Regulation of benzodiazepine prescribing practices: clinical implications

Regulatory Framework Implementation for the Prescription of Zolpidem in France, What Impact in the Older People?

BACKGROUND

Zolpidem is one of the most prescribed hypnotic drugs. In 2001, the World Health Organization alerted a risk of pharmacodependence associated with zolpidem. The French health authority decided in 2017 to enforce security on the prescription of zolpidem to reduce those risks. The aim of our study was to evaluate the impact of regulatory framework implementation, secure prescription pad, on the prevalence and incidence of prescriptions of zolpidem according to the age.

METHODS

This study was based on an observational study using the French healthcare data system. Two age categories were defined: "younger" and "older" (<65 years, ≥65 years); in order to study the evolution of prevalence and incidence of zolpidem use in our two groups, two periods were defined, before and after the implementation of the measure.

RESULTS

The prevalence decreased in the younger population by 51% (4012 vs. 7948 consumers), while that of the older population decreased by 42% (4151 vs. 7282). This difference in our two groups, with a greater decrease in the younger people, is statistically significant compared to the older people.

CONCLUSION

Our study showed that regulatory framework implementation and mandatory secure prescription pad is more effective for decreasing prevalence of zolpidem prescription for younger people compared to older people.

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population

OBJECTIVE

Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use.

METHOD

This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York (n = 125,837) or New Jersey Medicaid (n = 139,405).

RESULTS

During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users.

CONCLUSIONS

State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

Regulating Opioid Prescribing Through Prescription Monitoring Programs: Balancing Drug Diversion and Treatment of Pain

Social policies have evolved to address the associated concerns related to the public health crises of drug abuse and undertreated pain. Prescription monitoring programs (PMPs) have been used for many years in this effort but are undergoing re-evaluation and restructuring in light of changes in technology as well as changes in our understanding of the collateral impact of such programs. We reviewed the state of PMPs in the United States and highlighted recent changes in these programs that have occurred nationally. The current changes occurring in California, with the most physicians of any U.S. state as well as the oldest triplicate-based serialized prescription program, are reviewed, with focus on the transition to tamper-resistant prescriptions that use security paper forms. Future trends for PMPs are described, including the potential for widespread use of electronic prescribing, which is gaining favor with the Drug Enforcement Agency.

A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders

BACKGROUND

Benzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms.

OBJECTIVE

The purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations.

METHODS

Using an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged >/=19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia.

RESULTS

A total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with >/=1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a -48.1% relative change (95% CI, -50.0% to -46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (-59.9% at 6 months; 95% CI, -63.9% to -55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use.

CONCLUSIONS

During the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

Prescribing benzodiazepines--a critical incident study of a physician dilemma

Use of benzodiazepines has been discussed extensively both among the public and within the medical society. The aim of this study was to explore the quality of dilemmas experienced by physicians when prescribing benzodiazepines. A questionnaire was sent to 213 Swedish General Practitioners. The critical incident technique was chosen as an appropriate method for surveying professional experiences. Concern for the patient and threats to the integrity of the physician were common dilemmas. The physicians did not believe that the patients were telling the truth or did not trust the patients' ability to handle the medicine. The most frequent consequences of the dilemmas were worry about a disturbed relationship with patients indicating an uncertainty as to how to create a good relationship with them. The participants in the study were aware of the national guidelines for prescribing benzodiazepines, but due to insufficient time a prescription was often chosen as a way to handle the dilemmas. Improvement in the rational use of benzodiazepines is not achieved by the medical board making new rules but rather by offering physicians education in communication and negotiating skills as well as more time with the individual patient who is requesting benzodiazepines.

Addiction to benzodiazepines

Benzodiazepines are sedative hypnotic medications that can induce a state of dependence. Dependence however is not the same as addiction. The development of dependence is a predictable phenomenon, influenced by dose, duration of treatment, and a number of other factors including individual characteristics of the benzodiazepine user. It is unclear whether there are meaningful differences among benzodiazepines in producing a state of dependence. Benzodiazepine dependence is also characterized by a predictable discontinuation syndrome. Benzodiazepines are rarely abused by non-substance abusers. The regulation of benzodiazepines although the legitimate therapeutic use has been significantly reduced.

A controlled trial of educational visiting to improve benzodiazepine prescribing in general practice

A randomised controlled trial studied the effect of an educational visit on benzodiazepine prescribing. An approximately representative sample of 286 general practitioners was allocated to an intervention or a control group. Rates of benzodiazepine prescriptions were derived from two comprehensive self-report surveys seven months apart. Two months after the first survey the intervention group received an educational visit and supporting material from a doctor or pharmacist, ostensibly unconnected with the surveys. The overall benzodiazepine prescribing rate fell by 23.7 per cent from the first to the second surveys, from 4.93 to 3.76 prescriptions per 100 encounters (P < 0.001). Anxiety and insomnia diagnosis rates also declined from 4.68 to 3.76 per 100 encounters (19.7 per cent). After adjusting for confounders, there was a differential downward trend in prescriptions per diagnosis of insomnia but not to a statistical level. The same was true of initial prescriptions per insomnia diagnosis. In a subsidiary analysis selecting only new insomnia diagnoses, the intervention had a strong effect in reducing initial prescriptions (odds ratio 0.18, 95 per cent confidence interval 0.04 to 0.73). No effect was seen on prescribing for anxiety diagnoses. Educational practice visiting for benzodiazepine prescribing in anxiety, as we conducted it, is not justified in an unselected population of general practitioners. Specific education on prescribing for insomnia is probably useful. Our interpretation of the reduction in benzodiazepine prescribing is that probably there was an effect from self-monitoring alone which overwhelmed a main-analysis intervention effect. Retrospective diagnosis may also have obscured a real intervention effect.

Current benzodiazepine issues

This article deals with some of the recent evidence bearing on the issues of the liability of benzodiazepines to lead to abuse, dependence, and adverse behavioral effects. Reviews of epidemiological, clinical and experimental literature indicated that the previous conclusion about abuse of these drugs still holds: the vast majority of the use of benzodiazepines is appropriate. Problems of nonmedical use arise nearly exclusively among people who abuse other drugs. Nevertheless, there are reasons for concern about patients who take benzodiazepines regularly for long periods of time. These drugs can produce physiological dependence when taken chronically, and although this does not appear to result in dose escalation or other evidence of "psychological dependence," physiological dependence can result in patient discomfort if drug use is abruptly discontinued. Also, physicians are currently prescribing shorter-acting benzodiazepines in preference to longer-acting benzodiazepines. The shorter-acting drugs can produce a more intense withdrawal syndrome following chronic administration. Furthermore, rates of use of benzodiazepines increase with age, and elderly patients are more likely than younger ones to take the drug chronically. The clearest adverse effect of benzodiazepines is impairment of memory. This, too, may be particular concern in older patients whose recall in the absence of drug is typically impaired relative to younger individuals, and who are more compromised following drug administration.