Benzodiazepine prescribing practices for homeless veterans with mental illness

What question were you investigating?

Despite elevated risk for substance use disorder and overdose death in the homeless population, benzodiazepine prescribing for this population has not been examined.

Our team therefore set out to answer the questions:

• What is the rate of benzodiazepine prescribing to homeless vs. non-homeless veterans with mental illness in the VA system?
• Are homeless veterans more likely to receive risky and potentially inappropriate prescriptions?

What methods did you use?

We used logistic regression to compare likelihood of benzodiazepine prescribing and tests to compare indicators of risky and potentially inappropriate benzodiazepine prescribing patterns for homeless veterans with mental illness and their housed counterparts.

Our approach was unique in that it is the first study to attempt to investigate this question. We were able to do so in a large, national VA database, the country's largest provider of homeless services.

What did you find?

We found that although homeless veterans were less likely than their housed peers to receive a benzodiazepine prescription, they were more likely to receive risky and potentially in appropriate prescriptions, including multiple concurrent benzodiazepine prescriptions and concurrent prescriptions for benzodiazepines and opioids or sedatives.

What are the implications?

To our knowledge this was the first study to examine prescribing patterns for benzodiazepines as treatments for a homeless population, providing novel evidence about a vulnerable and understudied population at high risk for substance use disorder, overdose, and death. These findings of high rates of concurrent prescribing with other sedating medications are of substantial clinical concern, given that drug overdose death in the homeless population is a leading cause of death, at rates up to 30-fold higher than for the U.S. general population. Our results highlight the need for heightened attention to safe benzodiazepine prescribing practices for homeless veterans.

What are the next steps?

Our hope is that paper can inform clinicians about the importance of prudent prescribing of benzodiazepines to homeless patients and encourage providers to talk with patients about whether and how they combine substances when considering whether to prescribe benzodiazepines.