Association of Primary Care Risk Mitigation Visits and Nonelective Emergency Department Visits in Patients Using Long-term Opioid Therapy.

Objective: To determine risk factors for nonelective emergency department visits (NEDVs) and whether primary care visits incorporating risk mitigation tools prevented NEDVs among patients using long-term opioid therapy (LOT). Patients and Methods: We retrospectively searched the electronic health records at Mayo Clinic primary care outpatient practices in Arizona and Florida in all of 2018 and 2019 for the records of individual adult patients using LOT. Patient and clinician demographic characteristics and patient risk factors were compared between patients with and without risk mitigation visits. Univariate and multivariable logistic regression was used to determine risk factors for NEDVs. Results: Among 457 patients using LOT identified during the study period, most were women (n=266, 58.2%), and the median age was 69 years. Long-term opioid therapy risk mitigation visits were performed equally by family medicine and internal medicine clinicians and by a significantly higher proportion of Florida clinicians than Arizona clinicians (87.0% vs 70.5%; P<.001). Older age, falls, and mental health care utilization all increased the risk of NEDVs. Risk mitigation visits were protective against NEDVs (odds ratio, 0.56; 95% CI, 0.35-0.89; P=.01) after adjustment for older age, falls, and mental health care utilization. Conclusion: Risk mitigation visits are effective in preventing NEDVs, and all patients using LOT should have such visits when possible.

An observational study of the factors associated with frequency of outpatient benzodiazepine prescribing to patients receiving chronic opioid analgesic therapy in primary care at a major academic center.

BACKGROUND: Prescribing benzodiazepines to patients taking chronic opioid analgesic therapy increases risks of adverse events. In 2016, the Centers for Disease Control and Prevention recommended avoidance of benzodiazepine prescribing concurrently with opioids, and various organizations have instituted similar guidelines. We aimed to determine the frequency and patterns of benzodiazepine prescribing at Mayo Clinic primary care (Community Internal Medicine, Family Medicine) clinics for patients taking chronic opioid analgesic therapy and the characteristics of patients receiving the prescriptions and providers administering them. METHODS: This retrospective observational study included adult patients taking chronic opioid analgesic therapy for 2 full years in 2018 and 2019 at Mayo Clinic primary care practices in Arizona and Florida. We assessed electronic health records for these individual patients to determine whether they received a benzodiazepine prescription during the study period and how frequently they received a prescription. Variations in prescriptions by provider specialty, location, and sex were studied. Documented data included receipt of a benzodiazepine prescription by patients with at-risk alcohol use or alcohol use disorder, depression, anxiety, chronic obstructive pulmonary disease, falls, and psychiatric referral. Data were compared between patients who received benzodiazepines and those who did not with the Kruskal-Wallis test or χ2 test, and the Wilcoxon signed rank test was used to assess whether the change in number of benzodiazepine prescriptions (2018 vs. 2019) was different from zero. RESULTS: Study participants (N = 457) were predominantly women (n = 266, 58.2%); median age was 69 years. In total, 148 patients (32.4%) received benzodiazepine prescription. These patients were more likely to be women (P = .046) and younger (P = .02). Mean percentage change was 176.9% (P < .001) in number of benzodiazepine prescriptions provided from 2018 to 2019. Frequency of referral to mental health providers was low, as was presence of an established mental health provider despite a greater prevalence of anxiety (P < .001) and depression (P = .001) among patients receiving benzodiazepines. CONCLUSION: Benzodiazepine prescription to individual patients taking chronic opioid analgesic therapy significantly increased from 2018 to 2019 despite the documented risks and harms associated with such practice. No statistically significant difference was observed in frequency of benzodiazepine prescriptions between practice location, sex of provider, or specialty.

Prescribing patterns and attitudes of primary care providers regarding long-term opioid therapy.

OBJECTIVE: To assess prescribing and referral patterns and attitudes of primary care providers treating patients receiving long-term opioid therapy (LOT) according to recent guidelines. DESIGN, SETTING, AND PARTICIPANTS: An anonymous 25-question survey was distributed to all primary care providers at Mayo Clinic in Arizona (from April 30 through May 22, 2020). MAIN OUTCOME MEASURES: Knowledge and comfort with LOT guidelines, prescribing patterns, referral patterns to behavioral and pain specialties, patients' concomitant substance use, and response variability by provider sex and specialty. RESULTS: Most of the 31 survey respondents were familiar with LOT guidelines and were comfortable in prescribing opioids; 36 percent reported no increase in prescribing safety. Patient education on naloxone was infrequent. Access affected referral to behavioral and addiction specialties; 87.1 percent referred patients to pain medicine specialists despite reporting little long-term improvement in symptoms. For a significantly larger proportion of internal medicine and women's health (IM/WH) providers, compared with family medicine (FM) providers, Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7-item scale scores were the reasons for behavioral health referral. Many providers prescribed additional substances. More female providers reported that patients used gabapentin concomitantly (p = .03). More FM providers than IM/WH providers typically referred patients receiving LOT to addiction specialists (p = .02). Most expressed a need for a multispecialty LOT clinic, and 83.9 percent supported buprenorphine prescribing. CONCLUSIONS: Despite familiarity with LOT guidelines, many providers felt that patient safety and prescribing diligence have not improved. Patient education on naloxone treatment is needed, and access to behavioral specialists is a barrier to referrals.