescriptions for them.
Known as deprescribing, the process of tapering or stopping the use of prescription medications that are no longer needed or are potentially causing harm is particularly important in the case of highly addictive drugs like benzodiazepines and opioids. The National Institute on Drug Abuse (NIDA) reports that opioid overdoses kill more than 200 Americans a day, with benzos involved in close to 15% of these cases. Patients taking both drugs can face a fatal overdose risk 10 times higher than those using opioids alone, according to one study NIDA cites. Use and overuse of these medications can also cause dizziness, weakness, breathing problems and confusion, issues that can be exacerbated by older age.
Delivering Data to Doorsteps
Keller’s study adapted materials from an intervention originally used in Canada, called Eliminating Medications Through Patient Ownership of End Results (EMPOWER), for a population of older patients of 22 primary care providers in the Cedars-Sinai Medical Group in Los Angeles County. In the study, 308 patients received the EMPOWER materials in the mail, while 291 patients received standard care.
“Many physicians assume that patients are already aware of the risks of benzodiazepines, but our study found that patients may not know these risks. These medications may have been initially prescribed decades ago — before we knew all of the risks of benzodiazepines or when the person was younger and had a lower risk of falls, fractures, etc.,” says Keller, who holds the Leonard and Sophie Davis Early Career Endowed Chair in Minority Aging at the USC Leonard Davis School. “We found that several patients reached out to their physicians using the patient portal and expressed surprise that these medications had serious risks. That was really illuminating and increases our motivation to make sure that people know that these medications aren’t without risks.”
The EMPOWER materials not only illustrate the risks of benzodiazepines but also offer alternative strategies for managing symptoms and provide an example tapering schedule for gradually reducing medication use, all within a short brochure. Another powerful part of the intervention was a letter from the patient’s primary care physician that encouraged the patient to come in and talk to them about these medications.
Overall, 26% of patients who received the EMPOWER brochure had stopped benzodiazepine use completely, versus 17% of the control group, when assessed after nine months.
In the future, Keller and her colleagues hope to reach out to different populations with the brochures, which have been translated into multiple languages. They also plan to provide the EMPOWER materials to hospital patients who have experienced a fall, fracture or other serious event.
Addressing the Issue
Researchers from Columbia University and USC discovered that letters can make a big difference when it comes to promoting safer opioid prescribing. Their study found that sending letters to doctors made a significant and lasting impact in prompting them to check a state database before prescribing opioids.
The focus was on clinicians who prescribe opioids alongside benzodiazepines or gabapentinoids — medications that when combined with opioids both substantially raise the risk of overdose. The researchers wanted to know if they could reduce dangerous prescriptions by encouraging more doctors to use state prescription monitoring programs (PMPs), which track these risky drug combinations. Although almost all states have PMPs in place, many doctors still don’t use them regularly, explains senior author Mireille Jacobson, associate professor at the USC Leonard Davis School and co-director of the Aging and Cognition Program at the USC Schaeffer Center for Health Policy and Economics.
“Well-meaning clinicians are still prescribing way too many opioids,” she says. “Getting them to check these types of databases can help them make more informed — and safer — decisions about medication use.”
The research team partnered with the state of Minnesota’s PMP and enrolled 12,000 clinicians who were randomly divided into groups: Some received no letter, while others were sent one of three types of letters. The letters, sent in early 2021, either informed them about a new requirement to check the PMP before prescribing opioids, provided information on their potentially risky prescribing habits or included both messages.
Clinicians who received the letter about the mandate to check the PMP were more likely to engage with the system. In fact, PMP searches increased by 9%, and this bump in activity lasted for at least eight months after the letters were sent. Clinicians who received the combination letter (mandate and prescribing info) showed similar improvements. Additionally, many signed up for PMP accounts, an essential step for using the system.
The researchers are encouraged that more clinicians enrolled in the system and searched for patient medication data, even though these letters did not lead to detectable changes in what they prescribed.
“Prescription monitoring programs can help make opioid prescribing safer, but they’re only effective if doctors actually use them,” says Adam Sacarny of Columbia University Mailman School of Public Health, the study’s first author. “Our research shows that a simple letter can make that happen.”
Missives with a Mission
Delivering a stark message succeeded in reducing opioid prescriptions in a third USC study. A letter notifying providers their patient died from an overdose reduced the number of opioid prescriptions they wrote for up to a year.
That study, led by author Jason Doctor, professor and Norman Topping National Medical Enterprise Chair in Medicine at the USC Sol Price School of Public Policy, follows a 2018 report by the same team that found the same impact, but only had three months of data.
“Clinicians don’t necessarily know a patient they prescribed opioids to has suffered a fatal overdose,” says Doctor, who is also the co-director of the Behavioral Sciences Program at the USC Schaeffer Center. “We knew closing this information loop immediately reduced opioid prescriptions. Our latest study shows that change in prescribing behavior seems to stick.”
Doctor and his team sent letters from their county’s medical examiner to 809 clinicians — predominantly medical doctors — who had prescribed opioids to 166 people who had suffered fatal overdoses in San Diego County. The letter was intended to be informative and respectful in tone while providing information about safer prescribing. The researchers compared prescribing patterns among these clinicians with those who had not received the letter.
While there was a gradual reduction in opioid prescribing across the board, study authors found the rate of the reduction was faster and more robust among those who received the letter. The earlier study found that in the three months after receiving the letter, prescribing decreased by nearly 10% compared with the control group, which didn’t receive a letter. The new study found that after one year, those who received the letter wrote 7% fewer prescriptions than clinicians who hadn’t received the notification.
The big takeaway, says Doctor, is that the letters from the medical examiner provide a unique opportunity to communicate with physicians in the wake of overdose deaths to save lives from both legal and illegal opioids.
“The letter is a nudge to providers that the opioid epidemic is in their community and affecting their patients. It is easy to read the headlines and assume you are not part of the problem,” he says. “Doctors have an opportunity to talk to their patients and consider alternatives to opioids.”
Doctor and other study authors are working with Los Angeles County to examine lessons from the research and are looking at potential public policy interventions, including mandating such notifications from county medical examiners to clinicians.
Several of the researchers say they’d like to experiment with email in future studies. But a common lesson in all these letters: Don’t write off mail just yet.
