Alprazolam use and related harm among opioid substitution treatment clients – 12 months follow up after regulatory rescheduling

Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line

Background

Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province.

Methods

Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups.

Results

Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies.

Conclusion

Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.

A narrative review of evidence to guide deprescribing among older adults

Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.

Policies for Deprescribing: An International Scan of Intended and Unintended Outcomes of Limiting Sedative-Hypnotic Use in Community-Dwelling Older Adults

Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.

Not what the doctor ordered: Motivations for nonmedical prescription drug use among people who use illegal drugs

BACKGROUND

Nonmedical Prescription Drug Use (NMPDU) is common among people who use illegal drugs. NMPDU is particularly problematic among this population however, as medications such as benzodiazepines and gabapentinoids can potentiate the harmful effects of opioids. Despite these harms, there is some evidence that NMPDU can have harm reducing and therapeutic potential for some people who use illegal drugs. This study provides further evidence of the harm reducing motives for NMPDU among people who use illegal drugs in community and prison settings in Wales, UK.

METHODS

In depth, semi-structured interviews were conducted with 60 interviewees recruited from statutory and third sector drug treatment providers operating in five towns and cities in Wales, and from two Welsh prisons. Eligibility was based primarily on whether the person was currently (or previously) a user of illegal drugs and had recent experience of NMPDU.

RESULTS

NMPDU was found to be largely driven by insufficient access to certain prescription medications and treatment. In this context, NMPDU played an important role in alleviating legitimate medical concerns and overcoming logistical and regulatory barriers associated with Opioid Substitution Therapy. NMPDU also had everyday practicality and mitigated many of the everyday harms experienced by people who use drugs, including opioid withdrawal and stimulant comedowns.

CONCLUSION

Results suggest that NMPDU has the potential to mitigate a number of legitimate medical concerns in the absence of treatment. Finding nuanced ways of responding to patient need whilst reducing the potential for NMPDU are therefore needed, and harm reduction strategies that harness the knowledge and expertise of people who use drugs should be encouraged. Additional policy measures that attend to the inequities and social-structural factors that produce and maintain the need to consume prescription medications in ways that are not intended are also required.

Alprazolam use among a sample of Australians who inject drugs: Trends up to six years post regulatory changes

INTRODUCTION

Alprazolam is a high potency triazolobenzodiazepine that is associated with a disproportionate amount of harm compared to other benzodiazepines. In Australia, amid growing concerns of extra-medical use and harms, alprazolam was up-scheduled from Schedule 4 (prescription only) to Schedule 8 (controlled drug) on 1 February 2014, with further restrictions introduced on 1 February 2017. This study aims to examine the impact of these regulatory changes among cross-sectional samples of people who inject drugs (PWID), from 2011-2019.

METHODS

Data were obtained from the 2011-2019 Illicit Drug Reporting System, comprising cross-sectional samples of PWID recruited annually from Australian capital cities (approximately ~900 per year).

RESULTS

By 2019, the proportion of PWID who reported past six-month use of non-prescribed (17%) and prescribed (4%) alprazolam had halved compared to 2011 (39% and 13%, respectively), with no evidence of an increase in use of other sedative substances. Following the up-scheduling of alprazolam in 2014, there was an increase in the median last price paid for 2 mg of diverted alprazolam ($5AUD pre-rescheduling versus $7AUD post rescheduling), with 61% of those able to answer reporting that diverted alprazolam had become 'more difficult' to obtain post versus pre-rescheduling. The correlates associated with non-prescribed alprazolam use remained relatively consistent pre- and post-regulatory change, with past-month criminal activity, past six-month opioid agonist therapy and past six-month use of non-prescribed other benzodiazepines associated with non-prescribed alprazolam use in both the 2013 and 2018 samples.

CONCLUSIONS

Regulatory changes appear to have resulted in sustained reductions in alprazolam use amongst our annual cross-sectional sentinel samples of PWID, although a considerable minority (17%) continued to report non-prescribed use in 2019. To achieve further reductions in non-prescribed use and associated harms, these regulatory changes need to be coupled with other interventions, such as direct consumer engagement and harm reduction messaging. Our findings suggest that people receiving opioid agonist therapy remain a key target population for such interventions.

Codeine use and harms in Australia: evaluating the effects of re-scheduling

BACKGROUND AND AIMS

Globally, codeine is the most-used opioid. In December 2016, Australia announced that low-strength codeine (≤ 15 mg) would be re-scheduled and no longer available for purchase over-the-counter; this was implemented in February 2018. We aimed to evaluate the effect of this scheduling change on codeine misuse and use and misuse of other opioids.

DESIGN AND SETTING

Interrupted time-series analysis of monthly opioid exposure calls to New South Wales Poisons Information Centre (NSWPIC, captures 50% of Australia's poisoning calls), January 2015- January 2019 and monthly national codeine sales, March 2015-March 2019. We incorporated a washout period (January 2017 - January 2018) between the announcement and implementation, when prescriber/consumer behaviour may have been influenced.

PARTICIPANTS

Intentional opioid overdoses resulting in a call to NSWPIC.

MEASUREMENTS

We used linear segmented regression to identify abrupt changes in level and slope of fitted lines. Codeine poisonings and sales were stratified into high strength (> 15 mg per dose unit) and low strength (≤ 15 mg). Only low-strength formulations were re-scheduled.

FINDINGS

We observed an abrupt -50.8 percentage [95% confidence interval (CI) = -79.0 to -22.6%] level change in monthly codeine-related poisonings and no change in slope in the 12 months after February 2018. There was no increase in calls to the NSWPIC for high-strength products, level change: -37.2% (95% CI = -82.3 to 8%) or non-codeine opioids, level change: -4.4% (95% CI = -33.3 to 24.4%). Overall, the re-scheduling resulted in a level change in opioid calls of -35.8% calls/month (95% CI = -51.2 to -20.4%). Low-strength codeine sales decreased by 87.3% (95% CI = -88.5 to -85.9%), with no increase in high-strength codeine sales in the 14 months following re-scheduling, -4.0% (95% CI = -19.6 to 14.6%).

CONCLUSIONS

Codeine re-scheduling in Australia appears to have reduced codeine misuse and sales.

A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review

Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

National Institute on Drug Abuse International Program: improving opioid use disorder treatment through international research training

PURPOSE OF REVIEW

For more than 25 years, the National Institute on Drug Abuse (NIDA) has supported research-training programs, establishing a global research network and expanding the knowledge base on substance use disorders. International research to inform approaches to opioid addiction is particularly important and relevant to the United States, where opioid misuse, addiction, and overdose constitute an emerging public health crisis. This article summarizes the NIDA International Program and illustrates its impact by reviewing recent articles about treatment approaches for opioid use disorders (OUD).

RECENT FINDINGS

Studies in several countries have demonstrated the effectiveness of physician office-based opioid substitution therapies. Other research has demonstrated the effectiveness of different formulations and doses of the opioid antagonist naltrexone, as well as different approaches to providing naloxone to treat opioid overdose. Continuing research into implementation of evidence-based treatment in international settings with limited resources is applicable to US regions that face similar structural, legal, and fiscal constraints.

SUMMARY

The current review describes international research on OUD treatment and opioid overdose, most coauthored by former NIDA fellows. The findings from outside the United States have important implications for best practices domestically and in other countries that are experiencing increases in OUD prevalence and related overdose deaths.

Polydrug abuse among opioid maintenance treatment patients is related to inadequate dose of maintenance treatment medicine

BACKGROUND

Polydrug abuse is a known problem among opioid-dependent patients receiving opioid maintenance treatment (OMT). However, improved laboratory diagnostics is required to reveal polydrug abuse in its current scope. Furthermore, there are few studies focusing on the relationship between polydrug abuse and adequacy of the dose of OMT medicine. This study aimed to evaluate the polydrug abuse among opioid-dependent patients receiving OMT with inadequate (Group IA) and adequate (Group A) doses of OMT medicine as experienced by the patients. Craving for opioids and withdrawal symptoms were evaluated as indicators of the adequacy rating.

METHODS

This is a retrospective register-based study of 60 OMT patients on either methadone or sublingual buprenorphine/naloxone medication, whose polydrug abuse was studied from urine samples by means of a comprehensive high-resolution mass spectrometry method.

RESULTS

Inadequate doses of the OMT medicines were associated with higher subjective withdrawal scores and craving for opioids. Six groups of abused substances (benzodiazepines, amphetamines, opioids, cannabis, new psychoactive substances, and non-prescribed psychotropic medicines) were found among OMT patients. Group IA patients showed significantly more abuse of benzodiazepines and amphetamines than the Group A patients. All the new psychoactive substances and most of the non-prescribed psychotropic medicines were detected from the Group IA patients. There was no difference in the doses of the OMT medicine between Groups IA and A patients.

CONCLUSIONS

Polydrug abuse, detected by definitive laboratory methods, was widespread and more common among Group IA than Group A patients, emphasizing the requirement for individual OMT medicine dose adjustment.