Patterns in the use of benzodiazepines in British Columbia: examining the impact of increasing research and guideline cautions against long-term use

Predicting 30-day risk from benzodiazepine/Z-drug dispensations in older adults using administrative data: A prognostic machine learning approach

OBJECTIVE

To develop a machine-learning (ML) model using administrative data to estimate risk of adverse outcomes within 30-days of a benzodiazepine (BZRA) dispensation in older adults for use by health departments/regulators.

DESIGN, SETTING AND PARTICIPANTS

This study was conducted in Alberta, Canada during 2018-2019 in Albertans 65 years of age and older. Those with any history of malignancy or palliative care were excluded.

EXPOSURE

Each BZRA dispensation from a community pharmacy served as the unit of analysis.

MAIN OUTCOMES AND MEASURES

ML algorithms were developed on 2018 administrative data to predict risk of any-cause hospitalization, emergency department visit or death within 30-days of a BZRA dispensation. Validation on 2019 administrative data was done using XGBoost to evaluate discrimination, calibration and other relevant metrics on ranked predictions. Daily and quarterly predictions were simulated on 2019 data.

RESULTS

65,063 study participants were included which represented 633,333 BZRA dispensation during 2018-2019. The validation set had 314,615 dispensations linked to 55,928 all-cause outcomes representing a pre-test probability of 17.8%. C-statistic for the XGBoost model was 0.75. Measuring risk at the end of 2019, the top 0.1 percentile of predicted risk had a LR + of 40.31 translating to a post-test probability of 90%. Daily and quarterly classification simulations resulted in uninformative predictions with positive likelihood ratios less than 10 in all risk prediction categories. Previous history of admissions was ranked highest in variable importance.

CONCLUSION

Developing ML models using only administrative health data may not provide health regulators with sufficient informative predictions to use as decision aids for potential interventions, especially if considering daily or quarterly classifications of BZRA risks in older adults. ML models may be informative for this context if yearly classifications are preferred. Health regulators should have access to other types of data to improve ML prediction.

Safety of Alprazolam Use in Pregnancy in Western Australia: A Retrospective Cohort Study Using Linked Health Data

The use of alprazolam in pregnancy can adversely affect maternal and neonatal health. This study examined neonatal outcomes following exposure to alprazolam in pregnancy. Women prescribed alprazolam during pregnancy (n = 48) between 2014 and 2018 were identified from routinely-collected state administrative prescribing records and perinatal data. Two comparison groups of women; 1) prescribed alprazolam outside of pregnancy (n = 96) and 2) women never prescribed alprazolam (n = 96) were also identified. The health of women and their children was examined using administrative hospital, mortality and perinatal data and compared to the comparison groups using generalized linear models. Prenatal alprazolam exposure was not associated with a reduction in average birth weight or gestational age. However, neonates prenatally exposed to alprazolam were more likely be classified as having low birth weight for gestational age compared with alprazolam comparison group (OR: 4.46, 95% CI: 1.54-12.95) and the non-alprazolam comparison group (OR: 3.27, 95% CI: 1.22-8.79). There were no cases of perinatal mortality or floppy baby syndrome in alprazolam-exposed neonates. While the use of alprazolam during pregnancy was not associated with an increased risk of severe adverse neonatal outcomes (e.g. perinatal mortality), it was associated with neonates being born with a low birth weight for gestational age.

Predicting benzodiazepine prescriptions: A proof-of-concept machine learning approach

Introduction

Benzodiazepines are the most commonly prescribed psychotropic medications, but they may place users at risk of serious adverse effects. Developing a method to predict benzodiazepine prescriptions could assist in prevention efforts.

Methods

The present study applies machine learning methods to de-identified electronic health record data, in order to develop algorithms for predicting benzodiazepine prescription receipt (yes/no) and number of benzodiazepine prescriptions (0, 1, 2+) at a given encounter. Support-vector machine (SVM) and random forest (RF) approaches were applied to outpatient psychiatry, family medicine, and geriatric medicine data from a large academic medical center. The training sample comprised encounters taking place between January 2020 and December 2021 (N = 204,723 encounters); the testing sample comprised data from encounters taking place between January and March 2022 (N = 28,631 encounters). The following empirically-supported features were evaluated: anxiety and sleep disorders (primary anxiety diagnosis, any anxiety diagnosis, primary sleep diagnosis, any sleep diagnosis), demographic characteristics (age, gender, race), medications (opioid prescription, number of opioid prescriptions, antidepressant prescription, antipsychotic prescription), other clinical variables (mood disorder, psychotic disorder, neurocognitive disorder, prescriber specialty), and insurance status (any insurance, type of insurance). We took a step-wise approach to developing a prediction model, wherein Model 1 included only anxiety and sleep diagnoses, and each subsequent model included an additional group of features.

Results

For predicting benzodiazepine prescription receipt (yes/no), all models showed good to excellent overall accuracy and area under the receiver operating characteristic curve (AUC) for both SVM (Accuracy = 0.868-0.883; AUC = 0.864-0.924) and RF (Accuracy = 0.860-0.887; AUC = 0.877-0.953). Overall accuracy was also high for predicting number of benzodiazepine prescriptions (0, 1, 2+) for both SVM (Accuracy = 0.861-0.877) and RF (Accuracy = 0.846-0.878).

Discussion

Results suggest SVM and RF algorithms can accurately classify individuals who receive a benzodiazepine prescription and can separate patients by the number of benzodiazepine prescriptions received at a given encounter. If replicated, these predictive models could inform system-level interventions to reduce the public health burden of benzodiazepines.

Alterations in the dentate gyrus of the offspring of rats treated with alprazolam during gestation

Benzodiazepine (BZD) abuse is a global problem, including pregnant women. For this population, the drug of choice is usually alprazolam, which acts as a GABAergic agonist and may compromise the development of integrative areas of the nervous system, such as the dentate gyrus (DG) of the hippocampus. In this context, we studied the changes in the DG of the offspring of rats treated with alprazolam during gestation: control, treatment 1 (T1: 1.25 mg/animal), and an overdose group (T2: 30 mg/animal). Alprazolam was administered orally ten days before mating and during the gestational period. After birth, newborns were counted, sexed, and the body mass of each pup was measured. The newborns' brains were extracted and processed for morphological study of the DG or for total protein extraction of the hippocampus. The results showed that alprazolam can affect the cell number and area, and increased euchromatin in both granular and molecular layers of the DG, especially in the overdose group. Also, alprazolam upregulated the NF-κB and reduced GFAP and caspase-3. Based on our findings, we conclude that the DG is a plausible region of influence by BZDs during embryogenesis. An overdose during gestation may cause structural changes in the DG.

Mandatory prescription drug monitoring programs and overlapping prescriptions of opioids and benzodiazepines: Evidence from Kentucky

BACKGROUND

In response to the opioid epidemic, many states implemented mandates requiring providers to check prescription drug monitoring programs (PDMPs) before prescribing opioids. We examine how overlapping benzodiazepine and opioid prescriptions changed after Kentucky implemented a PDMP mandate in July 2012.

METHODS

We conducted an interrupted time series analysis using monthly data from Kentucky's PDMP from 2010 to 2016. Separate analyses were conducted for overlapping prescriptions from a single provider or multiple providers, and by sex and age group. We also conducted an individual-level longitudinal analysis that compared changes in utilization patterns after the mandate went into effect to changes in earlier periods during which the mandate was not in effect.

RESULTS

Kentucky's PDMP mandate was associated with an immediate 7.5 % decline in the rate of overlapping benzodiazepine and opioid prescriptions and a significant change in the trend from increasing to decreasing. Approximately half of the immediate effect in level terms was explained by decreases in overlapping prescriptions written by a single provider. Our longitudinal analysis suggests that over one year the mandate reduced initiation of overlapping prescriptions by 29.3 % and reduced continuation of overlapping prescriptions by 9.4 %. The effects of the policy were largest for women and men aged 36-50.

CONCLUSIONS

Though not the main rationale for the policy, Kentucky's PDMP mandate reduced overlapping prescriptions of benzodiazepines and opioids. Further efforts to reduce overlapping prescriptions should consider the effects on populations such as women over 50, who have high rates of overlapping prescriptions.

Anxiolytic-like effect of Suanzaoren-Wuweizi herb-pair and evidence for the involvement of the monoaminergic system in mice based on network pharmacology

BACKGROUND

Suanzaoren-Wuweizi herb-pair (SWHP), composed of Zizyphi Spinosi Semen (Suanzaoren in Chinese) and Schisandrae Chinensis Fructus (Wuweizi in Chinese), is a traditional herbal formula that has been extensively used for the treatment of insomnia. The study aimed to explore the targets and signal pathways of Suanzaoren-Wuweizi (S-W) in the treatment of anxiety by network pharmacology, and to verify the pharmacodynamics and key targets of SWHP in mice.

METHODS

The Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP) as well as literature mining were used to obtain the main chemical ingredients of Suanzaoren and Wuweizi. The SwissTargetPrediction platform was used to predict drug-related targets. The GeneCards, TTD, DisGeNET and OMIM databases were used to obtain potential targets for the treatment of anxiety with the chemical components of S-W. Drug-disease intersection genes were selected, and a protein-protein interaction (PPI) network was constructed using STRING. The core targets of S-W in the treatment of anxiety were selected according to the topological parameters, and GO functional enrichment as well as KEGG pathways enrichment analyses were performed for potential targets. The relationship network of the "drug-active ingredient-disease-target-pathway" was constructed through Cytoscape 3.8.0. The pharmacodynamics of SWHP in the treatment of anxiety was evaluated by the elevated plus maze (EPM), the light/dark box test (LDB) and the open field test (OFT). The mechanisms were examined by measuring monoamine neurotransmitters in brain of mice.

RESULTS

The results showed that there were 13 active ingredients for the treatment of anxiety in the network. This includes sanjoinenine, swertisin, daucosterol, schizandrer B, wuweizisu C and gomisin-A. Additionally, there were 148 targets, such as AKT1, TNF, SLC6A4, SLC6A3, EGFR, ESR1, HSP90AA1, CCND1, and DRD2, mainly involved in neuroactive ligand-receptor interactions, the Serotonergic synapse pathway and the cAMP signaling pathway. After 1 week of treatment, SWHP (2 and 3 g/kg) induced a significant increase on the percentage of entries into and time spent on the open arms of the EPM. In the LDB test, SWHP exerted anxiolytic-like effect at 2 g/kg. In the open-field test, SWHP (2 g/kg) increased the number of central entries and time spent in central areas. The levels of brain monoamines (5-HT and DA) and their metabolites (5-HIAA, DOPAC) were decreased after SWHP treatment.

CONCLUSIONS

The anti-anxiety effect of SWHP may be mediated by regulating 5-HT, DA and other signaling pathways. These findings demonstrated that SWHP produced an anxiolytic-like effect and the mechanism of action involves the serotonergic and dopaminergic systems, although underlying mechanism remains to be further elucidated.

Impact of the 2018 Japan Floods on benzodiazepine use: a longitudinal analysis based on the National Database of Health Insurance Claims

PURPOSE

Natural disaster has an impact on mental health. The 2018 Japan Floods, which took place in July 2018 were one of the largest water disasters in Japan's recorded history. We aimed to evaluate the change in the number of benzodiazepine prescriptions by physicians before and after the disaster.

METHODS

A retrospective cohort study based on the National Database of Health Insurance Claims was conducted in the flood-stricken areas between July 2017 and June 2019. The subjects were divided between victims and non-victims according to certification by local governments. Members of both groups were then categorized into three groups based on their pre-flood use of benzodiazepines: non-user, occasional user, and continuous user. Difference-in-differences (DID) analysis with a logistic regression model was conducted to estimate the effect of the disaster among victims by comparing the occurrence of benzodiazepine prescriptions before and after the disaster.

RESULTS

Of 5,000,129 people enrolled, 31,235 were victims. Among all participants, the mean prescription rate for benzodiazepines in victims before the disaster (11.3%) increased to 11.8% after the disaster, while that in non-victims (8.3%) decreased to 7.9%. The DID analysis revealed that benzodiazepine prescription among victims significantly increased immediately after the disaster (adjusted ratio of odds ratios (ROR) 1.07: 95% confidence interval 1.05-1.11), and the effect of the disaster persisted even 1 year after the disaster (adjusted ROR 1.2: 95% confidence interval 1.16-1.24).

CONCLUSION

The flood increased the number of benzodiazepines prescriptions among victims, and the effect persisted for at least 1 year.

A nationwide cohort study of the association of benzodiazepines with SARS-CoV-2 infection and clinical outcomes

The evidence for the impact of benzodiazepine (BZD) use on infection or clinical outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is limited. We evaluated the association of BZD use with SARS-CoV-2 infection and the clinical outcomes of coronavirus disease 2019 (COVID-19) using a nationwide COVID-19 database from South Korea. This nationwide cohort study was performed using the COVID-19 database from the Health Insurance Review and Assessment Service of Korea, and SARS-CoV-2 positivity was investigated according to BZD use. SARS-CoV-2-positive adult patients were assessed in three groups, those who needed hospitalization, those with severe symptoms requiring intensive care, and those who died. A multivariate logistic regression model was used for all the analyses. After adjusting for potential confounding factors, there was no association between BZD use and SARS-CoV-2 positivity. SARS-CoV-2-positive patients with BZD use showed an increased risk of need for hospitalization from COVID-19 compared to those without BZD use (odds ratio [OR]: 1.33, 95% confidence interval [CI] 1.07-1.65). In addition, there was a higher risk for long-term users (OR: 2.64, 95% CI 1.08-6.47). Chronic BZD use contributed to a higher risk of the need for hospitalization among COVID-19 patients, whereas BZD use did not increase the risk of SARS-CoV-2 test positivity, severe outcomes, or mortality.

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.

Benzodiazepines utilization in Brazilian older adults: a population-based study

OBJECTIVE

To evaluate the utilization of benzodiazepines (BZD) in Brazilian older adults, based on the Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey of Access, Use and Promotion of Rational Use of Medicines).

METHODS

The PNAUM is a cross-sectional study conducted between 2013 and 2014, representing the Brazilian urban population. In the present study, we included 60 years or older (n = 9,019) individuals. We calculated the prevalence of BZD utilization in the 15 days prior to survey data collection according to independent variables, using a hierarchical Poisson regression model. A semistructured interview performed empirical data collection (household interview).

RESULTS

The prevalence of BZD utilization in the older adults was 9.3% (95%CI: 8.3-10.4). After adjustments, BZD utilization was associated with female sex (PR = 1.88; 95%CI: 1.52-2.32), depression (PR = 5.31; 95%CI: 4.41-6, 38), multimorbidity (PR = 1.44; 95%CI: 1.20-1.73), emergency room visit or hospitalization in the last 12 months (PR = 1.42; 95%CI: 1.18-1.70 ), polypharmacy (PR = 1.26; 95%CI: 1.01-1.57) and poor or very poor self-rated health (PR = 4.16; 95%CI: 2.10-8.22). Utilization was lower in the North region (PR = 0.18; 95%CI: 0.13-0.27) and in individuals who reported abusive alcohol consumption in the last month (PR = 0.42; 95%CI: 0.19-0.94).

CONCLUSION

Despite contraindications, results showed a high prevalence of BZD utilization in older adults, particularly in those with depression, and wide regional and sex differences.

Risk of long-term benzodiazepine and Z-drug use following the first prescription among community-dwelling adults with anxiety/mood and sleep disorders: a retrospective cohort study

OBJECTIVE

To measure the incidence of long-term benzodiazepine receptor agonist (BZRA) use among individuals with anxiety, mood and/or sleep disorders. To identify factors associated with long-term use following the first prescription.

METHODS

This was a population-based retrospective cohort study using administrative databases in Manitoba, Canada. Individuals with anxiety/mood or sleep disorder who received their first BZRA between 1 April 2001 and 31 March 2015 were included. Long-term use was defined as ≥180 days. Logistic regression modelling was used to examine predictors of long-term use.

RESULTS

Among 206 933 individuals included, long-term BZRA use in the first episode of use was 4.5% (≥180 days) following their first prescription. Factors associated with ≥180 days of use included male sex (adjusted OR (aOR) 1.33, 95% CI 1.27 to 1.39), age ≥65 (aOR 5.15, 95% CI 4.81 to 5.52), income assistance (aOR 1.68, 95% CI 1.55 to 1.81), previous non-BZRA psychotropic (aOR 1.93, 95% CI 1.83 to 2.02) or opioid use (aOR 1.16, 95% CI 1.11 to 1.22), high comorbidity (aOR 1.43, 95% CI 1.32 to 1.55), high healthcare use (aOR 1.46, 95% CI 1.33 to 1.60) and psychiatrist prescriber (aOR 2.11, 95% CI 1.93 to 2.32).

CONCLUSIONS

Less than 1 in 20 patients use BZRAs ≥180 days in their first treatment episode. Several factors were associated with long-term use following the first prescription and further investigation into whether these factors need to be considered at the point of prescribing is warranted. In light of these findings, future research should examine the predictors of cumulative repeat episodes of BZRA exposure.

General practitioners' compliance with benzodiazepine discontinuation guidelines in patients treated with long-term lorazepam: A case-vignette cross-sectional survey

AIM

To study determinants associated with GPs' compliance with benzodiazepine discontinuation guidelines through a case-vignette of a patient with multimorbidity treated with long-term lorazepam for insomnia.

METHODS

This cross-sectional survey was performed in a sample of French GPs. The questionnaire included items on their characteristics and questions related to the management of a case-vignette with long-term lorazepam use consulting for a prescription renewal. GPs who proposed a dedicated consultation to discuss discontinuation or progressive discontinuation were considered as "following guidelines", while they were considered as "out-of-guidelines" if they proposed immediate discontinuation or decided not to discontinue lorazepam. A backward selection process was used to select factors to be included in the final logistic regression model. The probabilities of out-of-guidelines practice and their 95% confidence interval (95% CI) were then plotted using a heatmap graph.

RESULTS

Of 1,177 GPs, the majority (92.2%) were aware of the necessity to discontinue lorazepam and reported practice consistent with good practice guidelines. Women GPs aged under 50 years had the lowest estimated probability of out-of-guidelines practice. Conversely, men aged over 58 years with high consideration of patient preferences and low concern about the benefit-risk ratio of lorazepam had the highest probability of out-of-guidelines practice (27.3% [18.7%; 34.7%]).

CONCLUSION

GPs largely reported practice compliant with benzodiazepine discontinuation guidelines, although some GPs, mainly older men who overemphasise patient preferences, were more likely to adopt out-of-guidelines practice.

Preoperative Sedative-hypnotic Medication Use and Adverse Postoperative Outcomes

OBJECTIVE

To determine the association between preoperative benzodiazepine and nonbenzodiazepine receptor agonist ("Z-drugs") use and adverse outcomes after surgery.

BACKGROUND

Prescriptions for benzodiazepines and Z-drugs have increased over the past decade. Despite this, the association of preoperative benzodiazepines and Z-drug receipt with adverse outcomes after surgery is unknown.

METHODS

Using the Optum Clinformatics Datamart, we performed a retrospective cohort study of adults 18 years or older who underwent any of 10 common surgical procedures between 2010 and 2015. The principal exposure was one or more filled prescriptions for a benzodiazepine or Z-drug in the 90 days before surgery. The primary outcome was any emergency department visit or hospital admission for either (1) a drug related adverse medical event or overdose or (2) a traumatic injury in the 30 days after surgery.

RESULTS

Of 785,346 patients meeting inclusion criteria, 94,887 (12.1%) filled a preoperative prescription for a benzodiazepine or Z-drug. From multivariable logistic regression, benzodiazepine or Z-drug use was associated with an increased odds of an adverse postoperative event [odds ratio 1.13; 95% confidence interval: 1.08-1.18). In a separate regression, coprescription of benzodiazepines or Z-drugs with opioids was associated with a 1.45 odds of an adverse postoperative event (95% confidence interval: 1.37-1.53).

CONCLUSIONS

Preoperative benzodiazepines and Z-drug use is common and associated with increased odds of adverse outcomes after surgery, particularly when coprescribed with opioids. Counseling on appropriate benzodiazepine and Z-drug use in advance of elective surgery may potentially increase the safety of surgical care.

Quercetin and/or Ascorbic Acid Modulatory Effect on Phenobarbital-Induced Sleeping Mice Possibly through GABAA and GABAB Receptor Interaction Pathway

Depressive disorder is a recurrent illness that affects large numbers of the general population worldwide. In recent years, the goal of depression treatment has moved from symptomatic response to that of full remission. However, treatment-resistant depression is a major challenge in the treatment of depression or depression-related disorders. Consensus opinion, therefore, suggests that effective combined aggressive initial treatment is the most appropriate strategy. This study aimed to evaluate the effects of quercetin (QUR) and/or ascorbic acid (AA) on Phenobarbital-induced sleeping mice. QUR (50 mg/kg) and/or AA (25 mg/kg) with or without intraperitoneally pre-treated with GABA receptor agonist (diazepam: 2 mg/kg, i.p.) or antagonist (Flumazenil: 2.5 mg/kg, i.p.) to underscore the effects, as well as the possible involvement of the GABA receptor in the modulatory action of QUR and AA in sleeping mice. Additionally, an in silico study was undertaken to predict the involvement of GABA receptors in the sleep mechanism. Findings suggest that the pretreatment of QUR and AA modulated the onset and duration of action of the standard drugs in experimental animals. The acute administration of QUR and/or AA significantly (p < 0.05) reversed the DZP-mediated onset of action and slightly reversed the duration of sleep time in comparison to the vehicle (control) group. A further combination of QUR or AA with the FLU resulted in an enhancement of the onset of action while reducing the duration of action, suggesting a FLU-like effect on the test animals. In in silico studies, AA and QUR showed good to moderate binding affinities with GABA_A and GABA_B receptors. Both QUR and AA produced a stimulatory-like effect on mice, possibly through the GABA_A and GABA_B receptor interaction pathways. Further studies are necessary to verify this activity and clarify the exact mechanism of action(s) involved.

Driving performance assessments for benzodiazepine receptor agonist-related impairment: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify, map, and characterize the evidence for assessments that measure driving performance in people taking benzodiazepine receptor agonists.

INTRODUCTION

Benzodiazepines and Z-drugs are widely prescribed for the treatment of anxiety disorders and insomnia even though they are not recommended as an initial treatment for these indications. Benzodiazepine and Z-drug use is associated with an elevated risk of traffic accidents, and guidance documents instruct patients to consult with their health care providers for instructions on how to safely operate a motor vehicle while consuming these medications. However, little is known about the assessments that measure driving performance regarding the extent and length of impairment from the consumption of the individual benzodiazepines and Z-drugs.

INCLUSION CRITERIA

Eligible studies will include participants who are new, intermittent, or chronic users of benzodiazepines and Z-drugs. No exclusions will be applied regarding the health status of participants or whether their benzodiazepine and Z-drug use is for an approved indication as indicated by government agencies (eg, Health Canada) or practice guidelines. Studies that examine the consumption of a benzodiazepine and Z-drug in association with the operation of a motor vehicle (real or simulated) with direct or indirect objective or standard subjective measures or indicators of impairment while operating a motor vehicle will be considered.

METHODS

Embase (Elsevier), MEDLINE (Ovid), and PsycINFO (EBSCO) will be searched as sources of published studies. Only studies published in English will be included, and there will be no limit on dates of publication. After screening the titles and abstracts of identified citations, two independent reviewers will retrieve potentially relevant full-text studies and extract data. Data will be presented in diagrammatic or tabular form accompanied by a narrative summary.

Prescribing Pattern of Hypnotic Medications in Patients Initiating Treatment at Japanese Hospitals: A Nationwide, Retrospective, Longitudinal, Observational Study Using a Claims Database

Background

Prolonged treatment of insomnia using benzodiazepine (BZD) receptor agonists, including BZD and non-BZD hypnotic drugs, can cause drug dependence, tolerance, abuse and other adverse events. These side effects are more common and/or severe in older adults taking different hypnotic drugs concomitantly. Therefore, a single prescription is limited to 30 daily doses for most BZD receptor agonists and restrictions apply to the prescription of more than three types of hypnotic drugs in Japan. Little is known, however, about the real-world prescribing pattern of hypnotic drugs in Japan.

Objective

We analysed prescribing patterns for hypnotic drugs in Japan to evaluate whether real-world use differs from guideline recommendations.

Methods

In this nationwide, retrospective, longitudinal, observational study, we analysed the types of hypnotic drugs prescribed, duration of medication and treatment setting in a subset of hospitals in Japan using a hospital-based administrative claims database (Medical Data Vision). Patients initiating treatment with hypnotic drugs between January 2012 and December 2016 were included in the analyses to assess the duration of medication and occurrence of co-prescription of a second and third hypnotic drug, within a year from prescription of the first hypnotic drugs.

Results

In 261,167 patients analysed, the first hypnotic drugs prescribed were BZDs (59.7%), non-BZDs (36.8%), a melatonin receptor agonist [MRA] (3.1%) and an orexin receptor antagonist [ORA] (0.4%). Benzodiazepine and non-BZD hypnotic drugs were mostly prescribed in inpatient settings (57.7% and 63.0%, respectively) and the MRA and ORA mostly in outpatient settings (62.6% and 65.4%, respectively). The departments that prescribed the most patients their first hypnotic drugs were internal medicine (23.6%), general surgery (11.8%), orthopaedic surgery (11.4%) and urology (5.3%). Of the total prescriptions of MRA and ORA as the first hypnotic drugs, 22.0% and 31.8% were in internal medicine, 4.4% each in general surgery, 6.0% and 4.5% in orthopaedic surgery, 9.7% and 4.4% in neurology, and 10.1% and 12.2% in psychiatry departments, respectively. Mean duration of medication was 1.13 months for non-BZDs, 1.15 months for BZDs, 1.29 months for the ORA and 1.83 months for the MRA. Overall, 5.3% (95% confidence interval 5.2–5.4) of patients were prescribed a second hypnotic drug; of these, 8.4% (95% confidence interval 8.0–8.9) were prescribed at least three hypnotic drugs within a year. Patients who were prescribed three or more hypnotic drugs received higher doses of the first drug than patients who received fewer hypnotic drugs.

Conclusions

Benzodiazepine receptor agonists were the most common hypnotic drugs prescribed as the first drug to patients in Japan. Further education and awareness may be needed on the risk of complications and adverse events associated with these therapies. The duration of BZD receptor agonist use was shorter than for the MRA and ORA, in accordance with prescribing guidelines. Long-term use and co-prescribing of hypnotic drugs were also uncommon.

Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study

BACKGROUND

Several studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium.

METHODS

This retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission.

RESULTS

Among 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008).

CONCLUSIONS

Abrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.

A New Paradigm for Achieving a Rapid Antidepressant Response

The substantive delay (often 4-6 weeks) between the commencement of an antidepressant and any discernible improvement in depressive symptoms is an ongoing concern in the management of depressive disorders. This delay incurs the risk of cessation of medication, self-harm/suicide and ongoing 'damage' to the brain caused by the illness. Both historically and now, off-label polypharmacy has been used in clinical practice in an attempt to facilitate both immediate- and long-term relief from symptoms. While somewhat effective, this strategy was unregulated and associated with severe adverse side effects for patients. In this article we proffer an alternative paradigm to achieve a more rapid antidepressant response by conceptualising the gap in terms of windows of response. The Windows of Antidepressant Response Paradigm (WARP) frames treatment response as windows of time in which a clinical response can be expected following initiation of an antidepressant. The paradigm defines three distinct windows-the immediate-response window (1-2 days), fast-response window (up to 1 week) and slow-response window (from 1 week onwards). Newer agents such as rapid-acting antidepressants are considered to act within the immediate-response window, whereas atypical antipsychotic augmentation strategies are captured within the fast-response window. The slow-response window represents the delay experienced with conventional antidepressant monotherapy. Novel agents such as esketamine and brexpiprazole are discussed as examples to better understand the clinical utility of WARP. This framework can be used to guide research in this field and aide the development of newer, more effective antidepressant agents as well as providing a strategy to guide the prescription of multiple agents in clinical practice.

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

IMPORTANCE

The proportion of patients who develop long-term benzodiazepine use remains controversial, as do the length of time before long-term use develops and the factors associated with long-term use.

OBJECTIVE

To investigate the incidence of long-term benzodiazepine and related drug (BZDR) use and factors associated with the development of long-term use implementing a follow-up design with new BZDR users.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used a nationwide cohort of 129 732 new BZDR users in Finland. New users of BZDRs aged 18 years or older were identified from the prescription register maintained by the Social Insurance Institution of Finland as individuals who initiated BZDR use during 2006 and had not used BZDRs from 2004 to 2005. The follow-up continued until death, long-term hospitalization, a gap of 2 years in BZDR use, or December 31, 2015. The population was analyzed according to age at treatment initiation, categorized into younger (<65 years) and older (≥65 years) subcohorts. Analyses were conducted from May 2019 to February 2020.

EXPOSURES

Use of BZDRs, modeled from register-based data using the PRE2DUP (from prescriptions to drug use periods) method.

MAIN OUTCOMES AND MEASURES

Long-term BZDR use, defined as continuous use of 180 days or longer, and factors associated with long-term vs short-term use, compared using Cox proportional hazards models.

RESULTS

Among the 129 732 incident BZDR users, the mean (SD) age was 52.6 (17.7) years, and 78 017 (60.1%) individuals were women. During the follow-up period, 51 099 BZDR users (39.4%) became long-term users. Long-term treatment was more common in the older subcohort (19 103 individuals [54.5%]) than the younger subcohort (31 996 individuals [33.8%]). At 6 months, 28 586 individuals (22.0%) had become long-term users: 11 805 (33.7%) in the older subcohort and 16 781 (17.7%) in the younger subcohort. The largest proportions of initiators who became long-term users were those persons who initiated treatment with nitrazepam (76.4%; 95% CI, 73.6%-79.1%), temazepam (63.9%; 95% CI, 62.9%-65.0%), lorazepam (62.4%; 95% CI, 59.7%-65.1%), or clonazepam (57.5%; 95% CI, 55.9%-59.2%). Factors associated with the development of long-term use included male sex, older age, receipt of social benefits, psychiatric comorbidities, and substance abuse.

CONCLUSIONS AND RELEVANCE

The findings of this population-based cohort study conducted in Finland suggest that the incidence of subsequent long-term BZDR use in individuals who initiate use of BZDRs is high, especially among older persons, and that the specific BZDR used initially is associated with the development of long-term BZDR use and should be carefully considered when prescribing BZDRs. The observed factors that appear to be associated with development of long-term BZDR use also should be considered in clinical decision-making when starting and monitoring BZDR treatment.

Anxiolytic-Like Action of Selected 4-(Alkylamino)-3-nitrocoumarin Derivatives in BALB/c Mice

In this work, we explored the possible polypharmacological potential of the already established antimicrobials against gastrointestinal pathogens, 4-(alkylamino)-3-nitrocoumarins, as antianxiety agents, using a battery of in vivo experiments. Three chosen coumarin derivatives, differing in the substituent (sec-butylamino, hexadecylamino, or benzylamino) at position 4, at the doses of 25, 50 and 100 mg kg^-1 , were evaluated in light/dark, open-field, horizontal wire and diazepam-induced sleep models using male BALB/c mice. Depending on the applied dose, all three tested coumarins displayed a noteworthy anxiolytic-like effect. 4-(sec-Butylamino)-3-nitro-2H-chromen-2-one and 4-(hexadecylamino)-3-nitro-2H-chromen-2-one could be recognized as true anxiolytics in the lowest applied dose, based on three tests, without exerting any sedative effects. Thus, the 3-nitrocoumarin core deserves further chemical diversity exploration in the 'antianxiety' direction.

Benzodiazepines, Codispensed Opioids, and Mortality among Patients Initiating Long-Term In-Center Hemodialysis

BACKGROUND AND OBJECTIVES

Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing.

RESULTS

Within 1 year of hemodialysis initiation, 10,854 (16%) patients were dispensed a short-acting benzodiazepine, and 3262 (5%) patients were dispensed a long-acting benzodiazepine. Among those who were dispensed a benzodiazepine during follow-up, codispensing of opioids and short-acting benzodiazepines occurred among 3819 (26%) patients, and codispensing of opioids and long-acting benzodiazepines occurred among 1238 (8%) patients. Patients with an opioid prescription were more likely to be subsequently dispensed a short-acting benzodiazepine (adjusted hazard ratio, 1.66; 95% confidence interval, 1.59 to 1.74) or a long-acting benzodiazepine (adjusted hazard ratio, 1.11; 95% confidence interval, 1.03 to 1.20). Patients dispensed a short-acting benzodiazepine were at a 1.45-fold (95% confidence interval, 1.35 to 1.56) higher mortality risk compared with those without a short-acting benzodiazepine; among those with opioid codispensing, this risk was 1.90-fold (95% confidence interval, 1.65 to 2.18; Pinteraction<0.001). In contrast, long-acting benzodiazepine dispensing was inversely associated with mortality (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72 to 0.99) compared with no dispensing of long-acting benzodiazepine; there was no differential risk by opioid dispensing (Pinteraction=0.72).

CONCLUSIONS

Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.

Use of benzodiazepines and z-drugs not compliant with guidelines and associated factors: a population-based study

Benzodiazepines and z-drugs are primarily indicated for the treatment of sleep disorders and anxiety symptoms. Their frequent long-term use contrasts with the international guidelines that limit treatment duration to a maximum of 4 weeks. The objective of this study was to assess the frequency of their use that was not in accordance with guidelines in the French general population between 2007 and 2012 and associated characteristics. A cohort of 67,550 benzodiazepine new users was set up in an exhaustive database for health-care reimbursements and representative of the French population. Benzodiazepine use not in accordance with guidelines was defined as the concomitant dispensation of several benzodiazepines, the dispensation of treatment over a period longer than recommended, or a new dispensing within the 2 months following the end of a previous treatment of maximum recommended duration, considering that French recommendations distinguish between hypnotic (4 weeks) and anxiolytic benzodiazepines (12 weeks). Benzodiazepine use not in accordance with guidelines was high, in about 30% of new hypnotic users and 20% of new anxiolytic users. Its frequency was stable over the study period. Associated characteristics were similar for new hypnotic or anxiolytic users, i.e.. older age, treatment initiation by a psychiatrist, presence of a chronic disease, hospitalization, or another psychotropic treatment. These findings provide a solid basis for establishing a public health policy to reduce benzodiazepine use not compliant with guidelines. They should be further explored in patients most at risk in the present study, e.g., patients treated by a psychiatrist.

Long-term use of hypnotics: Analysis of trends and risk factors

OBJECTIVE

Patients with chronic insomnia are prone to long-term use of hypnotics. Reported risk factors include aging, female sex, and comorbid psychiatric disorders. However, most previous studies have been cross-sectional cohort studies.

METHOD

We conducted a retrospective cohort study using medical service payment data for 330,000 people to determine the duration of prescription of hypnotics and the risk factors for long-term use. We followed up 3981 patients (2382 M, 1599 F, age 40.3 ± 12.4 years) who were prescribed hypnotics for the first time between April 2005 and March 2008.

RESULTS

Of these 3981 patients, 59.6% were prescribed hypnotics for only 1 month, 11.3% were prescribed hypnotics for 2 consecutive months, and 10.1% of patients continued receiving prescriptions for the entire 12-month observation period. In multiple logistic time-dependent Cox analyses, use of antidepressants, mean dose of hypnotics, and advanced age were significantly associated with long-term use of hypnotics (p < 0.01). In an analysis of the association between long-term use of hypnotics and prescribed dosage, high monthly dose, advanced age, and department of first visit were significantly associated with long-term use (p < 0.01).

CONCLUSION

These clinical indicators may be effective for early identification of patients with insomnia who are at high risk of developing physical dependence on hypnotics.

Designing a Pharmacist Opioid Safety and Intervention Tool

BACKGROUND

Despite the recent increase in opioid overdoses across Canada, few pharmacy-led initiatives have been implemented to address issues related to opioid prescribing in the hospital setting.

OBJECTIVES

The primary objective of this study was to develop a clinical tool, intended for use by hospital pharmacists and informed by best practices from the literature, that would provide a structured approach to enhancing the safety of opioid prescribing. The secondary objective was to collect pharmacists' opinions about the feasibility and utility of this tool.

METHODS

A comprehensive literature search and pharmacist focus group analysis provided content for development of a candidate clinical tool. This tool was then piloted by clinical pharmacists working on general medical and surgical units in a single hospital. Pharmacists participating in the pilot were invited to complete an online survey concerning their perceptions of the tool. Descriptive statistics were used to analyze the survey results.

RESULTS

The literature search and focus group analysis led to development of a candidate clinical tool that focused on Medication review, Optimization, Reassessment, and Education (MORE). It included key risk factors relating to opioid safety, along with suggested mitigating strategies. The MORE tool was piloted for 3 weeks by 14 clinical pharmacists, 9 of whom responded to the subsequent survey. Five respondents indicated that the clinical tool increased their ability to identify risk factors. Five respondents also noted an increase in their ability to identify possible interventions. Most respondents felt that the tool was useful and that it would be feasible to integrate it into their practice; however, they noted that a more streamlined version could improve ease of use.

CONCLUSIONS

The MORE tool was well received by clinical pharmacists. Implementation of the tool into routine practice requires additional changes to improve ease of use. Suggestions for modifying and streamlining the tool will be incorporated into future versions.

Benzodiazepine use in Sao Paulo, Brazil

OBJECTIVES

To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil.

METHODS

5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition.

RESULTS

The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use.

CONCLUSION

These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Effect of reimbursement restriction policy on the use of benzodiazepines in the Netherlands: an interrupted time series analysis

OBJECTIVES

Use of benzodiazepines has health risks. Reimbursement was restricted in the Netherlands from January 2009 onwards with the goal to reduce chronic use and healthcare expenditures. The aim of this study is to assess the initial and long-term effects of this policy on benzodiazepine use.

DESIGN

Interrupted time series analysis, segmented regression models, Kaplan-Meier survival analysis and Cox proportional hazards analysis.

SETTING

A 10% random sample of benzodiazepine dispensings by outpatient pharmacies between January 2002 and August 2015 were obtained from the PHARMO database. This database covered a catchment area representing about 3.6 million residents in 2015.

PARTICIPANTS

2 500 800 benzodiazepine prescriptions from 128 603 patients were included.

INTERVENTION

Reimbursement restriction policy from January 2009 onwards.

OUTCOME MEASURES

Changes in: the volume of dispensed prescriptions and doses, the incidence, prevalence of incidental, regular and chronic use and discontinuation rates of benzodiazepines.

RESULTS

The volume of dispensed prescriptions and doses decreased by 12.5% (95% CI 9.0% to 15.9%) and 15.1% (95% CI 11.4% to 17.3%) respectively in January 2009 compared with December 2008. A clear initial effect on the overall incidence (-14.7%; 95% CI -19.8% to 9.6%) and the prevalence of incidental (-17.8%; 95% CI -23.9% to 11.7%), regular (-20.0%; 95% CI -26.1% to 13.9%) and chronic (-16.0%; 95% CI -23.1% to 8.9%) use was observed. A statistically significant reduction in the monthly trend per 1000 medication users was observed for the overall incidence (-0.017; 95% CI -0.031 to 0.003) and the prevalence of incidental (-3.624; 95% CI -4.996 to 2.252) but not for regular (-0.304; 95% CI -1.204 to 0.596) and chronic (0.136; 95% CI -0.858 to 1.130) use. Patients who started treatment before policy had a slightly higher probability of discontinuation (HR=1.013; 95% CI 1.004 to 1.022).

CONCLUSIONS

The reimbursement policy had a significant initial effect on the volume, incidence and prevalence of benzodiazepine use. In addition, there is a statistically significant reduction in the monthly trend of overall incidence and of the prevalence of incidental use. No statistically significant reduction in the monthly trend of chronic use, the main purpose of the reimbursement restriction, could be demonstrated.

Characterisation of concurrent use of prescription opioids and benzodiazepine/Z-drugs in Alberta, Canada: a population-based study

OBJECTIVE

The objective of this study is to characterise concurrent use of benzodiazepine receptor modulators and opioids among prescription opioid users in Alberta in 2017.

DESIGN

A population based retrospective study.

SETTING

Alberta, Canada, in the year 2017.

PARTICIPANTS

All individuals in Alberta, Canada, with at least one dispensation record from a community pharmacy for an opioid in the year 2017.

EXPOSURE

Concurrent use of a benzodiazepine receptor modulator and opioid, defined as overlap of supply for both drugs for at least 1 day.

MAIN OUTCOME MEASURES

Prevalence of concurrency was estimated among subgroups of patient characteristics that were considered clinically relevant or associated with inappropriate medication use.

RESULTS

Among the 547 709 Albertans who were dispensed opioid prescriptions in 2017, 132 156 (24%) also received prescriptions for benzodiazepine receptor modulators. There were 96 581 (17.6%) prescription opioid users who concurrently used benzodiazepine receptor modulators with an average of 98 days (SD=114, 95% CI 97 to 99) of total cumulative concurrency and a median of 37 days (IQR 10 to 171). The average longest duration of consecutive days of concurrency was 45 (SD=60, 95% CI 44.6 to 45.4) with a median of 24 days (IQR 8 to 59). Concurrency was more prevalent in females, patients using an average daily oral morphine equivalent >90 mg, opioid dependence therapy patients, chronic opioid users, patients utilising a high number of unique providers, lower median household incomes and those older than 65 (p value<0.001 for all comparisons).

CONCLUSIONS

Concurrent prescribing of opioids and benzodiazepine receptor modulators is common in Alberta despite the ongoing guidance of many clinical resources. Older patients, those taking higher doses of opioids, and for longer durations may be at particular risk of adverse outcomes and may be worthy of closer follow-up for assessment for dose tapering or discontinuations. As well, those with higher healthcare utilisation (seeking multiple providers) should also be closely monitored. Continued surveillance of concurrent use of these medications is warranted to ensure that safe drug use recommendations are being followed by health providers.

Effectiveness and safety of long-term benzodiazepine use in anxiety disorders: a systematic review and meta-analysis

Long-term benzodiazepines (BZDs) use is not endorsed in the treatment guidelines for anxiety disorders, but is prevalent in the real-world clinical settings. A systematic literature review was performed by using PubMed (last search: May 2019) to identify randomized controlled trials (RCTs) or maintenance studies following RCT that examined the effectiveness of BZDs in patients with anxiety disorders for a duration of 13 weeks or more. Meta-analyses were then conducted regarding changes in the Hamilton Anxiety Rating Scale (HAM-A) scores from baseline through endpoint, all-cause discontinuation, side effects, and the numbers of panic attacks at endpoint. Eight studies were identified (N = 1228). There were no significant differences in all outcomes between BZDs and antidepressants after the initial 8-week treatment. While no significant difference was noted in the HAM-A score changes between BZDs and placebo, BZDs resulted in a lower discontinuation rate and more frequent constipation and dry mouth than placebo. Our study indicates that for those who respond to an initial 8-week treatment, continuing BZDs is equivalent to antidepressants in efficacy and safety. However, the limited number of studies warranted further investigations of the long-term effectiveness and safety of BZDs.

Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort

OBJECTIVES

To examine the association between effort-reward imbalance and incident long-term benzodiazepine use (LTBU).

METHODS

We included 31 077 employed participants enrolled in the French population-based CONSTANCES cohort between 2012 and 2014 who had not undergone LTBU in the 2 years before enrolment. LTBU was examined using drug reimbursement administrative databases. The effort-reward imbalance was calculated in quartiles. We computed ORs (95% CIs) for LTBU according to effort-reward imbalance over a 2-year follow-up period. We adjusted for age, gender, education, occupational grade, income, marital status, tobacco smoking, risk of alcohol use disorder, depressive symptoms and self-rated health.

RESULTS

Over the 2-year follow-up, 294 (0.9%) participants experienced incident LTBU. In the univariable analysis, effort-reward imbalance was associated with subsequent LTBU with ORs of 1.79 (95% CI 1.23 to 2.62) and 2.73 (95% CI 1.89 to 3.95) for the third and fourth quartiles, respectively, compared with the first quartile. There was no interaction between effort-reward imbalance and any of the considered variables other than tobacco smoking (p=0.033). The association remained significant in both smokers and non-smokers, with higher odds for smokers (p=0.031). In the fully adjusted model, the association remained significant for the third and fourth quartiles, with ORs of 1.74 (95% CI 1.17 to 2.57) and 2.18 (95% CI 1.50 to 3.16), respectively. These associations were dose dependent (p for trend <0.001).

CONCLUSIONS

Effort-reward imbalance was linked with incident LTBU over a 2-year follow-up period after adjustment for sociodemographic and health-related factors. Thus, screening and prevention of the risk of LTBU should be systematised among individuals experiencing effort-reward imbalance, with special attention paid to smokers.

Factors associated with long-term prescription of benzodiazepine: a retrospective cohort study using a health insurance database in Japan

OBJECTIVES

Current clinical guidelines discourage long-term prescription of benzodiazepines and Z-drugs (BZD); however, the practice continues to exist. The aim of this study was to investigate the proportion of long-term BZD prescriptions and its risk factors.

DESIGN

Retrospective cohort study using a health insurance database.

SETTING

Japan.

PARTICIPANTS

A total of 86 909 patients were identified as outpatients aged 18 to 65 years who started BZD between 1 October 2012 and 1 April 2015. After excluding patients who underwent surgery on the day of first BZD prescription (n=762) and patients without 8 months follow-up (n=12 103), 74 044 outpatients were analysed.

MAIN OUTCOME MEASURES

We investigated the proportion of long-term prescriptions for ≥8 months among new BZD users. We assessed patient demographics, diagnoses, characteristics of the initial BZD prescription and prescribers as potential predictors of the long-term BZD prescription. Multivariable logistic regression was performed to assess the association between long-term prescription and potential predictors.

RESULTS

Of the new BZD users, 6687 (9.0%) were consecutively prescribed BZD for ≥8 months. The long-term prescription was significantly associated with mood and neurotic disorder, cancer, prescription by psychiatrists, multiple prescriptions, hypnotics and medium half-life BZD in the initial prescription.

CONCLUSION

Despite the recent clinical guidelines, 9% of new BZD users were given prescriptions for more than 8 months. Physicians should be aware of risk factors when prescribing BZDs for the first time.

Physicians' beliefs and attitudes about Benzodiazepines: a cross-sectional study

BACKGROUND

In 2015, Portugal was the OECD country with the highest reported consumption of BZD. Physician's perceptions and attitudes regarding BZD are main determinants of related prescription habits. This study aimed to characterize beliefs and attitudes of Portuguese physicians regarding the prescription, management challenges, benefits, risks and withdrawal effects of BZD.

METHODS

A cross-sectional, observational study with online data collection through anonymous self-administered questionnaire. Physicians registered with the Portuguese Medical Association were invited to participate through direct e-mail message. Physicians were asked to give their opinion (using a 5-points Likert scale) regarding the prescription of BZD, their benefits and risks in the management of insomnia and anxiety, the possible adverse effects of chronic use and alternative non-pharmacologic approaches. Descriptive statistics were used and groups were compared through logistic regression.

RESULTS

A total of 329 physicians participated in the study (56% family physicians). Mean age was 44.10 ± 15.2 years, with 19.03 ± 14.9 years of clinical experience. Fifty eight percent of participants were female. Physicians reported BZD's negative impact on cognitive function (89%), association with road traffic accidents (88%) and falls (79%). Also, 58% shared the belief that chronic use is justified if the patient feels better and without adverse events. Although 68% reported to feel capable of helping patients to reduce or stop BZD, 55% recognized difficulties in motivating them. Compared to other medical specialists (altogether), family physicians were significantly more aware about the adverse effects of BZD and considered that chronic use may not be justified. Conversely, more family physicians expressed concerns about their skills to motivate patients engaging in withdrawal programs and to support them during the process.

CONCLUSION

Our results show that physicians' awareness about risks of BZD chronic use is adequate though their attitudes and self-perceived skills towards promoting BZD withdrawal can be improved. Interventions in primary care are needed to capacitate physicians to better motivate patients for BZD withdrawal.

Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review

Background

Benzodiazepines (BZDs) and z-drugs are effective drugs, but they are prescribed excessively worldwide. International guidelines recommend a maximum treatment duration of 4 weeks. Although these drugs are effective in the short-term, long-term BZD therapy is associated with considerable adverse effects, the development of tolerance and, finally, addiction. However, there are different interventions in terms of patient-centered care that aim to reduce the use of BZDs and z-drugs as well as assist health care professionals (HCPs) in preventing the inappropriate prescription of BZDs.

Aim

The aim of this systematic review was to identify interventions that promote patient-centered treatments for inappropriate BZD and z-drug use and to analyze their effectiveness in reducing the inappropriate use of these drugs.

Methods

To identify relevant studies, the PubMed, EMBASE, PsycINFO, Psyndex, and Cochrane Library databases were searched. Studies with controlled designs focusing on adult patients were included. Trials with chronically or mentally ill patients were excluded if long-term BZD and z-drug use was indicated. Study extraction was performed based on the Cochrane Form for study extraction. To assess the quality of the studies, we used a tool based on the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials.

Results

We identified 7,068 studies and selected 20 for systematic review. Nine interventions focused on patients, nine on HCPs, and two on both patients and HCPs. Intervention types ranged from simple to multifaceted. Patient-centered interventions that provided patient information effectively increased the appropriate use of BZDs. The educational approaches for HCPs that aimed to achieve appropriate prescription reported inconsistent results. The methods that combined informing patients and HCPs led to a significant reduction in BZD use.

Conclusions

This is the first review of studies focused on patient-centered approaches to reducing the inappropriate prescription and use of BZDs and z-drugs. The patient-centered dimension of patient information was responsible for a decrease in BZD and z-drug consumption. Further, in some studies, the patient-centered dimensions responsible for reducing the prescription and use of BZDs and z-drugs were the clinician’s essential characteristics and clinician-patient communication.

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.

Trends in the long-term use of benzodiazepine anxiolytics and hypnotics: A national register study for 2006 to 2014

PURPOSE

Long-term benzodiazepine (BZD) treatment continues to be a debated topic. Because individual BZDs have different clinical profiles, we assessed the nationwide trends of long-term BZD use at active substance level during years 2006 to 2014.

METHODS

This study covered all reimbursed BZD purchases (n = 408 572-521 823 annually) for adults recorded in the Finnish Prescription Register. We assessed long-term use (annual cumulative purchase of ≥180 defined daily doses) in general, and at active substance level with the most commonly used BZD anxiolytics (oxazepam, diazepam, alprazolam, and clonazepam for nonepilepsy indications) and hypnotics (zopiclone, zolpidem, and temazepam) included. The persistence rates for each substance were assessed separately.

RESULTS

The prevalence of long-term BZD use among Finnish adults declined significantly from 5.3% to 3.6%, during years 2006 to 2014. Despite this decline, there was a significant increase in the long-term use of clonazepam for nonepilepsy indications and zolpidem (28.0% and 17.5%, respectively). Long-term use was common in the aged population, as well as among the users of hypnotics or clonazepam. Persistent use of 9 consecutive calendar years varied between 7.5% for incident alprazolam users and 21.0% for incident clonazepam users.

CONCLUSIONS

We found a declining trend in long-term BZD use, but the decline was not uniform between the substances-the long-term use of clonazepam and zolpidem even increased. Follow-up research is needed to assess whether the decline in BZD use is accompanied by an increased use of other types of anxiolytic or hypnotic drugs or other forms of treatment.

Decreasing Trend in the Use and Long-Term Use of Benzodiazepines Among Young Adults

OBJECTIVE

Patterns of benzodiazepine (BZD) use and long-term use among young adults are not well known. Our aim was to study trends in BZD use and long-term use among 18-25-year-old young adults by gender and active substance in a nationwide retrospective longitudinal register-based setting.

METHODS

All Finns aged 18-25 years with reimbursed purchases of BZDs in 2006-2014 recorded to the Finnish Prescription Register were included. Annual prevalence rates of BZD use and long-term use among young adults were reported overall, according to gender, drug group (anxiolytic or hypnotic), and active substance. Long-term use of BZDs was defined as purchasing ≥180 Defined Daily Doses (DDDs) in at least two drug purchases during a calendar year.

RESULTS

Overall prevalence of BZD use among young adults decreased from 24.0 to 18.8 users per 1000 inhabitants in 2006-2014. Prevalence of long-term use decreased from 5.5 to 3.3 users per 1000 inhabitants. Overall BZD use was higher among females, whereas long-term use was more common among males. Use of anxiolytics was more common than use of hypnotics. Oxazepam, alprazolam, zopiclone, and zolpidem were the most used BZDs, whereas alprazolam and clonazepam were the substances with most long-term use. The use and long-term use of BZDs have decreased annually since 2008 among Finnish young adults. Further research is needed to investigate the reasons behind the decline.

The Problem of Benzodiazepine Use and Its Extent in the Driver Population: A Population-Based Registry Study

Background: Benzodiazepines are driving-impairing medicines (DIM). This study presents current consumption of dispensed benzodiazepines in the Spanish general population, with a focus in pattern of use and concomitant medicines consumed with. Methods: A population-based registry study was carried out to assess the year-2016 granted benzodiazepines dispensation in Castile and León. Weighting was performed to obtain the adjusted benzodiazepine consumption for licensed drivers according to age and gender using our national drivers' license census data. Results: Benzodiazepines were used by 15.38% of the general population and 10.97% of drivers. Nearly 2% of the population and more than 1% of drivers took these medicines every day. The amount consumed (until 3 or more benzodiazepines per day) and concomitant use of other DIM were also higher. Women were the most frequent consumers, and anxiolytic use was usual. Consumption increases with age, but there were differences between men and women drivers from 60 years old. Conclusions: The current use of benzodiazepines must serve to awareness of the healthcare personnel, patients, and authorities on their risks, above all on the road safety.

Analysis of changes in trends in the consumption rates of benzodiazepines and benzodiazepine-related drugs

Background

To analyse trends in the rates of consumption of benzodiazepine (BZD) anxiolytics, BZD hypnotics and non-BZD hypnotics and the association with contextual factors.

Methods

Descriptive time series study. Units of analysis were monthly dose per inhabitant per day (DID) and dose per medical card per day(DCD) of benzodiazepine(BZD anxiolytics(BZD-A), BZD hypnotics(BZD-H) and non-BZD hypnotics(Non-BZD-H) between January 2006-December 2015. We analysed 6 primary healthcare districts(PHD) and used defined daily doses (DDDs) to calculate the monthly DIDs(overall and by ATC group). Trends and monthly percentage change (MPC) were analysed through joinpoint regression.

Results

The annual DID increased by 26% overall, the trend was different across ATC groups. Consumption in BZD-A and BZD-H increased (27.1%,61.9%), consumption in Non-BZD-H decreased by 35%. There was high variability in DCD across the PHD, with an overall increase of 10.2%(5.7%-22.9%). By ATC, DCD increased by 10.4% in BZD-A(4.2%-22.2%) and by 44.2% in BZD-H(33.2%-76.5%). The overall DCD in the Non-BZD-H decreased by 42.1%(19.7%-50.8%). We found an initial upward trend in consumption of BZD-A until April/2008(monthly percentage change -MPC- +0.5%), followed by a slightly slower increase (+0.1%). No changes in trend were detected in BZD-H. In Non-BZD-H, we observed an upward trend until February/2013(+0.1%), followed by a sharp decrease until August/2013(-6.3%), and finally a slight decrease(-0.3%).

Conclusions

BZD consumption has increased in the last decade, with variability across areas. The changes in trends do not coincide with the financial crisis, introduction of prescriptions by active ingredient, electronic prescriptions or copayment. The only decrease in the Non-BZD-H may be linked to an intervention.

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting

BACKGROUND

Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines.

METHODS

Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines.

RESULTS

In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability.

CONCLUSIONS

Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.

Therapeutical strategies for anxiety and anxiety-like disorders using plant-derived natural compounds and plant extracts

Anxiety and anxiety-like disorders describe many mental disorders, yet fear is a common overwhelming symptom often leading to depression. Currently two basic strategies are discussed to treat anxiety: pharmacotherapy or psychotherapy. In the pharmacotherapeutical clinical approach, several conventional synthetic anxiolytic drugs are being used with several adverse effects. Therefore, studies to find suitable safe medicines from natural sources are being sought by researchers. The results of a plethora experimental studies demonstrated that dietary phytochemicals like alkaloids, terpenes, flavonoids, phenolic acids, lignans, cinnamates, and saponins or various plant extracts with the mixture of different phytochemicals possess anxiolytic effects in a wide range of animal models of anxiety. The involved mechanisms of anxiolytics action include interaction with γ-aminobutyric acid A receptors at benzodiazepine (BZD) and non-BZD sites with various affinity to different subunits, serotonergic 5-hydrodytryptamine receptors, noradrenergic and dopaminergic systems, glutamate receptors, and cannabinoid receptors. This review focuses on the use of both plant-derived natural compounds and plant extracts with anxiolytic effects, describing their biological effects and clinical application.

Trends in the prescription of benzodiazepines for the elderly in Korea

BACKGROUND

This study examined trends in the prescription of benzodiazepines for the elderly (age over 65 years) in Korea, a country with a higher level of spending on pharmaceuticals compared to that in other Organization for Economic Cooperation and Development (OECD) countries, and identified factors related to the inappropriate use of such drugs.

METHODS

We used the National Health Insurance Claims Data (NHICD) for the period 2009-2013, including all reimbursed drug-prescribing information. Following the OECD's prescribing quality indicators (PQIs), we looked at the prevalence, quantities, durations, and inappropriate (long-term or high-quantity) use of benzodiazepines, some of the most widely prescribed, but potentially inappropriate, drugs for the elderly. We also performed multivariate logistic regression analyses to identify factors related to the inappropriate use of these drugs.

RESULTS

The annual prevalence of benzodiazepine prescribing for elderly subjects decreased slightly over time but remained high (37.9% in 2009 and 35.1% in 2013). There were also small decreases in the inappropriate long-term use of benzodiazepines over the five years, with a 0.6 decrease in the Defined Daily Dose and a 4.1 per 1,000 decreases in elderly user-days. The proportion of subjects using long-acting benzodiazepines also fell from 263.6 to 220.4 per 1,000 elderly patients. The regression analyses found that the inappropriate long-term use of benzodiazepines in the elderly was significantly related to the patients visiting several institutions and physicians prescribing more than 30 days' worth of medication.

CONCLUSIONS

The prevalence of prescribing potentially inappropriate drugs, such as benzodiazepines, remains high in Korea. Policy efforts, such as a periodic assessment of prescribing, restricting prescribing days, and more practical guidelines, are needed to improve the quality of prescribing.

Benzodiazepines and risk of all cause mortality in adults: cohort study

Objectives To evaluate the risk of all cause mortality associated with initiating compared with not initiating benzodiazepines in adults, and to address potential treatment barriers and confounding related to the use of a non-active comparator group.Design Retrospective cohort study.Setting Large de-identified US commercial healthcare database (Optum Clinformatics Datamart).Participants 1:1 high dimensional propensity score matched cohort of benzodiazepine initiators, and randomly selected benzodiazepine non-initiators with a medical visit within 14 days of the start of benzodiazepine treatment (n=1 252 988), between July 2004 and December 2013. To address treatment barriers and confounding, patients were required to have filled one or more prescriptions for any medication in the 90 days and 91-180 days before the index date (ie, the date of starting benzodiazepine treatment for initiators and the date of the selected medical visit for benzodiazepine non-initiators) and the high dimensional propensity score was estimated on the basis of more than 300 covariates.Main outcome measure All cause mortality, determined by linkage with the Social Security Administration Death Master File.Results Over a six month follow-up period, 5061 and 4691 deaths occurred among high dimensional propensity score matched benzodiazepine initiators versus non-initiators (9.3 v 9.4 events per 1000 person years; hazard ratio 1.00, 95% confidence interval 0.96 to 1.04). A 4% (95% confidence interval 1% to 8%) to 9% (2% to 7%) increase in mortality risk was observed associated with the start of benzodiazepine treatment for follow-ups of 12 and 48 months and in subgroups of younger patients and patients initiating short acting agents. In secondary analyses comparing 1:1 high dimensional propensity score matched patients initiating benzodiazepines with an active comparator, ie, patients starting treatment with selective serotonin reuptake inhibitor antidepressants, benzodiazepine use was associated with a 9% (95% confidence interval 3% to 16%) increased risk.Conclusions This large population based cohort study suggests either no increase or at most a minor increase in risk of all cause mortality associated with benzodiazepine initiation. If a detrimental effect exists, it is likely to be much smaller than previously stated and to have uncertain clinical relevance. Residual confounding likely explains at least part of the small increase in mortality risk observed in selected analyses.

Long-term use of benzodiazepines in older patients in Germany: a retrospective analysis

BACKGROUND

The purpose of this study was to analyze the prevalence of long-term benzodiazepine use in older adults treated in general and neuropsychiatric practices in Germany.

METHODS

This study included 32,182 patients over the age of 65 years who received benzodiazepine prescriptions for the first time between January 2010 and December 2014 in general and neuropsychiatric practices in Germany. Follow up lasted until July 2016. The main outcome measure was the proportion of patients treated with benzodiazepines for >6 months.

RESULTS

The proportion of patients with benzodiazepine therapy for >6 months increased with age (65-70 years: 12.3%; 71-80 years: 15.5%; 81-90 years: 23.7%; >90 years: 31.6%) but did not differ significantly between men (15.5%) and women (17.1%). The proportion of patients who received benzodiazepines for >6 months was higher among those with sleep disorders (21.1%), depression (20.8%) and dementia (32.1%) than among those with anxiety (15.5%). By contrast, this proportion was lower among people diagnosed with adjustment disorders (7.7%) and back pain (3.8%).

CONCLUSION

Overall, long-term use of benzodiazepines is common in older people, particularly in patients over the age of 80 and in those diagnosed with dementia, sleep disorders, or depression.

A prospective evaluation of the depression–nutrient intake reverse causality hypothesis in a cohort of community-dwelling older Canadians

Studies have investigated the potential protective effects that diet may have on late-life depression incidence. This disorder can, however, affect the person’s food intake, widely known as the reverse causality hypothesis of depression. To test this hypothesis, we compared mean nutrient intakes from three 24-h recalls during the year depression was detected (Geriatric Depression Scale ≥11 or antidepressant medication) with intakes from 1 year earlier among community-dwelling older adults (67–83 years) followed up annually in the 4-year Québec Longitudinal Study on Nutrition and Aging, who were free of depression and cognitive impairment at baseline. Participants (n 158, 64·4 % female) who became depressed and had data available for all follow-up years were matched by age group and sex with non-depressed participants. General linear mixed models were adjusted for percentage changes in physical activity, functional autonomy and stressful life events reported at the time of positive screening. A significant group effect for the dietary intake of all three B-vitamins was observed, as depression cases had consistently lower dietary intakes than controls (P<0·01). Over time, intakes of dietary vitamin B12 declined within depressed participants in bivariate analysis, but there was no time×group effect for any nutrient tested in the multivariate analyses. Intakes of energy, protein, saturated fat and total dietary fibre did not change in cases v. controls. Among community-dwelling older adults, declines in dietary vitamins B6, B12 and folate may precede depression incidence. To help preventative efforts by programmes and practitioners, longitudinal cohorts of longer duration should investigate the extent of the decline in dietary intakes relative to the time of depression.

Patterns, predictors and persistence of chronic sedative use: a population-based observational study of older adults in British Columbia, Canada

BACKGROUND

Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada.

METHODS

This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years.

RESULTS

Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013.

INTERPRETATION

Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.

National Trends in Antidepressant, Benzodiazepine, and Other Sedative-Hypnotic Treatment of Older Adults in Psychiatric and Primary Care

OBJECTIVE

To describe how use of antidepressants, benzodiazepines, and other anxiolytic/sedative-hypnotics among older adults (age ≥ 65 years) has changed over time among visits to primary care providers and psychiatrists.

METHODS

Data were from the National Ambulatory Medical Care Survey (years 2003-2005 and 2010-2012), a nationally representative cross-section of outpatient physician visits. Analysis focused on visits to primary care providers (n = 14,282) and psychiatrists (n = 1,095) at which an antidepressant, benzodiazepine, or other anxiolytic/sedative-hypnotic was prescribed, which were stratified by demographic and clinical characteristic (including ICD-9-CM diagnosis) and compared across study intervals. Odds of medication use were calculated for each stratum, adjusting for demographic and clinical characteristics.

RESULTS

The visit rate by older adults to primary care providers where any of the medications were prescribed rose from 16.4% to 21.8% (adjusted odds ratio [AOR] = 1.43, P < .001) while remaining steady among psychiatrists (75.4% vs 68.5%; AOR = 0.69, P = .11). Primary care visits rose for antidepressants (9.9% to 12.3%; AOR = 1.28, P = .01) and other anxiolytic/sedative-hypnotics (3.4% to 4.7%; AOR = 1.39, P = .01), but the largest growth was among benzodiazepines (5.6% to 8.7%; AOR = 1.62, P < .001). Among patients in primary care, increases primarily occurred among men, non-Hispanic white patients, and those with pain diagnoses as well as those with no mental health or pain diagnoses.

CONCLUSIONS

From 2003 to 2012, use of the most common psychotropic medications among older adults seen in primary care increased, with concentration among patients with no mental health or pain diagnosis. As the population of older adults grows and receives mental health treatment in primary care, it is critical to examine the appropriateness of psychotropic use.