1. Characterizing Benzodiazepine Use in Ambulatory Palliative Care Patients Living with Cancer
Courtney Cobert, Amy Dunleavy,
Tiffany Khachikian, and Meghal Patel
Faculty Adviser: Dr. Kashelle Lockman

2. Outline Purpose & Methods Results Discussion & Limitations
Conclusion & Further Research
Outline
Tiffany Khachikian – abstract & methods
Amy Dunleavy – results
Meghal Patel – discussion & limitations
Courtney Cobert – conclusion & further research opportunities

3. 67% 5-fold Why Is This Important? Between 1996-2013
Benzodiazepine prescriptions increased by 67%
Overdose fatalities increase more than 5-fold
Marcus A. Bachhuber, Sean Hennessy, Chinazo O. Cunningham, and Joanna L. Starrels.  Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996–2013. American Journal of Public Health: April 2016, Vol. 106, No. 4, pp doi: /AJPH
Bachhuber M, et al. American Journal of Public Health 2016; Vol 106, No. 4, pp
Bachhuber M, et al. American Journal of Public Health 2016; Vol 106, No. 4, pp

4. Why Is This Important? Since 2013
Benzodiazepines involved in 30% of drug overdose deaths
Bachhuber M, et al. American Journal of Public Health 2016; Vol 106, No. 4, pp

5. Why Is This Important? 2016: FDA BBW: BZDs + opioids
Extreme sleepiness
Respiratory depression
Coma
Death
In 2016, FDA requires strong warnings (BLACK BOX WARNING) for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use. Risks of combined use can cause extreme sleepiness, respiratory depression, coma, and death.
And yet, in palliative care patients, there is often a need for the combination of opioids with other medications to properly mange pain.
For our study:
Concurrent medication prescribing (with BZD) and increase risk of respiratory depression:
Opioids
Gabapentinoids
Muscle relaxants
Sedative hypnotics

6. Why Is This Important? “Lots of our patients come to us on benzos!”
-UIHC PC clinicians
Purpose: Determine prevalence of & indications for BZD use in patients living with cancer & receiving palliative care at UIHC
Why Is This Important?
UIHC: Observed a high prevalence of benzodiazepine prescribing upon referral to the ambulatory palliative care clinic.
Purpose: Determine the Prevalence of benzodiazepine use in ambulatory patients living with cancer and receiving palliative care at UIHC
The purpose of the study:
Characterize the indication for the benzodiazepine prescription
Characterize increase risk with concomitant use with opioids

7. Patient inclusion criteria: Patient exclusion criteria:
PC visit between January 1 and June 30, 2017
Patient ≥ 18
Has a cancer diagnosis
Patient exclusion criteria:
≤ 17 years old
No appointment during study period
Methods
A retrospective, single chart review
Demographics on everyone; only collected medication information on patients who were prescribed BZDs

8. Methods Demographic Data Collection
Palliative Care Diagnosis
Active Treatment
or Survivorship
Age
Death within study period
Yes or no
Gender
Male or Female
Type of Cancer
Methods Demographic Data Collection
Palliative Performance Scale
(PPS)
Demographics:
Age
Palliative care diagnosis
Active treatment (yes/no)
Survivorship (yes/no)
Death within study period
Palliative performance scale (PPS)
Gender (male/female)

9. Palliative Performance Scale (PPS)
100% Most Active Patient
70% Reduced Ambulation
50% Mainly sitting
30%
0% Death
Palliative Performance Scale (PPS)
Bed Bound
Tool commonly used in palliative care to assess a patient’s functional performance and to determine progression toward end of life
Below 70% there is significant signs of disease

10. Data Collected Risk factors for BZD induced respiratory depression
Alcohol consumption
Concomitant medication use
Frequency of medication use
Indication of medication
Duration of medication
Data Collected Risk factors for BZD induced respiratory depression
Risk Factors:
Alcohol consumption
Prescribed benzodiazepine
Prescribed opioid
Prescribed sedative hypnotic
Prescribed muscle relaxant
Prescribed neuropathic pain medications
Frequency/type of medication use
Indication of medication
Duration of medication use

11. Prevalence of Cancer Diagnosis, n = 114
Results
Inclusion and exclusion criteria
93/114 charts reviewed had cancer  81.6%
Of the 93 included, 17 patients died during study period due to all cause mortality
58/93 were on at least one BZD  62.4%
All other prevalence factors
are measured per the
93 patients who had cancer

12. Results Prevalence of BZD Prescription in Patients
with a Cancer Diagnosis, n = 93
Results

13. Results 62% 38% At least 1 BZD ≥ 2 BZDs
Prevalence of BZD Prescription, n = 93
62%
At least 1 BZD
38%
≥ 2 BZDs
Results

14. Number of Patients Prescribed BZD by Age
Results
Remove unable to determine data.. Then you will be able to make the font a good size. Is it better to graph this by raw number of by %?

15. Results Indications Anxiety 55% Procedures 26% Sleep 10% n=58
Top indications for prescribing the first BZD. Add %/n

16. Results Co-Prescribing
Prevalence of Concomitant
Respiratory Depressant Medications, n=58
Results Co-Prescribing
Co-Prescribing of BZD with Other Medications
Opioids: 79%
Gabapentinoid: 41%
Sedative Hypnotic: 15%
Muscle Relaxants: 10%
Co-prescribing
Opioids
Prevalence of opioid use: 79%
Prevalence of two opioids: 62.3%
Gabapentinoids
41.2%
Sedative Hypnotics
14.9%
Muscle Relaxant
9.7%

17. Results Benzodiazepine scheduling frequency
Type of BZD Use; n =58
Results Benzodiazepine scheduling frequency
**I just used the Frequency of the First Benzo since we just did the indication for first Benzos on slide 13 **
Scheduled or prn does not change the duration of how long they were on the first benzo

18. BZD Use by Palliative Performance Scale;
Results PPS
Make fonts bigger. Again, is it better to have raw #s vs percent?
PPS: no correlation between a reported decrease in PPS and increase in benzo
4 people with PPS<30%
50% were on one benzo
50% were on two benzos
PPS 40-49%
5/6 were on one benzo 83%
2/5 were on two benzos 40%
PPS 50-59%
10/19 were on one benzo 52.6%
3/19 were on two 16%
PPS 60-69%
6/11 were on one benzo 55%
No one was on two
PPS 70-79%
15/21 were on one benzo 71%
6/21 were on two benzos 29%
PPS >80%
19/30 were on one benzo 63%
6/30 were on two benzos 20%

19. Discussion Similar Studies
Cancer center
31%
Hospice
58%
Our study: 79%
Prevalence of benzo/SH + opioid use in palliative care cancer patients  43% decreased to 31% in 2016 at MD Anderson Cancer center
Haider A. et al.(S762) J Pain Symp Manage. 2018; 55(2): 690 – 691.
Henderson M. et al. Palliat Med. 2006;20(4):

20. Discussion Indication
31/58 = 53%
Anxiety most common indication  Henderson study: hospice cancer patients  anxiety most common indication (1/3 of prescriptions, but only 78% had indication recorded)
Bachhuber found similar results with 56% of prescriptions for anxiety in the general population
Some evidence for short term treatment but  increased adverse effects with increased duration of treatment
CBT, serotonergic agents
Bachhuber M, et al. American Journal of Public Health 2016; Vol 106, No. 4, pp
Henderson M. et al. Palliat Med. 2006;20(4):

21. Discussion General Population
Prevalence
5.6%
Co-prescribing
12%
Prevalence of benzodiazepine use: 62% vs 5.6% adults in general population
Co-prescription of opioid and benzo in general population: 79% vs 12%
Bachhuber M, et al. American Journal of Public Health 2016; Vol 106, No. 4, pp
Venkata HG, et al. BMJ 2017;356:j76

22. Discussion Limitations
External validity
Small sample size
Actual frequency of benzodiazepine use
Unclear indications
Chart review
Discussion Limitations
Small sample size can undermine external and internal validity

23. Where do we go from here? Larger Sample Size Consider Prescribers
Utilize sites outside UIHC Palliative Care Clinic
Expand the time frame assessed; follow patients longitudinally
Consider Prescribers
Who is prescribing
Indication for prescribing
Consider only patients on chronic BZDs
Assess prevalence of chronic use of BZDs
Assess indication of chronic BZD
Educate prescribers and patients
Analyze their attitudes toward BZDs
Educate on BZD risks & drug interactions
Where do we go from here?
This is the only study done that looked at only benzo use specifically in cancer patients receiving palliative care
Based on what we found in our study, there are several areas that can be expanded on to further the knowledge in this area
Further research needs to be done with a larger sample size – we only looked at a small population at UIHC in a 6 month time frame
Look at prevalence of benzo use at other sites
Expand the time frame, maybe even from initiation of care?
Prescribers – we only looked at the fact that patients were prescribed a benzo and why
Analyze who is prescribing benzos
Focus on what indications prescribers are using
Consider patients who are only on benzodiazepines chronically – like me mentioned, acute use was included in our study (procedures) which is important but not as relevant to respiratory depression adverse effect from benzos
Exclude procedural indications for the medication
Educate physicians and patients on proper use of benzos for certain indications
Analyze their attitudes
Make them aware of risks involved with co-prescribing
What they can use instead of benzos for anxiety, etc.
**EMPOWER trial if asked about patient education
Separate study design
Put in system alerts or best practice alerts into the medication records

24. Summary
High prevalence of benzodiazepine prescribing in cancer patients
Additional co-prescribing leads to increased risk of respiratory depression and death
Effects of these medications need to be considered when developing patient therapy plans

25. Questions

26. Sources
Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996–2013. Am J Public Health ;106(4): doi: /AJPH
Haider A, Azhar A, Naqvi S, et al. Concurrent Use of Opioids and Benzodiazepines or Non-Benzodiazepines Sedative Hypnotics Among Cancer Patients Referred to Outpatient Palliative Care Clinic of a Comprehensive Cancer Care Center (S762). J Pain Symptom Manage. 2018;55(2): doi: /j.jpainsymman
Henderson M, MacGregor E, Sykes N, Hotopf M. The use of benzodiazepines in palliative care. Palliat Med. 2006;20(4): doi: / pm1151oa
Journal of Public Health: April 2016, Vol. 106, No. 4, pp doi: /AJPH
Venkata HG, Chauhan G, Ram BS. Co-prescription of Opioids and Benzodiazepines. BMJ. 2017;356(7). doi: /bmj.j760