lournal

of Substance

Abuse,

4, 179-185

(1992)

BRIEF REPORT

Physician

Failure to Record Alcohol Use History When Prescribing Benzodiazepines Antonnette V. Graham Case Western

Reserve University

Theodore V. Parran, Jr. St. Vincent’s

Charity

Hospital

and Health

Center

Carlos R. Jakn Case Western

Reserve University

The purpose of this pilot study was (1) to determine the proportion of patients in an ambulatory medical clinic who have an alcohol history recorded when prescribed benzodiazepines, and (2) to assess the adequacy of the alcohol history when obtained. Medical records of 35 outpatients who obtained prescriptions for benzodiazepines at a large inner-city teaching hospital medical clinic were audited. In none of the records was there evidence that the physician had sufficient knowledge of the patient’s alcohol use to safely prescribe a benzodiazepine. In 57% of the records, no information about alcohol use was recorded. In the remaining 15 medical records, the information recorded was limited. The implications of prescribing benzodiazepines without knowledge of drinking status are discussed.

In ambulatory practice there is a high prevalence of alcohol abuse and/or dependence (Cleary et al., 1988) and anxiety disorders (Diamond & Grauer, 1987; Walker, 1981). Physicians should be aware of patients’ alcohol use when prescribing anxiolytic medication because of the hazards of synergy and crossaddiction between benzodiazepines and ethanol. Because anxiety frequently is a presenting symptom in patients with a drinking or alcohol withdrawal problem, physicians should carefully evaluate the patient’s alcohol use patterns before prescribing. Otherwise, medication that can be beneficial in warranted situations could be misused (Ciraulo, Sands, & Shader, 1988). According to currently accepted standards of care, it is recommended that prescribing benzodiazepines be avoided in patients suffering from alcohol abuse Special thanks to several people who made contributions to this article: Steve Zyzanski and Susan Flocke of Case Western Reserve University, Department of Family Medicine, for their help with the data analysis, and Michael Grodach of St. Vincent Charity Hospital and Health Center for auditing the medical records. This research was supported by grant No. #2 D15 PE55034-04 from the Health Resources Services Administration of the U.S. Department of Health and Human Services. Correspondence and requests for reprints should be sent to Antonnette V. Graham’s Family Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4950. 179

A.V.

180

Graham,

T.V. Parran,

and C.R. Ja6n

or dependence, except during detoxification (Hollister, 1990; PDR, 1990; Schuckit, 1987). When benzodiazepines are prescribed to actively drinking alcoholics, there is a risk of (1) concurrent ingestion leading to the danger of synergy and symptoms of overdose, and (2) alternate ingestion leading to a drugsubstitution pattern in which a drinking problem may be disguised, delaying its recognition. In abstinent alcoholics, the ingestion of sedative-hypnotic drugs may (1) rekindle craving and 1e::d eventually to relapse when sedatives are discontinued, or (2) become a permanent “need” that is difficult for the physician to discontinue. A review of the literature reveals no studies of physician knowledge of the patient’s alcohol use when prescribing anxiolytics. Therefore, the purpose of this pilot study was to determine the proportion of patients in an ambulatory medical clinic who have an alcohol history recorded when prescribed benzodiazepines, and to assess the adequacy of the alcohol history when obtained. METHODS This study was conducted in the outpatient medical clinic of a large inner-city private teaching hospital. Medical records of patients who were prescribed benzodiazepines were consecutively identified by the ambulatory care clinic discharge nurse during the fall of 1989. The medical records of patients of internal medicine residents and attending staff were audited. Thirty-five records of patients receiving prescriptions for benzodiazepines were identified. If a patient was seen more than once during the data collection period (i.e., for prescription refills), the record was audited only on the first physician encounter. In order to prevent investigation-induced bias through defensive changes in prescribing or recording practices, the study was not discussed with any of the medical providers or nursing staff. The records of patients obtaining prescriptions for diazepam, chlordiazepoxide, lorazepam, alprazolam, oxazepam, triazolam, or clorazepate were audited by the research assistant, a physician’s assistant with several years of experience working in a substance-abuse unit. If alcohol information or evidence of use of a screening instrument was not in the record, the study guidelines assumed that the questions were not asked. This is in keeping with widely accepted standards of quality assurance. The dependent variables for the study were the presence of recorded information about alcohol use and the adequacy of that information. The entire medical record was audited, including initial history and physical, problem list, progress notes, inpatient discharge summaries, and emergency room reports. The audits gathered information on patient age and gender, level of physician training (resident vs. faculty), and reference to alcohol consumption. If the use of alcohol was noted, the record was further examined for the adequacy of that data including: the quantity, frequency, and type of alcohol consumed; behavioral manifestations or medical consequences of drinking; use of standard alcoholism screening tools; questions about family history of alcoholism; and location in the chart of the information regarding alcohol use.

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and Benmdiazepine

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Quantitative data were analyzed using descriptive statistics, chi-square analyses, and z tests. Stratified analyses by patient age, gender, and level of physician training were performed to assess whether patient or physician characteristics influenced recording about alcohol use. Age was trichotomized from a continuous variable. RESULTS Of the 35 patients obtaining a prescription for benzodiazepines, 69% were seen by faculty physicians, 26% by resident physicians, and in 6% of the cases, the identity of the prescribing physician was indiscernible. Sixty-six percent of the patient sample were women, reflecting a gender distribution typical of the clinic population served. The mean age was 66 years, with a range of 33 to 87, which was older than the clinic population. In 20 (57%) of the medical records, no information about alcohol use was identified. In 3 (9%) of these records, there was no indication that a benzodiazepine had been prescribed, even though the patient left the visit with a prescription. Fifteen (43%) of the records with some alcohol information had incomplete data. Twelve had insufficient information to judge whether alcohol abuse was or was not a problem. The three records that listed alcoholism on the problem list provided no additional information in the progress note about the logic of choosing to prescribe a benzodiazepine. In none of the records was there documentation of the discussion of the risks of concomitant use of alcohol and benzodiazepines (see Table 1). Chi-square analyses revealed no association between demographic variables (patient age or gender) or physician level of training (resident or faculty) to whether the record contained information about alcohol use.

Table 1. Prescriptions

Alcohol

Information

Classification

Recorded

of Information

No history included History included Frequency Quantity Type of beverage Patterns or consequences Standardized screening tests Family history Location of alcohol information Initial history and physical Problem list Progress note Discharge summary or emergency Note.

Percentage

totals

may

exceed

100%

on

35 Patients

Receiving

Rec&ded

room because

report categories

are not

Anxiolytic

n

%

20 15 6 9 3 7 0 0

57 43 17 26 9 20 0 0

6 3 9 6

17 9 26 17

mutually

exclusive.

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Graham,

T.V.

Parran,

and C.R. Jack

DISCUSSION The data from this study are important in a society where drinking is a widespread social activity, alcoholism is common, and the concurrent use of alcohol and antianxiety agents is prevalent (Schuckit, 1987). Accepted standards of clinical practice include cautioning patients about the amplification of sedative effects and cognitive impairment if alcohol is consumed while taking benzodiazepines. The consequences of the synergistic effects of these two depressant drugs are hazardous and can be fatal due to memory blackouts, car accidents (Girre, Facy, Lagier, 8c Dally, 1988), overdoses, or suicides (Schuckit, 1984). Patients often are unaware that long-acting benzodiazepines remain in the system for several days after ingestion, and physicians need to outline explicitly the risks of any alcohol use. Furthermore, because benzodiazepine ingestion may increase tolerance, when prescribing ceases, the “need” for alcohol may intensify. Finally, alcohol use may cause or exacerbate symptoms of sleep disorders and anxiety. The essence of diagnosing alcoholism is in the assessment of the patterns and consequences of drinking rather than in quantity and frequency information (Coulehan, Zettler-Segal, Block, McClelland & Schulberg, 1987). However, quantity and frequency questions often comprise a physician’s entire alcohol history (Hays & Spickard, 1987; Lewis, Niven, Czechowicz, 8c Trumble, 1987). We found the most commonly noted information about alcohol use was quantity, and that was recorded in only 26% of the records. Frequency and type of beverage consumed were recorded less frequently. Because clues of alcoholism are often subtle, especially early in the disorder, it is important for physicians to have a structured, standardized approach for an alcohol history. Several screening questionnaires have proven useful (Hays & Spickard, 1987), including the CAGE Questionnaire (Ewing, 1971) and the Michigan Alcoholism Screening Test (MAST; Selzer, 1971). None of the records in this study showed any indication that a standardized screening instrument was used or that physicians were accurately assessing the importance of information related to adverse consequences as a predictor of alcohol abuse. In fact, in three cases even when alcoholism was entered on the problem list, benzodiazepines were prescribed without comment. Also, none of the records had evidence that information regarding a family history of alcohol problems was obtained despite substantial research indicating that family history is a potent risk factor for the development of alcoholism and other drug addictions (Mirin Jc Weiss, 1989). Although dangerous for everyone, the combination of alcohol and antianxiety agents can be life threatening for the alcoholic. The medical literature contains many reports of the phenomena of benzodiazepine abuse and dependence by patients with alcoholism (Freed, 1973; Hollister, 1990; Miller & Gold, 1990; Sokolow, Welte, Hynes, & Lyons, 1981). Clinical experts (Chan, 1984) and benzodiazepine manufacturers (PDR, 1990) have consistently warned against prescribing benzodiazepines in patients with a history of alcohol problems. This study demonstrates serious discrepancies between currently recommended standards of care and typical clinical behavior specific to the safe prescribing of benzodiazepines.

Alcohol

and Benzodiazepine

Prescribing

183

This sample represented more faculty physician than resident records (69% vs. 26% with 6% unknown). However, in the clinic 60% of patients are typically seen by residents and only 40% by faculty. The proportion of faculty clinician records in this sample was shown to be significantly discrepant (z = 4.12, p < .OOl). This discrepancy may be related to the small sample size or to sampling bias. However, this overdocumentation of faculty records supports a growing concern over the need for faculty development in the prescribing of controlled drugs in particular, and substance abuse in general. Because there were no differences in the performance between faculty and residents, one may conclude that faculty ignorance or apathy about this issue is being transmitted to residents. There were several limitations of this study that temper our conclusions. First, it is important to note the small sample size. Preliminary analyses were conducted for overall trends, and we believed that the trends were strong enough to warrant publication, regardless of the small sample size, because it is doubtful that a larger sample would lead to any improvement in physician performance. Second, the mean age of patients was 66. Although patient age did not influence recording of alcohol information, generalizations to other age groups must be made with caution. Third, this study was conducted at a single site and the noted physician behaviors may not be observed in other locations. Fourth, in this study, the chart-audit technique used was dependent upon documentation practices. Romm and Putnam (1981) found that procedures and diagnoses are documented by physicians more completely than other aspects of care, so it could be argued that more history was taken than was documented. Subsequent research might use exit interviews of patients and/or physicians to study this issue further. The prescribing of benzodiazepines in medical care has become a source of concern because of problems of abuse and dependence (Woods, Katz, & Winger, 1988). However, benzodiazepines are highly effective medications when appropriately prescribed and are one of the most commonly prescribed classes of medications in this nation (Khantzian & McKenna, 1979). In a society where the rates of alcoholism are increasing for both men and women (Ross, 1989), it is vitally important for physicians to make prudent decisions when assessing the benefits and risks of prescribing mood-altering drugs. Specific information about the relationship between the presenting symptom and drinking should be documented to avoid inadvertent drug substitution. Standards of care stipulate that an adequate history to rule out alcoholism is essential prior to the prescribing of these medications. An adequate alcohol history should include a careful family history for substance abuse disorders in addition to a structured screening tool like the CAGE or the MAST questionnaires as a minimum. When a patient screens positive, further information should be obtained and documented. Although quantity and frequency data are helpful, they may be subject to distortion unless placed in context of the patterns and consequences of alcohol use. For patients who screen positive on the CAGE or MAST, Liepman (1984) recommended a means for physicians to organize their data acquisition and documentation (see Table 2). This pilot study shows that when physicians prescribe benzodiazepines, alcohol use histories are generally scanty or nonexistent. These preliminary results

A.V.

184

Table 2.

Chemicals:

A mnemonic

to Organize

Graham,

and Record

Substance

Consequences/Complications Help sought (self-attempts, 12-step programs, formal detoxification and Environment/Enablers (context) Maximum doses/Minimum doses (tolerance) Intake (what, when, where, with whom, how much, polydrug combinations, Concerns (motivation, readiness to change) Abstinence (have there been any episodes, why, what started/terminated Loss of control (quantity, frequency) Synergy (other illnesses, other medication) ‘Used

with

permission

of author,

Michael

R. Liepman,

T.V. Parran,

and C.R. Ia&

Abuse

Data’

rehabilitation)

sources,

routes)

the episode)

MD

further investigation with a larger sample, in different sites, and with additional populations. Exit interviews of patients and physicians might be employed to help distinguish poorly documented, adequate histories from inadequate b&tories. We recommend physician training on the importance of proper assessment and documentation of alcohol use histories prior to prescribing benzodiazepines.

warrant

REFERENCES Chan,

A.W.K. (1984). Effects of combined alcohol and benzodiazepine: A review. Drug and Alcohol De@ndence, 13, 316-341. Ciraulo, D.A., Sands, B.F., & Shader, R.I. (1988). Critical review of liability for benzodiazepine abuse among alcoholics. American Journal of Psych&y, 145, 150 I- 1506. Cleary, P.D.. Miller, M., Bush, B.T., Warburg, M.W., Delbanco, T.L., & Aronson, M.D. (1988). Prevalence and recognition of alcohol abuse in a primary care population. American Journal of Medicine, 85, 466-47 I. Coulehan, J.L., Zettler-Segal, M., Block, M., McClelland, M., & Schulberg. H.C. (1987). Recognition of alcoholism and substance abuse in primary care patients. Archives of Internal Medicine, 137, 349-352. Diamond, E.L.. & Grauer, K. (1987). The spectrum of anxiety disorders in family practice. American Family Physician, 36, l67- 173. Ewing, J. (1971). Detecting alcoholism: The CAGE questionnaire. Journal of fhe Amen’can Medical Associafion, 252, 1905- 1907. Freed, E.X. (1973). Drug abuse by alcoholics: A review. International Journal o[ fhe Addictiotrc, 8, 45 I 473. Girre, C., Facy, F., Lagier, G., & Dally, S. (1988). Detection of blood benzodiazepines in injured people: Relationship with alcoholism. Drug and Alcohol Dependence, 21, 61-65. Hays, J.T., & Spickard, W.A., Jr. (1987). Alcoholism: Early diagnosis and treatment. Journal of General Internal Medicine, 2, 420-427. Hollister, L.E. (1990). Interactions between alcohol and benzodiazepines. Recent Developmenk in Alcoholism, 8, 223-239. Khantzian, E.J., & McKenna, C.J. (1979). Acute toxic and withdrawal reactions associated with drug use and abuse. Annals of Inkrnal Medicine, 90, 36 l-372. Lewis, D. C.. Niven, R. G., Czechowicz, D., & Trumble, J. G. (1987). A review of medical education in alcohol and other drug abuse. Journal of the American Medical Association, 257, 2945-2948. Liepman, M.R. (1984). Alcohol and drug abuse in the family. In J. Christie-Seely (Ed.), Working with the family in primary care: A systems approach to health and illness. New York: Praeger. Miller, N.S., & Gold, M.S. (1990). Th e contemporary alcoholic. New Jersey Medicine, 87, 35-39. Mirin, S.M., & Weiss, R.D. (1989). Genetic factors in the development of alcoholism. Psychiattic Annals, 19, 239-242.

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Physician’s Desk Reference (PDR). (1990). Oradell, NJ: Medical Economics. Romm, R.J.. & Putnum, S.M. (1981). The validity of the medical record. Medical Care, 19, 310-315. Ross, H.E. (1989). Alcohol and drug abuse in treated alcoholics: A comparison of men and women. Alcoholism: Clinical & Experimt=xfal Research, 13, 8 1O-8 16. Schuckit, M.A. (1984). Drug and alcohol abuse: A clinical guide to d&no& and treatment (2nd ed.). New York: Plenum. Schuckit, M.A. (1987). Alcohol and drug interactions with antianxiety medications. The American Journal of Medicine, 82(Suppl. 5A), 27-32. Seizer, M.L. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Jounlal of Psychiatry 127. 89-94. Sokolow, L., Welte, J., Hynes, G., & Lyons, J. (1981). Multiple substance abuse by alcoholics. Britirh Journal of Addiction, 76, 147- 158. Walker, J.I. (1981). The anxious patient. The Journul ofFamily Practice, 12, 733-738. Woods, J.H., Katz, J.L., & Winger, G. (1988). Use and abuse of benzodiazepines. Journal of the Amencan Medical Association, 260, 3476-3479.

Physician failure to record alcohol use history when prescribing benzodiazepines.

The purpose of this pilot study was (1) to determine the proportion of patients in an ambulatory medical clinic who have an alcohol history recorded w...
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