DISCONTINUATION OF CHRONIC BENZODIAZEPINE USE AMONG ADULTS IN THE U.S.

Introduction Benzodiazepine (BZD) use is common and growing in the U.S., with a prescription filled by 5.6% of adults in the U.S., including 8.6% of those ≥65. Clinical guidelines and expert opinion recommend that BZDs should primarily be prescribed on a short-term basis, yet chronic BZD use (i.e., >120 days) is common—ranging from 14.7% among those 18-35 who are prescribed a BZD to 31.4% among adults ≥65—and increasing. As chronic BZD use continues and grows, increasing numbers of adults in the U.S. will accumulate time at-risk for BZD-related harms. To understand more about patients with chronic prescription BZD use and which patients discontinue use, we evaluated 2014-2016 healthcare claims from a large U.S. health insurer. The objectives of this study were to: 1) determine the rate of BZD discontinuation among chronic users; 2) identify which patient clinical characteristics predict discontinuation; 3) determine whether additional non-clinical characteristics (e.g., geography, provider) are associated with discontinuation; and 4) determine the relative contribution of these patient and provider-level factors to BZD discontinuation. Methods We performed a retrospective cohort study using nationwide insurance claims data (Optum Clinformatics Data Mart data) from 2014-2016 of U.S. adults ≥18 years old with chronic BZD use (i.e., >120 days) during the baseline year. The primary outcome was BZD discontinuation among chronic users after one year of follow-up. A series of multilevel logistic regression models examined the association of BZD discontinuation with patient and provider characteristics and estimated variation in discontinuation attributable to provider. Covariates included patient sociodemographics, medical and psychiatric comorbidity, co-prescribed opioids and other psychotropics, and characteristics of the prescribed BZD. Results Of 144,184 chronic BZD users, 13.2% discontinued use after one year. 57.0% of chronic BZD patients received an opioid prescription, which was more common than any clinical diagnosis. Census division was strongly associated with discontinuation (e.g., relative to the Mid-Atlantic, patients in the Pacific had an adjusted odds ratio [AOR] for discontinuation of 1.83 [99% confidence interval [CI] 1.60-2.10]). Females had lower odds of discontinuation (AOR 0.83, 99% CI 0.79-0.87), while African-American patients had higher odds (AOR 1.12, 99% CI 1.03-1.21). Those prescribed a high-potency BZD had lower odds of discontinuation (AOR 0.51, 99% CI 0.48-0.55), as did those prescribed an opioid (AOR 0.94, 99% CI 0.89-0.99). After adjusting for patient and provider-level factors, differences between providers accounted for 5.8% of variation in BZD discontinuation. The median odds ratio for provider was 1.54, an association with discontinuation larger than almost all patient-level clinical variables. Conclusions A small minority of patients prescribed chronic BZD in a given year are no longer prescribed BZDs one year later. The decision to prescribe and then discontinue a BZD—or any other medical treatment—should be driven by a clinical need. However, we found there is significant variation in the likelihood of discontinuation accounted for by non-clinical factors such as race, geography, and a patient's provider. Given the harms associated with co-prescribing of BZDs and opioids, it is worrisome that use of a prescription opioid was more common among chronic BZD patients than any other clinical diagnosis and was associated with lower odds of BZD discontinuation and efforts should continue to focus on those co-prescribed opioids. Finally, since chronic BZD use is rarely the goal when a new BZD is started, clinicians may increase the likelihood of discontinuation by selecting a low-potency option. This research was funded by Dr. Maust receives support from the Beeson Career Development Award Program (NIA K08AG048321, the American Federation for Aging Research, The John A. Hartford Foundation, and The Atlantic Philanthropies) and 1R01DA045705.