Emergency Department Provider Perspectives on Benzodiazepine-Opioid Co-Prescribing: A Qualitative Study

Abstract

Objective

Benzodiazepines and opioids are prescribed simultaneously (i.e. “co-prescribed”) in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid co-prescribing occurs and providers’ reasons for co-prescribing.

Methods

We conducted focus groups with ED providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semi-structured interviews to elicit perspectives on benzodiazepine-opioid co-prescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid co-prescribing.

Results

Participants acknowledged co-prescribing rarely and reluctantly, and often provided specific discharge instructions when co-prescribing. The decision to co-prescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g. low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to co-prescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of co-prescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial.

Conclusions

In this qualitative study of ED providers, we found that benzodiazepine-opioid co-prescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to co-prescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.

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