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The Northeast Community Center for Behavioral Health (NECCBH) created the Motivational Interviewing for Benzodiazepine Reduction program in 2015 in an attempt to proactively address the increasingly deadly misuse of benzodiazepine medications in the Philadelphia community we serve. A 2016 report by the Philadelphia Department of Public Health showed that between 2003 and 2015 benzodiazepines were present in 90% of the overdose deaths involving opioid medications. The Motivational Interviewing for Benzodiazepine Reduction program is a structured set of agency policies for benzodiazepine prescribing utilizing Motivational Interviewing as a central component for reduction. NECCBH psychiatrists assess whether clients are at the: Pre-contemplation, Contemplation, Preparation, or Action stage of change regarding benzodiazepines, and base their clinical interactions accordingly. Because readiness to change is not an inherent trait of the client but a fluctuating result of interpersonal interaction, Motivational Interviewing gives the doctor an effective, person centered tool for benzodiazepine reduction. An additional component of the program involves the concrete monitoring of benzodiazepine use by using the Pennsylvania Prescription Drug Monitoring Program as well as random oral drug screens. The collaborative approach inherent in Motivational Interviewing allows the doctor to more easily communicate results of the monitoring in a way that maintains client engagement.
The use of Motivational Interviewing to improve outcomes in the specific area of benzodiazepine reduction is an innovative use of an ethical, economical, and culturally sensitive technique to address a serious problem that has little published guidance for best practices. As managed care has pushed for cost savings in recent decades, the role for psychiatrists in most behavioral health clinics has shifted to providing clients with brief, medication management appointments rather than therapy sessions. The beauty of utilizing Motivational Interviewing to collaborate with clients over benzodiazepine reduction is in its straightforward, (usable even in brief 20-minute medication encounters) approach to helping clients change. Motivational Interviewing has robust research verifying its effectiveness, including with substance use issues. Since reduction of benzodiazepines is often difficult and emotionally-charged for clients, a formalized and understandable evidence-based practice helps both the physician and the client collaborate rather than engage in a power struggle.
NECCBH made a determined effort to design specific policies and procedures to address the challenges of working with benzodiazepines in an area where abuse and misuse are common. As the initiative began to show positive results, NECCBH made a commitment to share what was working with other providers in the area. In July of 2016, NECCBH presented the Benzodiazepine Reduction Program at the Philadelphia Evidence-based Practice and Innovation Center (EPIC) Open House: A Celebration of What Makes Evidence-based Practices Work. The EPIC presentation brought together 30 Philadelphia area providers to present their programs and share their successes and approaches with other agencies. NECCBH provided information and suggestions during the event. It is important to note that the benzodiazepine reduction policies that NECCBH implemented were designed to be user-friendly and simple to adapt to different agency environments. Subsequent to the EPIC program, NECCBH has continued to network with other local agencies.
The NECCBH Benzodiazepine Reduction Program uses existing structures, only changing the culture and focus of the client-physician interactions to promote successful outcomes, so is economically sustainable. Sustainability requires Motivational Interviewing (MI) training for all physicians, meetings to review cases and monitor adherence to the policies, and internal tracking of benzodiazepine prescribing and client use. NECCBH has MI trainings and weekly Medical Review meetings integrated into the physicians’ schedules and is currently working to automatically track benzodiazepine use with the new electronic health record being implemented in 2017. The recent focus on overdose deaths in the US has brought much-needed attention to the role benzodiazepines often play. The Philadelphia Department of Behavioral Health and Intellectual disAbility Services has recently started working to promote many of the very policies that NECCBH already has in place so has been gathering information from NECCBH and has a vested interest in continuation of the program.
The innovative NECCBH approach to benzodiazepine reduction is fairly simple to duplicate and adapt to other agencies. However, because the approach requires a change in mindset, it is important that an on-site “champion” who believes in the approach works to achieve buy-in from all the parties involved. Because Motivational Interviewing (MI) is a well-known approach with validated effectiveness, promoting the use of the technique should not pose an insurmountable obstacle for agencies. The prescribers at the agency seeking to emulate the NECCBH approach need training on effective use of Motivational Interviewing and there are many quality MI trainers throughout the United States. Once the basic benzodiazepine reduction policy concepts are understood, adding ongoing medical review meetings and policies to track benzodiazepine data can be designed to suit the individual agency. This combination ensures that there is a sustainable focus on the problem with a well-defined agency plan to address it.
Since creating and implementing the Motivational Interviewing for Benzodiazepine Reduction program in 2015, NECCBH has seen a marked reduction in benzodiazepine use. The data from the first year, (6/2015 to 6/2016) showed that 63% of reviewed clients reduced monthly benzodiazepine use and 37% completely terminated use, with the results comparable across gender. More importantly, there was little evidence of client termination related to the tapering or discontinuation of the benzodiazepines. A main goal of using Motivational Interviewing to help clients choose to stop benzodiazepines (rather than simply discontinuing prescriptions) is to prevent shifting the problem-use to another provider. This prevents client desire to “doctor-shop” or illegally purchase diverted benzodiazepine medications on the street, both of which fuel the overdose epidemic. It is hoped that the initial success is continuing in 2016/2017 and that the NECCBH electronic health record implementation in 2017 will simplify benzodiazepine data gathering and analysis this summer.