Benzodiazepine Use, Misuse, and Harm at the Population Level in Canada: A Comprehensive Narrative Review of Data and Developments Since 1995

Is alcohol and psychoactive medication use associated with excess hospital length-of-stay and admission frequency? A cross-sectional, observational study

BACKGROUND

Hospital length-of-stay and admission frequency are commonly used indicators of disease burden and health resource expenditures. However, the impact of psychoactive prescription medication use and harmful alcohol consumption on both the duration and frequency of hospital admissions is under-explored.

METHODS

We conducted an analysis of data gathered from 2872 patients admitted to the Emergency Department at Lovisenberg Diaconal Hospital in Oslo, Norway. Psychoactive medicines (benzodiazepines, opioids, and z-hypnotics) were detected via liquid chromatography-mass spectrometry analysis of whole blood, while alcohol consumption was self-reported through the Alcohol Use Disorder Identification Test-4 (AUDIT-4). Using logistic regression, we examined associations with our primary outcomes, which were excess length-of-stay and admission frequency, defined as exceeding the sample median of 3.0 days and 0.2 admissions per year, respectively.

RESULTS

Compared to the absence of psychoactive medication, and after adjusting for age, gender, malignant disease, pre-existing substance use disorder and admission due to intoxication, the detection of two or more psychoactive medicines was associated with both excess length-of-stay (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.20 to 2.14) and yearly hospitalization rate (OR, 3.72; 95% CI, 2.64 to 5.23). This association persisted when increasing the definition for excess length-of-stay to 4 and 5 days and to 1.0 and 1.5 admissions per year for admission frequency. Harmful alcohol consumption (AUDIT-4 scores of 9 to 16) was not associated with excess length-of-stay, but with excess admission frequency when defined as more than 1.0 admission per year when compared to scores of 4 to 6 (OR, 2.68; 95% CI, 1.58 to 4.57).

CONCLUSIONS

Psychoactive medication use is associated with both excess length-of-stay and increased antecedent admission frequency, while harmful alcohol consumption may be associated with the latter. The utility of our findings as a causal factor should be explored through intervention-based study designs.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

Global trends in the consumption of benzodiazepines and Z-drugs in 67 countries and regions from 2008 to 2018: a sales data analysis

STUDY OBJECTIVES

To investigate the trends in the consumption of benzodiazepines (BZDs) and Z-drugs at global, regional, and national levels from 2008 to 2018, across 67 countries and regions.

METHODS

This cross-sectional descriptive study investigated the consumption of BZDs and Z-drugs analyzed by global pharmaceutical sales data from the IQVIA-Multinational Integrated Data Analysis System database between 2008 and 2018. Consumption was measured in defined daily dose (DDD) per 1000 inhabitants per day (DDD/TID). The global, regional, and national trends were estimated using linear mixed models. Additional analyses were conducted by grouping countries by income level. The association between consumption and Gross Domestic Product (GDP) and the prevalence of different medical conditions was explored in univariable linear models.

RESULTS

BZD consumption decreased annually by -1.88% (95% CI: -2.27%, -1.48%), and Z-drugs increased by + 3.28% (+2.55%, +4.01%). In 2008, the top ten countries for BZD and Z-drug consumption were all European, ranging from 63.69 to 128.24 DDD/TID. Very low levels were found in Russia, Kuwait, United Arab Emirates, Saudi Arabia, French West Africa, and the Philippines, with DDD/TID < 1. The consumption in high-income countries was much higher than in middle-income countries. The results showed that increased consumption of BZDs and Z-drugs was statistically associated (p < 0.05) with higher GDP and increased prevalence of anxiety, self-harm, neurological disorders, chronic respiratory diseases, cardiovascular diseases, and cancers.

CONCLUSIONS

Distinct differences in consumption and trends of BZDs and Z-drugs were found across different countries and regions. Further exploration is needed to understand the association and safety of the use of BZDs and Z-drugs in patients with comorbidities.

Management of sleep disorder by preceptors in a family medicine residency program in Calgary, Alberta: a mixed-methods study

BACKGROUND

Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems.

METHODS

Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis.

RESULTS

Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management.

INTERPRETATION

Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.

Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective

Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.

Prepandemic psychotropic drug status in Portugal: a nationwide pharmacoepidemiological profile

The prescription of psychotropic drugs has been rising in Europe over the last decade. This study provides a comprehensive profile of prepandemic consumption patterns of antidepressant, antipsychotic, and anxiolytic drugs in Portugal considering full nationwide psychotropic drug prescription and dispensing records (2016-2019) against several criteria, including active ingredient, sociodemographics, medical specialty, and incurred costs. An increase of 29.6% and 34.7% in the consumption of antipsychotics and antidepressants between 2016 and 2019 is highlighted, accompanied by an increase of 37M Eur in total expenditure (> 20M Eur in public copay) for these classes of drugs. Disparities in sociodemographic and geographical incidence are identified. Amongst other pivotal results, 64% of psychotropic drug prescriptions are undertaken by general practitioners, while only 21% undertaken by neurological and psychiatric specialties. Nationwide patterns of psychotropic drug prescription further reveal notable trends and determinants, establishing a reference point for cross-regional studies and being currently assessed at a national level to establish psychosocial initiatives and guidelines for medical practice and training.

The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions

The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply. Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., 'benzodope') in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts. This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.

Neuroprotective effect of Ziziphi Spinosae Semen on rats with p-chlorophenylalanine-induced insomnia via activation of GABAA receptor

Ziziphus jujuba var. spinosa (Bunge) Hu ex H.F.Chow [Rhamnaceae; Ziziphi Spinosae Semen (ZSS)] has attracted extensive attention as the first choice of traditional Chinese medicine in the treatment of insomnia. However, recent studies on the sleep-improving mechanism of ZSS have mainly focused on the role of single components. Thus, to further reveal the potential mechanism of ZSS, an assessment of its multiple constituents is necessary. In this study, ZSS extract (ZSSE) was obtained from ZSS via detailed modern extraction, separation, and purification technologies. The chemical constituents of ZSSE were analyzed by high-performance liquid chromatography-mass spectrometry (HPLC-MS). For in vivo experiments, a rat model of insomnia induced by p-chlorophenylalanine (PCPA) was established to investigate the potential effect and corresponding mechanism of ZSSE on improving sleep. Hematoxylin-eosin staining (HE) results revealed that the drug group showed prominent advantages over the model group in improving sleep. Moreover, the brain levels of γ-aminobutyric acid (GABA), glutamic acid (Glu), 5-hydroxytryptamine (5-HT), and dopamine (DA) were monitored via enzyme-linked immunosorbent assay (ELISA) to further study the sleep-improving mechanism of ZSSE. We found that sleep was effectively improved via upregulation of GABA and 5-HT and downregulation of Glu and DA. In addition, molecular mechanisms of ZSSE in improving sleep were studied by immunohistochemical analysis. The results showed that sleep was improved by regulating the expression levels of GABA receptor subunit alpha-1 (GABAARα1) and GABA acid receptor subunit gamma-2 (GABAARγ2) receptors in the hypothalamus and hippocampus tissue sections. Therefore, this work not only identified the active ingredients of ZSSE but also revealed the potential pharmacological mechanism of ZSSE for improving sleep, which may greatly stimulate the prospective development and application of ZSSE.

A protocol for a randomized controlled trial comparing Sleepwell, EMPOWER, and treatment-as-usual for benzodiazepine receptor agonist discontinuation in older adults: the your answers when needing sleep in New Brunswick (YAWNS NB) study

Background

Chronic benzodiazepine receptor agonist (BZRA) use among older adults is a public health concern given cognitive and physical risks. One in four older adults in New Brunswick, Canada, is a long-term user of BZRAs. Previous studies using a direct-to-patient approach as the primary intervention target have shown promise in reducing BZRA use. The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study aims to reduce the long-term use of BZRAs in older adults and increase the use of cognitive behavioural therapy for insomnia (CBTi), which is the recommended first line treatment.

Methods

The trial (ClinicalTrials.gov registration NCT04406103) is a three arm, open-label, parallel randomized controlled trial in NB, Canada. Eligible participants 65 years and older using BZRAs long-term will be randomly allocated to: the Eliminating Medications through Patient Ownership of End Results (EMPOWER) information package group; the Sleepwell information package group; or treatment-as-usual (TAU). Information packages will be mailed via Canada Post. The primary outcome of BZRA discontinuation at 6 months will be compared across groups. Secondary outcomes include participants with ≥25% BZRA dose reduction, and switching to newly prescribed alternate sedative-hypnotics. Several exploratory outcomes will also be examined.

Discussion

Targeting participants with information packages informing them of appropriate use, dangers, and approaches to reducing BZRA use and increasing CBTi use may be beneficial in a region of Canada with the highest rate of chronic BZRA use in older adults. Comparing information packages and TAU will provide insights into the effectiveness of direct-to-patient interventions for BZRA reduction.

Novel Designer Benzodiazepines: Comprehensive Review of Evolving Clinical and Adverse Effects

As tranquilizers, benzodiazepines have a wide range of clinical uses. Recently, there has been a significant rise in the number of novel psychoactive substances, including designer benzodiazepines. Flubromazolam(8-bromo-6-(2-fluorophenyl)-1-methyl-4H-[1,2,4]triazolo[4,3-a][1,4]benzodiazeZpine) is a triazolo-analogue of flubromazepam. The most common effects noted by recreational users include heavy hypnosis and sedation, long-lasting amnesia, and rapid development of tolerance. Other effects included anxiolysis, muscle-relaxing effects, euphoria, loss of control, and severe withdrawals. Clonazolam, or 6-(2-chlorophenyl)-1-methyl-8-nitro-4H-[1,2,4]triazolo[4,3-α]-[1,4]-benzodiazepine, is a triazolo-analog of clonazepam. It is reported to be over twice as potent as alprazolam. Deschloroetizolam (2-Ethyl-9-methyl-4-phenyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepine) is part of the thienodiazepine drug class, which, like benzodiazepines, stimulates GABA-A receptors. Meclonazepam ((3S)-5-(2-chlorophenyl)-3-methyl-7-nitro-1,3-dihydro-1,4-benzodiazepin-2-one) is a designer benzodiazepine with additional anti-parasitic effects. Although it has proven to be an efficacious therapy for schistosomiasis, its sedative side effects have prevented it from being marketed as a therapeutic agent. The use of DBZs has been a subject of multiple recent clinical studies, likely related to increasing presence and availability on the internet drug market and lack of regulation. Many studies have aimed to identify the prevalence of DBZs and their effects on those using them. This review discussed these designer benzodiazepines and the dangers and adverse effects that the clinician should know.

The Association between General Anesthesia and New Postoperative Uses of Sedative-Hypnotics: A Nationwide Matched Cohort Study

Sedative−hypnotic misuse is associated with psychiatric diseases and overdose deaths. It remains uncertain whether types of anesthesia affect the occurrence of new postoperative uses of sedative−hypnotics (NPUSH). We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching to compare the risk of NPUSH between general and neuraxial anesthesia among surgical patients who had no prescription of oral sedative−hypnotics or diagnosis of sleep disorders within the 12 months before surgery. The primary outcome was NPUSH within 180 days after surgery. Multivariable logistic regression models were used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI). A total of 92,222 patients were evaluated after matching. Among them, 15,016 (16.3%) had NPUSH, and 2183 (4.7%) were made a concomitant diagnosis of sleep disorders. General anesthesia was significantly associated both with NPUSH (aOR: 1.17, 95% CI: 1.13−1.22, p < 0.0001) and NPUSH with sleep disorders (aOR: 1.11, 95% CI: 1.02−1.21, p = 0.0212) compared with neuraxial anesthesia. General anesthesia was also linked to NPUSH that occurred 90−180 days after surgery (aOR: 1.12, 95% CI: 1.06−1.19, p = 0.0002). Other risk factors for NPUSH were older age, female, lower insurance premium, orthopedic surgery, specific coexisting diseases (e.g., anxiety disorder), concurrent medications (e.g., systemic steroids), postoperative complications, perioperative blood transfusions, and admission to an intensive care unit. Patients undergoing general anesthesia had an increased risk of NPUSH compared with neuraxial anesthesia. This finding may provide an implication in risk stratification and prevention for sedative−hypnotic dependence after surgery.

The influence of prescriber and patient gender on the prescription of benzodiazepines: results from the Florida Medicaid Dataset

BACKGROUND

Benzodiazepine (BZD) prescription rates have increased over the past decade in the United States. Available literature indicates that sociodemographic factors may influence diagnostic patterns and/or prescription behaviour. Herein, the aim of this study is to determine whether the gender of the prescriber and/or patient influences BZD prescription.

METHODS

Cross-sectional study using data from the Florida Medicaid Managed Medical Assistance Program from January 1, 2018 to December 31, 2018. Eligible recipients ages 18 to 64, inclusive, enrolled in the Florida Medicaid plan for at least 1 day, and were dually eligible. Recipients either had a serious mental illness (SMI), or non-SMI and anxiety.

RESULTS

Total 125 463 cases were identified (i.e., received BZD or non-BZD prescription). Main effect of patient and prescriber gender was significant F(1, 125 459) = 0.105, P = 0 .745, partial η2 < 0.001. Relative risk (RR) of male prescribers prescribing a BZD compared to female prescribers was 1.540, 95% confidence intervals (CI) [1.513, 1.567], whereas the RR of male patients being prescribed a BZD compared to female patients was 1.16, 95% CI [1.14, 1.18]. Main effects of patient and prescriber gender were statistically significant F(1, 125 459) = 188.232, P < 0.001, partial η2 = 0.001 and F(1, 125 459) = 349.704, P < 0.001, partial η2 = 0.013, respectively.

CONCLUSIONS

Male prescribers are more likely to prescribe BZDs, and male patients are more likely to receive BZDs. Further studies are required to characterize factors that influence this gender-by-gender interaction.

Paper-Based Electrochemical Devices for the Pharmaceutical Field: State of the Art and Perspectives

The current international pharmaceutical scenario encompasses several steps in drug production, with complex and extremely long procedures. In the last few decades, scientific research has been trying to offer valid and reliable solutions to replace or support conventional techniques, in order to facilitate drug development procedures. These innovative approaches may have extremely positive effects in the production chain, supplying fast, and cost-effective quality as well as safety tests on active pharmaceutical ingredients (APIs) and their excipients. In this context, the exploitation of electrochemical paper-based analytical devices (ePADs) is still in its infancy, but is particularly promising in the detection of APIs and excipients in tablets, capsules, suppositories, and injections, as well as for pharmacokinetic bioanalysis in real samples.

Psychological predictors of benzodiazepine discontinuation among older adults: Results from the PASSE 60

BACKGROUND

Long-term benzodiazepine (BZD) use among seniors is mostly inappropriate and associated with adverse health outcomes. To prevent these consequences, withdrawal is crucial, yet knowledge is limited about what predicts BZD discontinuation. Until now, most studies have focused on sociodemographic and BZD intake factors as predictors while neglecting psychological factors. This research addresses this issue by studying how the intensity of depressive symptoms, social support satisfaction, self-perceived competence in the ability to withdraw, and overall quality of sleep predict discontinuation in long-term older consumers.

METHOD

Seventy-three participants aged 60 years and older were enrolled in this study. There were four time measures: before discontinuation (T1), after (T2), 3 months after (T3), and 12 months after (T4). Data were collected in the "Programme d'Aide du Succès au SEvrage" (PASSE-60+) study.

RESULTS

Social support satisfaction predicted discontinuation at T2 and T4. Self-perceived competence in the ability to withdraw and depressive symptoms predicted discontinuation at T4. This later prediction was counterintuitive; higher depressive symptoms at T1 were linked with higher discontinuation success. BZD intake factors (length of use and dose) were good predictors for short term discontinuation. Psychological factors were moderate predictors for short term and good predictors for long term discontinuation.

CONCLUSION

Psychological factors are good predictors of discontinuation and are better predictors than BZD intake factors of long-term discontinuation. Discontinuation programs should focus on social support and self-perceived competence to improve their efficacy. Further studies are needed to acquire a more complete picture of the psychological predictors of discontinuation success. ClinicalTrials.gov Identifier: NCT02281175.

Benzodiazepine Prescribing in People with Chronic Obstructive Pulmonary Disease: Clinical Considerations

Benzodiazepines, available clinically for almost six decades, are still one of the most widely prescribed classes of medication. The proportion of the population prescribed benzodiazepines increases with age, and harms also increase with age. The prevalence of prescribing in people > 85 years of age is as high as one in three, including in people with chronic obstructive pulmonary disease (COPD). The prevalence of COPD also increases with age. In COPD, indications cited for prescribing a benzodiazepine include anxiety, sleep disorders, or chronic breathlessness. Each of these symptoms is prevalent in the population with COPD, especially later in the course of the illness. For anxiety and insomnia, there is evidence to support short-term use, with little robust evidence to support prescribing for the symptomatic reduction of chronic breathlessness. People prescribed benzodiazepines are more likely to experience drowsiness or somnolence, exacerbations of their COPD, and respiratory tract infections. Furthermore, the longer people take benzodiazepines, the more likely they will become dependent on them. Prescribing patterns vary internationally but prescriptions of longer-acting benzodiazepines are declining in favour of shorter-acting compounds. Other evidence-based therapies that can more safely treat these problematic symptoms are available. For people already taking benzodiazepines, there are a number of interventions that have been shown to reduce the rate of prescribing. For people with COPD and not taking a benzodiazepine, but with symptoms where there is evidence of benefit, clinicians should weigh carefully the potential net benefit and prescribe at the lowest dose for the briefest time possible.

Gender Differences in Predictors of Self-Medication with Tranquillizers and Sleeping Pills: Results of the Population-Based Study in Serbia

Background

Previous studies among the Serbian population concluded that the trend of self-medication with tranquillizers and sleeping pills requires deeper study. The objective is to identify gender differences in socio-demographic, health, and health service predictors of self-medication with tranquillizers and sleeping pills in a Serbian population of 15 years old and above.

Methods

This was a population-based, cross-sectional study. Data was extracted from the most recently available results of the Serbian National Health Survey of 2013. Multivariate logistic regression was used to determine independent self-medication predictors.

Results

The study included 14,623 participants, of which 51.77% were female. While 5.6% of the females reported self-medication with tranquillizers and sleeping pills, only 2.2% of males reported such practice (p<0.001). The presence of chronic disease, stress, and physical pain in the last month before the interview was significantly associated with an increased likelihood of self-medication with observed drugs in both genders. Age was the most significant socio-demographic predictor of self-medication in females, while in males it was unemployment. Women of 55–65 years of age showed a greater risk from self-medication with tranquillizers and sleeping pills in comparison to women of 15–24 years of age (aOR=4.75, 95% CI: 1.83–12.33). Unemployed males showed a greater tendency for such practice in comparison to employed (aOR=1.86, 95% CI: 1.19–2.91).

Conclusion

The findings highlighted predictors of self-medication with tranquillizers and sleeping pills and important differences between genders, which may contribute to the design of gender-sensitive surveillance, identification, and the prevention of such undesirable practices through evidence-based and appropriately tailored public health actions.

Beyond Prescriptions Monitoring Programs: The Importance of Having the Conversation about Benzodiazepine Use

: Internationally there is an escalation of prescription-related overdose deaths, particularly related to benzodiazepine use. As a result, many countries have implemented prescription monitoring programs (PMPs) to increase the regulation of benzodiazepine medications. PMPs centralize prescription data for prescribers and pharmacists and generate alerts to high-doses, risky combinations, or multiple prescribers with the aim to reduce inappropriate prescribing and subsequently the potential of patient harm. However, it has become clear that prescribers have been provided with minimal guidance and insufficient training to effectively integrate PMP information into their decision making around prescribing these medications. Accordingly, this paper discusses how PMPs have given rise to a range of unintended consequences in those who have been prescribed benzodiazepines (BDZs). Given that a gradual taper is generally required to mitigate withdrawal from BDZs, there are concerns that alerts from PMPs have resulted in BDZs being ceased abruptly, resulting in a range of unintended harms to patients. It is argued that best practice guidelines based upon a patient-centered framework of decision-making, need to be developed and implemented, in order to curtail the unintended consequences of PMPs. This paper outlines some key considerations when starting the conversation with patients about their BDZ use.

Screening for Psychotherapeutic Medication Misuse in Primary Care Patients: Comparing Two Instruments

INTRODUCTION

Prescription psychotherapeutic medication misuse is a growing problem in the United States, but no method exists to routinely screen for this in primary care. Our study sought to (1) describe the prevalence of prescription psychotherapeutic medication misuse in primary care and the characteristics of patients who misuse and (2) compare 2 screening instruments modified to identify prescription medication misuse in primary care.

METHODS

Primary care patients from underserved, urban clinics within a health system completed anonymous computer-directed health screens that included standard questions about prescription medication misuse. They were also administered the 4-item Cut down, Annoyed, Guilty, and Eye-opener questionnaire modified to focus on prescription medications (RxCAGE) and a 6-item Prescription Opioid Misuse Index (POMI-e) expanded to include other prescription medications.

RESULTS

Of 2,339 respondents, 15.3% were positive for at least 2 items on the RxCAGE and 18.6% were positive for at least 2 items on the POMI-e. Using our computer-directed health screen as a comparison, we found that POMI-e had a higher area under the curve (0.63). A positive POMI-e was associated with being male, white and unemployed, having depression and anxiety, and currently using illicit substances, smoking, and misusing alcohol.

CONCLUSIONS

Rates of prescription medication misuse were substantial with both RxCAGE and POMI-e showing promise as screening instruments. Future studies are needed to test prescription medication misuse screening tools in broader populations and pilot interventions for those screening positive.

Two health information systems to characterize poisoning in Brazil-a descriptive study

BACKGROUND

Poisoning is a worldwide public health problem that involves individuals of all ages and a wide range of chemicals. This study investigated the data from two health information systems to characterize poisoning events in the Federal District (DF), Brazil.

METHODS

Data related to the period from 2009 to 2013 were obtained from the poison information center (Centro de Informação Toxicológica, CIT) and the Notifiable Diseases Information System (Sistema Nacional de Agravos de Notificação, SINAN) of the DF.

RESULTS

A total of 3622 cases were reported to CIT-DF and 5702 cases to SINAN-DF. Most of the cases in CIT-DF (53%) occurred with children up to 9 years old, while this corresponded to 33.9% in SINAN-DF. Unintentional poisoning was the main circumstance involved in the cases. Pharmaceuticals were the main agent (44.3-47.1% of the cases), mainly clonazepan and paracetamol, and pesticides the most fatal (2.4% fatality rate). Out of the 47 fatal cases reported to the systems, only four were reported to both; six cases occurred with children up to 6 years.

CONCLUSION

Under-reporting and missing information were identified in both systems, but the data were complementary to describe the epidemiology of poisoning cases in the DF.

Benzodiazepine receptor agonist dispensations in Alberta: a population-based descriptive study

BACKGROUND

There is increasing concern over the use of benzodiazepine receptor agonists (BZRAs). The objective of this study was to describe BZRA dispensations in the province of Alberta in 2015 according to age, sex and appropriateness.

METHODS

A population-based descriptive study of people 10 years of age or older with at least 1 BZRA dispensation in Alberta, Canada, between Jan. 1 and Dec. 31, 2015, was conducted. Prevalence of BZRA use, characteristics of BZRAs dispensations, use at the individual level and appropriateness were determined.

RESULTS

A total of 372 870 people received 2 463 585 BZRA dispensations in Alberta in 2015. Prevalence of use at the population level was 10% overall, increased with age (p value for trend < 0.001) and was consistently highest among females. Twenty percent of patients used both Z-drugs and benzodiazepines. BZRA users had an average of 7 dispensations (standard deviation [SD] 20), 137 days of use overall (SD 123) and a maximum period of consecutive use of 90 days (SD 95). Days of consecutive use were highest among those aged 65 years or older (126 d). A total of 62 795 (17%) people used more than 1 distinct BZRA ingredient concurrently and 10% had 3 or more distinct prescribers.

INTERPRETATION

The prevalence of BZRA use was high and a substantial proportion of use appeared to be potentially inappropriate. This study supports the need for continued monitoring for the prescribing and use of these medications at the population level.

Patterns of benzodiazepines use in primary care adults with anxiety disorders

BACKGROUND

Benzodiazepines are among the most commonly prescribed drugs for anxiety disorders. While they are indicated as adjunctive treatment for short-term use according to clinical practice guidelines, previous studies have shown patterns of long-term use of benzodiazepines, which is problematic due to side effects, dependence and potential of abuse. The aims of this study were to examine among a large sample of primary care adults suffering from anxiety disorders: 1) benzodiazepine use patterns; and 2) correlates of long-term benzodiazepine use.

METHODS

Data were drawn from the "Dialogue" project, a large primary care study conducted in 64 primary care clinics in the province of Quebec, Canada. Following a mental health screening in waiting rooms, patients at risk of anxiety or depression completed the Composite International Diagnostic Interview-Simplified (CIDIS). A sample of 740 adults meeting DSM-IV criteria for Generalized Anxiety Disorder, Panic Disorder or Social Anxiety Disorder in the past 12 months took part in this study.

RESULTS

Benzodiazepines were used by 22.6% of participants with anxiety disorders in our primary care sample. A large majority of benzodiazepine users (88.4%) met our indicator of long-term use, as defined by utilization for more than 12 weeks including regular and as-needed use. Based on a logistic regression model, individual correlates associated with long-term benzodiazepine use included: being 30 years or older, having a comorbid physical illness, meeting criteria for comorbid agoraphobia, reporting the use of sleep-aids, and concurrent SSRI utilization.

LIMITATION

Data collection with self-reported questionnaires may be subject to information bias.

CONCLUSIONS

Despite knowledge of the risks of long-term use of benzodiazepines, this remains a pervasive problem. Clinicians need to be mindful of patterns and risk factors leading to long-term use of benzodiazepines in patients with anxiety disorders. Results of this study should raise awareness regarding appropriate prescription practices for benzodiazepines, including decision-making in initiation, duration of prescription, and use of strategies for discontinuation in current long-term benzodiazepine users.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Factors associated with sedative use and misuse among heroin users

BACKGROUND

Rates of both opioid and sedative use and misuse are rising. Comorbid opioid and sedative use is associated with especially severe consequences (e.g., overdose and poor health outcomes). Heroin users report multiple motivations for sedative use, including self-medication. We aimed to understand differences in lifetime substance use characteristics between heroin users with different sedative use histories.

METHODS

Substance use data were collected from 385 non-treatment seeking heroin users. Subjects were divided into four lifetime sedative-use groups: no use, medical use only, non-medical use only, and mixed medical and non-medical use. We examined patterns of use of various substances of abuse (tobacco, alcohol, marijuana, cocaine, heroin, and sedatives) and individual characteristics associated with each.

RESULTS

Non-medical sedative use (alone or in addition to medical use) was associated with more negative consequences from using all substances. Medical sedative use alone was not related to increased overdose or emergency room visits associated with heroin use. Non-medical sedative use was associated with increases in 15 of the 21 measured heroin consequences and only one of those - health problems - was also associated with medical sedative use.

CONCLUSIONS

Concomitant non-medical sedative use and heroin use is associated with significantly greater negative outcomes than those experienced by heroin users who report use of sedatives only as prescribed. Understanding these differences offers insight into risks related to using both substances and may help treatment providers create targeted harm reduction interventions for this population.

Prescription of potentially inappropriate medications among older people with intellectual disability: a register study

BACKGROUND

Older people have a greater disease burden and are more likely than younger to be prescribed medications. They are also more sensitive to adverse effects. With this in mind, a range of medications have been suggested inappropriate in this population. People with intellectual disability (ID) have a higher disease burden than the general population, putting them at even greater risk of prescription of such medications. The aim of this study was to describe prescription of potentially inappropriate medications among older people with ID in relation to prescriptions among their age peers in the general population.

METHODS

We established an administrative cohort of people with ID (ID cohort; n = 7936), using a Swedish national register. A referent cohort from the general population (gPop) was matched one-to-one by sex and year of birth. Data regarding prescription of potentially inappropriate medications were collected from the Swedish prescribed drug register for the years 2006-2012.

RESULTS

People with ID were more likely than the general population to be prescribed medications with anticholinergic effects, intermediate- or long-acting benzodiazepines, and antipsychotics at least once during the study period, and also had more number of years with prescription. Except for benzodiazepines, those in the ID cohort with at least one prescription had larger amounts prescribed than those in the gPop cohort. People in the ID cohort were less likely than the general population to be prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Among those with at least one prescription of NSAIDs, those in the ID cohort had prescriptions during fewer years and in lower amounts than those in the gPop cohort.

CONCLUSIONS

Although prescription of potentially inappropriate medications overall is more common among people with ID than in the general population, the opposite pattern is found for medications for pain management. This may be a result of pain being under-recognized and under-treated in this population. Thus, there is a need for training as well as increased knowledge and awareness among care and health care professionals regarding signs of adverse effects and the need of continuous evaluation of treatment in this vulnerable group.

Patients reasons for obtaining psychotropic medications without a prescription at retail pharmacies in Central Saudi Arabia

OBJECTIVE

To explore the possible causes behind adults seeking psychotropic medications without a prescription; identify the most commonly used psychotropic medications without a prescription; and determine the prevalence of depression and anxiety disorders among adults who used psychotropic medications without a prescription in Riyadh, Kingdom of Saudi Arabia.

METHODS

A cross-sectional study was conducted from November 2014 to August 2015. A convenience sample was taken by distributing a self-administered questionnaire among participants who had obtained psychotropic medications without a prescription from retail pharmacies during the 4 weeks prior to study intake in Riyadh, Kingdom of Saudi Arabia. In addition to the study questionnaire, the 9-item Patient Health Questionnaire was used to screen for major depressive disorder, and the 7-item Generalized Anxiety Disorder Scale was used to screen for general anxiety disorders.

RESULTS

Of the 302 subjects, 42.4% attributed their use of psychotropic medications without a prescription to the non-seriousness of their symptoms and 28.5% to the high cost of psychiatric services. Escitalopram was the most commonly used medication (31.8%), and 3 atypical antipsychotics were used by more than one-fifth of the study participants. The prevalence for major depressive disorder was 46.0% and 41.7% for generalized anxiety disorder.

CONCLUSION

Most of the participants were able to easily obtain psychotropic medications without a prescription. We recommend implementing strong policies to prevent retail pharmacies from dispensing psychotropic medications without a prescription.

Treatment of Insomnia With Traditional Chinese Herbal Medicine

Insomnia is a condition with sleep problems and many people suffered from it. Chronic insomnia can last for long time and it will severely affect people's health and the quality of life. In conventional medicine, the most commonly used the medicine is benzodiazepine. It is effective but also has significant side effects. Patients try to use some kinds of alternative medicines. Chinese medicinal herbs and formulas have been used in the treatment of insomnia for more than 2000 years in China. In recent decades, Chinese herbal medicine has been widely used in the Western countries. Many clinical studies including randomized controlled clinical trials and research on pharmacological action mechanisms of the herbs for treatment of insomnia have been conducted. It is very important and very helpful to review the published research papers to gather the available information for a critical analysis. This chapter evaluated the data from both of clinical studies and pharmacological researches on the therapeutic formulas and on some key herbs used in the treatment of insomnia. Clinical studies showed a very wide spectrum of herbs that were used in clinical treatment of insomnia. This was due to different syndrome patterns happened with insomnia. This brought complexity and difficulties to identify which are the essential key herbs or formulas. It was found Suanzaoren decoction (Ziziphus spinose decoction ) is the most frequently used formula for the treatment of insomnia. Based on the clinical data, several herbs were identified as most frequently used sedative and hypnotic herbs in Chinese herbal medicine including Suanzaoren (Ziziphus spinose ), Fuling (Poria cocos ), and Gancao (Glycyrrhiza uralensis ). The underlying pharmacological action mechanisms discovered in the studies on some key herbs used in the treatment of insomnia were evaluated. The major pharmacological action mechanisms shared by most of the sedative herbs are to act through the neurotransmitter gamma-aminobutyric acid (GABA) or via stimulation of GABAA_A receptor. Some herbs exert sedative activities via inhibition of 5-hydroxytryptamine 1A receptor. Another mechanism shown by some herbs is to upregulate the expression of orexin-A, leptin, orexin receptor-1, and leptin receptor in the brain, reducing insomnia-induced negative consequences, and thus indirectly help improvement of insomnia.

[Anxiety associated with substance abuse]

Substance abuse and anxiety is a common comorbid dyad and an example of so-called dual diagnosis in psychiatry. Comorbidity of anxiety and addictive disorders may be due to interdependence of these states as well as common predisposing factors and pathogenic mechanisms. There are various medicines in the treatment of anxiety associated with substance abuse, including benzodiazepines, calcium channel modulators, non-benzodiazepine anxiolytics, antidepressants and antipsychotics. One of the best approaches to the treatment of chronic anxiety disorders in drug treatment clinic is a long course of treatment with antidepressants, primarily with selective serotonin reuptake inhibitors as first line preparations. Such medications as pregabalin, buspirone, etifoxine and alimemazine are also of interest for the treatment of dual diagnosis patients.