IMPORTANCE: Opioid and benzodiazepine use by older adults is related to increased fall risk.
OBJECTIVE: To evaluate whether a centralized consultant pharmacist intervention increases opioid and benzodiazepine deprescribing and reduces falls among older adults in primary care.
DESIGN, SETTING, AND PARTICIPANTS: This intention-to-treat cluster randomized trial with 1-year follow-up included 2075 adults 65 years or older with long-term opioid use (n = 965) or benzodiazepine use (n = 1110) identified from electronic health record prescription data with a clinic visit from June 1, 2020, to July 31, 2022. Patients were from primary care clinics in the University of North Carolina Health Physician Network without embedded pharmacists, all using a shared electronic health record (EHR). Exclusions included active cancer treatment, dementia, or non-English-language preference. Statistical analysis was performed in November 2022.
INTERVENTION: Clinics were randomized to a centralized consultant pharmacist service or usual care. Pharmacists reviewed the EHR and the state's prescription drug monitoring program and then provided patient-specific opioid or benzodiazepine tapering recommendations for prescribers at intervention clinics. Control clinics received no deprescribing support.
MAIN OUTCOMES AND MEASURES: Primary outcomes were average daily morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs) ordered in the year after the index visit. Secondary outcomes included medication discontinuation (=180-day gap in orders) and incident falls identified using International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes.
RESULTS: A total of 2075 patients (mean [SD] age, 74.6 [0.13 for opioid group and 0.15 for benzodiazepine group] years; 1429 [68.9%] female) met criteria for long-term opioid or benzodiazepine use. Both intervention and control clinics showed reductions in opioid and benzodiazepine exposure, but between-group differences were not statistically significant. Mean (SD) daily MMEs decreased by 8.8% in intervention clinics (26.9 [54.2] to 24.5 [50.4]) and 5.4% in controls (18.7 [33.4] to 17.6 [32.0]) (P = .71); mean (SD) DMEs decreased by 11.4% (8.8 [10.4] to 7.8 [10.1]) and 1.5% (6.6 [8.2] to 6.5 [8.3]), respectively (P = .07). Although the proportion of patients who discontinued opioids was 21.4% in intervention clinics and 19.9% in control clinicals, this difference was not statistically significant (odds ratio [OR], 1.20; 95% CI, 0.85-1.71). The proportion of patients who discontinued benzodiazepines was 22.0% in intervention clinics and 18.4% in control clinics. This difference was not statistically significant (OR, 1.41; 95% CI, 0.94-2.03). There was no difference in the likelihood of incident falls between patients taking opioids in the control and intervention clinics (OR, 1.36; 95% CI, 0.94-1.96). In subgroup analyses, patients taking benzodiazepines with less than 10 daily DMEs had significantly reduced DMEs (effect size, -0.22; 95% CI, -0.36 to -0.08; P = .002).
CONCLUSIONS AND RELEVANCE: This cluster randomized trial found that a centralized consultant pharmacist model was feasible, integrated well into primary care workflows, and resulted in high practitioner acceptance of recommendations; however, it did not significantly reduce opioid or benzodiazepine prescribing or falls within 1 year. These results suggest that more intensive or sustained deprescribing strategies may be needed to produce clinically meaningful reductions in high-risk medication use among older adults in primary care clinics.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04272671.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
As a geriatrician, I come across patients on chronic medications, mostly benzodiazepines, but rarely patients on opioids seen by palliative care consultants. I try to de-prescribe, without great success, due to patient resistance. We don't have pharmacy consultants in our facility; I think they can be useful in helping clinicians to de-prescribe.
, McMaster University