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2023 HSR&D/QUERI National Conference Abstract

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1178 — Older Veterans’ Perceptions of Discontinuing Chronic Benzodiazepine Use: A Qualitative Study

Lead/Presenter: Linda Takamine,  COIN - Ann Arbor
All Authors: Takamine LH (Center for Clinical Management Research, Ann Arbor, MI), Maust DT (Center for Clinical Management Research, Ann Arbor, MI; Department of Psychiatry, University of Michigan, Ann Arbor, MI) Krein SK (Center for Clinical Management Research, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI)

Objectives:
In contrast to community-based settings, benzodiazepine (BZD) prescribing in the VA has steadily declined. One likely contributing factor was the VA Psychotropic Drug Safety Initiative, which during Phase 2 focused on appropriate psychotropic pharmacotherapy (including BZDs) for Veterans ? 75 years of age. Given anxiety among patients and providers about discontinuing BZDs, we sought to understand how older Veterans experienced BZD discontinuation and identify factors contributing to satisfaction with the process.

Methods:
This analysis is part of a larger mixed methods evaluation of facility efforts to address BZD prescribing. We used CDW data from 7 facilities to identify active, chronic BZD users, defined as having received >120 days of BZD supply during the pre-Phase 2 baseline year. Across the 7 facilities, we interviewed 21 older Veterans who had discontinued BZDs to determine their understanding of why they were taken off BZDs, their role in decision-making, any difficulties experienced, strategies for coping with tapering, issues with adherence, relationships with their providers, and overall satisfaction with stopping.

Results:
Veterans in our sample were primarily prescribed BZDs for anxiety, insomnia, and PTSD. Most remembered being told of the risks of BZD use at the time of stopping. While none reported obtaining BZDs from community sources, some reported moderate alcohol and cannabis use to help with symptom control. Patients with positive experiences believed that stopping was justified. All those who received an effective substitute were satisfied. Patients who lacked an effective substitute but who framed BZD use in negative terms (e.g., addiction, abuse), or had support from family, friends, or their spiritual life were also satisfied. Patients with negative experiences did not believe stopping was justified and none reported receiving an effective substitute. They also tended to frame their BZD use as non-problematic (e.g., used infrequently as needed). Some perceived that the decision to stop their BZD was not truly about clinical appropriateness, but yet another arbitrary mandate imposed by the organization. Patients’ relationships with their providers affected their understanding of stopping. If they were dissatisfied and the relationship was good, they claimed the VA forced their provider to stop the BZD. If the relationship was bad, they criticized both the VA and their provider.

Implications:
Receiving an effective substitute, framing BZD use as negative, and support from family, friends, and/or a spiritual practice contributed to positive experiences of stopping. Having no effective substitute, framing their own BZD use as non-problematic, and negative perceptions of VA patient care “mandates” contributed to negative experiences with stopping.

Impacts:
When safety concerns limit certain medications, the availability of effective alternatives for ongoing symptoms should be prioritized. Knowledge of BZD-related safety risks is not sufficient for some Veterans to accept the decision to stop, particularly if an initiative is perceived as another top-down organizational mandate. While patient trust in their clinician is important, trust in the VA as an organization is also critical to how Veterans experience these organizational initiatives, and is important to consider in future interventions perceived as limiting access to particular treatments.