Injunction Letters May Reduce Clinician Overprescription of Benzodiazepines

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Reductions in prescribed benzodiazepines were especially noted in continuing prescriptions.

Letters informing clinicians of patient death from overdose from a scheduled drug may be an effective, lost-cost way to reduce overprescription of benzodiazepines.

A randomized clinical trial led by Jason Doctor, PhD, of the University of Southern California, and colleagues found that such injunctions were associated with reductions in overall, high-dose, and new opioid prescriptions. A new secondary analysis conducted by the same team further examined associations between distribution of these letters and benzodiazepine prescribing.

“For the present analysis,” they wrote, “we assessed the change in benzodiazepines dispensed 3 months before (pre-period) and 1 to 4 months after (post-period) the injunctions were sent.” They then compared these changes in the intervention group (n = 353) with the control group (n = 390).

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The team used a mixed-effect generalized linear model of 2-mg diazepam pill count to evaluate the differences in the change in prescribing between physicians who received the letter and those who did not.

“The model accounted for whether any prescriptions were dispensed on a given day and, if so, the quantity of 2-mg pills,” they wrote.

Secondary outcomes sought by the team included new patients and those patients’ average day’s supply.


Of the 743 patients who filled a benzodiazepine prescription during the study period, alprazolam and lorazepam were the most frequently dispensed drugs.

The investigators found that use of daily 2-mg pills decreased by 3.7% more in the intervention group when compared with the control group (95% CI, −6.9% to −0.5%; P<.05).

Furthermore, on average, there were 2.9 fewer 2-mg diazepam pills dispensed per prescriber per month in the intervention group versus the control group.

Notably, there was no significant difference between groups from the pre-period to post-period in the change in probability, number, or average day’s supply of new treatment initiations. The secondary analysis also showed that, after controlling for new users and opioid coprescriptions, prescribers in the intervention group were not any more likely to reduce daily diazepam milligram equivalents by more than 20%.


“The observed moderate reductions that were associated with the letter seemed to concentrate among continuing prescriptions, which is what was associated with the increase in benzodiazepine prescribing from 2005 to 2012,” the team wrote.

“While the mechanism of the effect is not known, death notification may increase the salience of harmsfor opioid and benzodiazepine prescribing among physicians, thus potentially affecting risk posture,” they continued.

While they acknowledged their limitation in not assessing the clinical well-being of the patients or physicians in the intervention group, the investigators nonetheless recommended that medical examiners send letters or warnings to prescribing physicians following patient death from overdose from a scheduled drug.

The research letter, “Association of Fatal Overdose Notification Letters With Prescription of Benzodiazepines: Secondary Analysis of a Randomized Clinical Trial,” was published online in JAMA International Medicine.