As a consumer psychologist with expertise in memory, motivation, and persuasion, I was invited by Platt, Savage, and Rajagopal (2019) to offer my perspectives on the effectiveness of their intervention to decrease benzodiazepine (BZD) prescribing.
Anxiety disorders are the most common mental illness in the United States, and BZDs are frequently prescribed as a short-term s olution to manage anxiety, panic disorders, muscle spasm, seizures, and insomnia (Harvard Health Publishing, 2019). But BZDs have a downside—addiction may occur in just a few weeks (American Psychiatric Association, 2009), and withdrawal could have severe and potentially life-threatening symptoms (Billioti de Gage et al., 2014; Maust, Kales, Wiechers, Blow, & Olfson, 2016; National Institute on Drug Abuse, 2017).
Platt et al. (2019) implemented an intervention that augmented academic detailing with pharmaceutical detailing techniques for advocating reduced prescription of BZDs at an urban clinic. The clinic's prescription records showed an 80% decline in BZD prescribing in the 30-day postintervention period compared to the preintervention monthly prescription rate averaged over 12 months. The purpose of this commentary is to offer some psychological insights that may underlie the success of the intervention.
As suggested by Platt et al. (2019), educational programs and media coverage of the BZD dependence crisis may have prompted providers to cut back on BZD prescriptions in general. A comparison of prescription rates of similar clinics for the same period could shed light on whether the observed reduction is part of a general trend or attributable to the detailing intervention.
Academic researchers sometimes conduct face-to-face educational out-reach programs, referred to as academic detailing, to encourage the prescription of a drug or drugs to be consistent with evidence from randomized clinical trials. The goal is to improve patient care and potentially reduce health care cost. Prior studies on the effectiveness of academic detailing have reported prescription reduction rates of various drugs ranging from 14% to 41% (Avorn & Soumerai, 1983; Gonzales, Steiner, Lum, & Barrett, 1999; Ray, Schaffner, & Federspiel, 1985; Solomon, Van Houten, & Glynn, 2001). Hence, an 80% decline in prescription rate of BZDs observed by Platt et al. (2019) would suggest a huge success for the intervention implemented. What might account for this significant reduction in BZD prescription? To answer this question, it would be useful to first understand the strategies Platt et al. (2019) used.
Platt et al. (2019) gave an overview of BZD dangers, discussed harm reduction strategies, and presented alternative treatments for anxiety and insomnia to approximately 30 clinic providers—a standard academic detailing practice. The authors also adopted detailing strategies typically used by pharmaceutical sales personnel, bringing in catered food, distributing mugs and pens with the “No Benzo” logo, and putting up posters listing harm reduction strategies and alternative treatments.
I believe that the pharmaceutical detailing strategies Platt et al. (2019) adopted made a difference in the reduction of BZD prescription rates at the clinic. From the providers' perspective, the offering of food and souvenirs was not standard practice for academic detailing, and hence drew more attention to the event and the information presented. This additional attention likely made the message more meaningful and memorable, and in turn influenced their prescription behavior. Consumer research has shown that many purchase decisions are based more on how easily the brand name or other related information comes to mind, rather than brand preferences (Fazio, Powell, & Williams, 1989; Nedungadi, 1990). That is, consumers often buy what is most top-of-mind, rather than what they like most. Health care providers may be similar in their prescription behavior such that the more top-of-mind the information, the more likely they will include the information in their prescription decision. Thus, they may focus on what comes to mind as the most effective in the short-term to treat a patient's symptoms, without carefully considering the pros and cons of the different treatments. The presence of mugs and pens with the “No Benzo” logo likely served as useful reminders of the downsides of BZDs and alternative treatments for providers; hence, a reduction in BZD prescription rates was observed after the intervention.
From the patients' perspective, recent research shows that patients' requests for medication are on the rise. More central to this research, physicians are also more likely to prescribe the medication requested by patients (McKinlay, Trachtenberg, Marceau, Katz, & Fischer, 2014). Seeing the “No Benzo” signs on mugs and pens around the clinic likely prompted patients to think twice before asking their provider for a BZD prescription. And the prominently displayed “No Benzo” posters would also have made it easier for providers to discuss the pros and cons of various treatments for patients' symptoms.
The intervention strategy of combining academic and pharmaceutical detailing approaches adopted by Platt et al. (2019) represents an effective two-pronged effort to reduce BZD prescriptions by encouraging vigilant prescription decisions and facilitating patient education with respect to BZDs (Cook, Marshall, Masci, & Coyne, 2007). Future research may aim to examine the robustness of the effect of this novel intervention by conducting similar studies in other clinics.
Angela Y. Lee, PhD
Mechthild Esser Nemmers Professor of
Kellogg School of Management
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