A Pharmacist Consultant Service for Deprescribing Opioids and Benzodiazepines in Older Adults: A Cluster Randomized...

Opioid and benzodiazepine use by older adults is related to increased fall risk.

To evaluate whether a centralized consultant pharmacist intervention increases opioid and benzodiazepine deprescribing and reduces falls among older adults in primary care.

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.

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.

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.

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).

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.

ClinicalTrials.gov Identifier: NCT04272671.