Table 2.

Summary Themes and Representative Quotations

Themes	Representative Quotations
I. Linkage to the opioid epidemic.  Conversations about benzodiazepine-opioid co-prescribing are inextricably tied to general commentary on the opioid epidemic and its influence on prescribing.	“[T]he idea of giving that combination to somebody at home when you kind of put that back in your brain as like oh, this is conscious sedation, it makes you maybe a little bit more careful there. I also think that we are kind of in that shift where we’re seeing the issues of the opioid epidemic and all of that. I think we’re all in that shift, and I think some of us are much more I guess stingy than we were previously.” (Group 3) “That’s what I’m generally aware of – that it’s a dangerous thing we’re doing. It’s probably similar to addiction, where we know it’s a theoretical possibility, but until you’re confronted with the patient who is like, I was addicted by my first Norco script. That when you weigh that possibility against this patient who seems to be in extremis at the time, it’s hard to find the equipoise between not doing something that seems to be helping them.” (Group 2)
II. Co-prescribing is rare and reluctantly performed.  Providers state that they co-prescribe benzodiazepines and opioids, however they do so infrequently and with hesitation.	“I’m pretty remiss to actually do it. I do it, I will say I’ve done it, but there’s a lot of things that go through my mind when I prescribe these things together.” (Group 2) “I think prescribing like this is definitely with a certain type of patient, it’s not all the time and it’s for intractable pain when somebody comes in and they’re screaming. It’s not a common thing to send people home but yes, I have done it, so it’s not all the time.” (Group 1) ““[T]here are occasions when I still do co-prescribe in severe cases. I mean I do it very rarely, but I, there are absolutely cases and when I do it, I’m very, very specific on how I want the patients to take the pills.” (Group 4)
III. The decision to co-prescribe is multifactorial.
Subtheme A: Co-prescribing is diagnosis specific.   Providers endorse co-prescribing in specific clinical diagnoses, such as back or neck pain.	“I think we’re mostly talking about back pain with co-prescribing, and that’s about the only thing that I co-prescribe [for].” (Group 5)
Subtheme B: Co-prescribing is situational.   Providers consider co-prescribing in certain situational contexts — such as failed prior care that a patient may have received or a chronic pain complaint.	“I feel like I’m adding on Valium for the person who is already on oral narcotics coming in saying like my doctor gave me Norco last week and I’m still in pain, like what are we gonna do next?” (Group 2) “So it totally depends on the mechanism of injury, the chronicity of it, a patient who has known disc disease and even has had surgery is a totally different person than a healthy worker who bends and twists and lifts something at work and comes in with back pain.” (Group 5)
Subtheme C: Co-prescribing is influenced by provider beliefs.   Providers voiced specific beliefs about the effectiveness of combination therapy, which have been shaped by anecdotal observations, clinical training, or personal experiences with back pain.	“It works. I don’t think we’d do it if it didn’t work.” (Group 5) “I think it was sort of word of mouth in residency that [this] was the sort of back pain cocktail that we give to people in the emergency department.” (Group 4) “Older doctors told you this is what you use for back pain.” (Group 3) “It is your own experience sometimes that influences. I’ve had so much back trouble over the years… I mean that’s really influenced how I treat back patients…I only took the 2 mg of Valium that one time when my disc first went out…but it was impressive how much 2 mg worked.” (Group 5)
IV. Providers feel self-imposed pressure to escalate care.
Subtheme A: Providers feel pressure to alleviate symptoms.   Providers expressed a strong sense of self-imposed pressure to “do something more” for their patients.	“It’s kind of where these patients, you feel boxed in [because] they’ve…presented themselves in crisis and you can’t resolve that crisis in any reasonable way other than advancing something.” (Group 2) “Sometimes I’ll try like a Lidoderm patch, just to give them something so they feel like they’re getting some added therapy to what they came in with.” (Group 2)
Subtheme B: Providers feel pressure to avoid admission or repeat ED visits.   Providers often cited a reluctance to admit a patient or a desire to avoid a repeat ED visit as a reason for co-prescribing.	“And then you think about what’s the alternative? Like if they’re already on a narcotic to transition them to an IV narcotic to get them under control and bring them into the hospital? Or to just try an oral benzo and add that on to what they’re already taking and try to get them home.” (Group 2) “And so I kind of weigh a hospital admission versus the co-prescribing and I’ve kind of come to the conclusion, at least in my own mind and this may be wrong, that it’s better for the patient to stay out of the hospital and to not get into this cycle of admitting people for IV narcotics.” (Group 2) “Right and like I say to the residents all the time, it’s like a mantra…you make them feel better as soon as possible as best you can so that they go home and they don’t come back. Like from a convenience standpoint, a satisfaction standpoint, and like a financial standpoint.” (Group 4)
V. Provider beliefs about muscle relaxants are heterogeneous.   Providers voiced mixed beliefs about benzodiazepines and other “muscle relaxants” with respect to mechanism of action, safety profile, and effectiveness.	“I commonly do it for back pain. I think it’s, I feel it’s a standard to give muscle relaxants for bad back pain. I’m not convinced they really work though, usually low-dose Valium.” (Group 5) “Well and I think if you look at the data behind treating back pain, you know…there’s no question that benzodiazepines work better in terms of pain control than Flexeril does.” (Group 4) “I usually tell people, you know, I say there is no such thing as a true muscle relaxant.” (Group 5)
VI. Co-prescribing discharge counseling occurs.   Providers report that they sometimes provide specific discharge counseling when co-prescribing.	“I’ll tell you that there are occasions when I still do co-prescribe in severe cases…When I do it, I’m very, very specific on how I want the patients to take the pills, so I say: what you do is take two of the Percocet and then you wait two hours. If you’re not better, then you take one of the diazepam and that way they can do it on a schedule…I fully understand that’s a risk, but what I don’t want is for them to take a handful of pills and they’re probably still doing it that way.” (Group 4)