Zolpidem use and motor vehicle collisions in older drivers

Making a 'sex-difference fact': Ambien dosing at the interface of policy, regulation, women's health, and biology

The U.S. Food and Drug Administration's (FDA) 2013 decision to lower recommended Ambien dosing for women has been widely cited as a hallmark example of the importance of sex differences in biomedicine. Using regulatory documents, scientific publications, and media coverage, this article analyzes the making of this highly influential and mobile 'sex-difference fact'. As we show, the FDA's decision was a contingent outcome of the drug approval process. Attending to how a contested sex-difference fact came to anchor elite women's health advocacy, this article excavates the role of regulatory processes, advocacy groups, and the media in producing perceptions of scientific agreement while foreclosing ongoing debate, ultimately enabling the stabilization of a binary, biological sex-difference fact and the distancing of this fact from its conditions of construction.

Co-prescribing of opioids and benzodiazepines/Z-drugs associated with all-cause mortality—A population-based longitudinal study in primary care with weak opioids most commonly prescribed

Introduction: The risk of mortality associated with the co-prescribing of benzodiazepines and opioids has been explored in a number of papers mainly focusing on strong opioids. The mortality risk associated with the use of weak opioids has not been dealt with to a similar extent.

Objective: To assess the mortality risk in primary care patients with consistent 3-year co-prescribing of benzodiazepine/Z-drugs (benzodiazepine receptor modulators) and mainly weak opioids (codeine, tramadol).

Methods: Of 221,804 patients contacting the primary healthcare centres, 124,436 were selected for further analysis, 88,832 participants fulfilled the inclusion criteria, aged 10–69 years and were divided into four groups with neither any use of benzodiazepines/Z-drugs nor opioids as Group 1, 3 years’ use of opioids and no/minimal benzodiazepines/Z-drugs as Group 2, with benzodiazepines/Z-drugs and no/minimal opioids as Group 3, and finally both benzodiazepines/Z-drugs and opioids as Group 4. Hazard ratios were calculated with the no-drug group as a reference, using Cox proportional hazards regression model adjusted for age, sex, number of chronic conditions and cancer patients excluded (n = 87,314).

Results: Hazard ratios for mortality increased both in Group 3 where it was 2.66 (95% CI 2.25–3.09) and in Group 4 where it was 5.12 (95% CI 4.25–6.17), with increased dose and higher number of chronic conditions. In Group 4 an opioid dose-dependent increase in mortality among persons using >1000 DDDs benzodiazepines/Z-drugs was observed when those on less than ≤300 DDDs of opioids with HR 4.94 (95% CI 3.54–6.88) were compared to those on >300 DDDs with HR 7.61/95% CI 6.08–9.55). This increase in mortality was not observed among patients on <1000 DDDs of benzodiazepines/Z-drugs.

Conclusion: The study supports evidence suggesting that mortality increases in a dose-dependent manner in patients co-prescribed benzodiazepines/Z-drugs and weak opioids (codeine, tramadol). An association between the number of chronic conditions and a rise in mortality was found. Long-term use of these drugs should preferably be avoided. Non-pharmacological therapy should be seriously considered instead of long-term use of benzodiazepines/Z-drugs, and deprescribing implemented for chronic users of these drugs when possible.

Medication use and driving patterns in older drivers: preliminary findings from the LongROAD study

Background

The potential for impaired driving due to medication use can occur at any age, though older adults are more likely to take multiple prescribed medications and experience side effects that may affect driving ability. The purpose of this study was to characterize the relationship between medications and driving safety behaviors.

Methods

Data for this study came from the five-site Longitudinal Research on Aging Drivers (LongROAD) project. Participants were active drivers, age 65–79 years at enrollment, and patients at one of the 5 participating sites. Medication names and doses were obtained at baseline based on the “brown-bag review” method. Medications were coded using the American Hospital Formulary Service system. Driving data were collected by a GPS accelerometer installed in the study participants’ main vehicles.

Results

Medication data were available for 2949 (98.6%) of the 2990 participants, and 2898 (96.9% of all participants) had both medication data and at least 30 recorded days of driving. The median number of medications taken per study participant was seven, with a range of 0–51. Total number of medications was significantly associated with a higher rapid deceleration rate. Certain medication classes were significantly associated with other driving outcomes, including central nervous system agents (more speeding events), hormones and gastrointestinal medications (more rapid decelerations), electrolytes (fewer rapid decelerations), and antihistamines (greater right to left turn ratio).

Conclusions

Older adult drivers are taking large quantities of prescription and non-prescription medications that may affect their driving safety. Certain medication classes are associated with potentially adverse driving patterns, such as speeding and rapid decelerations, while others are associated with potentially protective maneuvers, such as right hand turning. Further research is warranted to identify and mitigate potential adverse effects of such medications on driving safety in older adults.

Chronic oral administration of Passiflora incarnata extract has no abnormal effects on metabolic and behavioral parameters in mice, except to induce sleep

Although the number of prescriptions and dependence on sleeping pills are increasing, the associations with unexpected abnormal behaviors and metabolic diseases caused by the overuse of sleeping pills are not well understood. In particular, such as abnormal eating-behavior and the occurrence of metabolic disorders caused by psychological unstable states are reported. For this reason, herbal medicine, which has not had such side effects in recent years, is attracting attention as an alternative medicine/food for sleeping inducer. We have used ethanol extracts from Passiflora incarnata (PI) to steadily obtain positive effects on sleep and brain microenvironment. However, as mentioned earlier, sleep-inducing efficacy can only be used safely if the behavioral and metabolic abnormalities do not appear.

Thus, in this study, we used Phenomaster equipment to continuously monitor the movement, feeding, water consumption, gas changes, etc. in C57BL/6 mice at a dose of 500 mg/kg/day for 5 consecutive days with PI extract group compared with the control group. Before sacrifice, differences in body composition of mice were also compared. Monitoring of 24 h/5 days through the equipment showed no change in PI-treated group in anything except for significant decrease in blood melatonin levels and activity after PI administration. Taken together, the statistically insignificance of any behavioral and metabolic phenomenon produced by repeated treatment of PI are not only expected to have an accurate sleep effect, but are also free of side effects of the prescribed sleeping pills. This study has given us greater confidence in the safety of the PI extracts we use for sleep-inducer.

GABA Receptors and the Pharmacology of Sleep

Current GABAergic sleep-promoting medications were developed pragmatically, without making use of the immense diversity of GABA_A receptors. Pharmacogenetic experiments are leading to an understanding of the circuit mechanisms in the hypothalamus by which zolpidem and similar compounds induce sleep at α2βγ2-type GABA_A receptors. Drugs acting at more selective receptor types, for example, at receptors containing the α2 and/or α3 subunits expressed in hypothalamic and brain stem areas, could in principle be useful as hypnotics/anxiolytics. A highly promising sleep-promoting drug, gaboxadol, which activates αβδ-type receptors failed in clinical trials. Thus, for the time being, drugs such as zolpidem, which work as positive allosteric modulators at GABA_A receptors, continue to be some of the most effective compounds to treat primary insomnia.

Reducing hypnotic use in insomnia management among Australian veterans: results from repeated national interventions

BACKGROUND

The Australian Government Department of Veterans' Affairs (DVA) Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) programme conducted two intervention (March 2009, follow-up intervention June 2012) both of which aimed to reduce hypnotic use among Australian veterans. We evaluated the effectiveness of the interventions, and estimated the associated health consequences.

METHODS

Both interventions targeted veterans who had been dispensed hypnotics prior to the intervention. Patient-specific prescriber feedback containing patient details and the volume of hypnotics dispensed, along with tailored educational information, was mailed to general practitioners. Veterans, pharmacists and directors of care in residential aged care facilities were mailed tailored educational information. Interrupted time-series and segmented regression modelling were used to determine the effect of the two interventions on the rate of hypnotics dispensing. The cumulative patient-months of hypnotic treatment avoided as a result of the interventions was calculated. We estimated improvements in health consequences of as a result of hypnotic treatment avoided based on the results of cohort studies in the same population identifying the association between hypnotic and sedative use on the outcomes of falls, and confusion.

RESULTS

After the first Veterans' MATES intervention in March 2009, hypnotic use declined by 0.2% each month, when compared to the baseline level (p = 0.006). The intervention effect was attenuated after one year, and use of hypnotics was found to increase by 0.2% per month after March 2010. Following the second intervention in June 2012, there was a further significant decline in use of 0.18% each month over the 12 months of follow up (p = 0.049). The cumulative effect of both interventions resulted in 20,850 fewer patient-months of treatment with hypnotics. This cumulative reduction in hypnotic use was estimated to lead to a minimum of 1 fewer hospital admissions for acute confusion and 7 fewer hospital admissions due to falls.

CONCLUSIONS

The Veterans' MATES insomnia interventions which involved multiple stakeholders were effective in reducing hypnotic use among older Australians. Repetition of key messages led to sustained practice change.

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

Prescription of Zolpidem and the Risk of Fatal Motor Vehicle Collisions: A Population-Based, Case-Crossover Study from South Korea

BACKGROUND

Zolpidem is one of the most frequently used hypnotics worldwide, but associations with serious adverse effects such as motor vehicle collisions have been reported.

OBJECTIVE

The objective of this study was to evaluate the association of fatal motor vehicle collisions with a prescription for zolpidem, considering the context of the motor vehicle collisions.

METHODS

We conducted a case-crossover study, where each case served as its own control, by linking data about fatal motor vehicle collisions from the Korean Road Traffic Authority between 2010 and 2014 with national health insurance data. The case period was defined as 1 day before the fatal motor vehicle collisions, and was matched to four control periods at 90-day intervals. Conditional logistic regression was performed to calculate the odds ratio for fatal motor vehicle collisions associated with zolpidem exposure, and odds ratios were adjusted for time-varying exposure to confounding medications. A stratified analysis was performed by age group (younger than 65 years or not), the Charlson Comorbidity Index, and whether patients were new zolpidem users.

RESULTS

Among the 714 subjects, the adjusted odds ratio for a fatal motor vehicle collision associated with a prescription for zolpidem the previous day was 1.48 (95% confidence interval 1.06-2.07). After stratification, a significantly increased risk was observed in subjects with a high Charlson Comorbidity Index (odds ratio 1.81; 95% confidence interval 1.16-2.84), the younger age group (odds ratio: 1.62; 95% confidence interval 1.03-2.56), and new zolpidem users (odds ratio 2.37; 95% confidence interval 1.40-4.00).

CONCLUSION

A prescription for zolpidem on the previous day was significantly related to an increased risk of fatal motor vehicle collisions in this population-based case-crossover study.

New, Occasional, and Frequent Use of Zolpidem or Zopiclone (Alone and in Combination) and the Risk of Injurious Road Traffic Crashes in Older Adult Drivers: A Population-Based Case-Control and Case-Crossover Study

BACKGROUND

Previous studies on the effect of zolpidem or zopiclone use on the risk of road traffic crashes (RTCs) have shown mixed results.

OBJECTIVE

Our objective was to determine the association between zolpidem or zopiclone use (as separate drugs or combined) and the occurrence of injurious RTCs among older adult drivers.

METHODS

This was a population-based matched case-control and case-crossover study based on secondary data linked together from Swedish national registers. Cases were drivers aged 50-80 years involved in a vehicle crash resulting in injuries between January 2006 and December 2009 for the case-control study (n = 27,096) and from February 2006 to December 2009 for the case-crossover study (n = 26,586). For the first design, four controls were matched to each case by sex, age, and residential area, and exposure was categorized into new, occasional, and frequent use of zolpidem only, zopiclone only, and combined zolpidem and zopiclone. For the case-crossover study, newly dispensed zolpidem or zopiclone users were assessed during the 28 days prior to the crash and compared with an equally long control period using a 12-week washout period. Matched adjusted odds ratios (OR) were computed using conditional logistic regression.

RESULTS

Increased ORs for all users were observed. In the case-control study, the highest odds were seen among newly initiated zolpidem-only users involved in single-vehicle crashes (adjusted OR 2.27; 95% confidence interval [CI] 1.21-4.24), followed by frequent combined zolpidem and zopiclone users [adjusted OR 2.20; CI 1.21-4.00]. In the case-crossover, newly initiated treatment with zolpidem or zopiclone showed an increased risk that was highest in the 2 weeks after the start of the treatment (OR 2.66; 95% CI 1.04-6.81).

CONCLUSIONS

These results provide more compelling evidence for the role of zolpidem or zopiclone in the occurrence of RTCs among older adults, not only in frequent users, but also at the beginning of treatment.

Patterns of Psychiatric Outpatient Practice in Taiwan: A Nationwide Survey

(1) Background: Limited studies have utilized nationwide data to assess the patterns of psychiatric practice in other countries. In this study, data from the National Health Insurance Research Database in Taiwan (NHIRD-TW) for 2012 was analyzed to determine the patterns of psychiatric outpatient practice in Taiwan; (2) Methods: To determine the patterns of psychiatric outpatient practice in Taiwan, the data were drawn from the datasets of Taiwan's National Health Insurance Research Database for 2012, with 619,760 records of outpatient visits representing 1/500 of all the claims in Taiwan for that year. The analysis of psychiatric outpatient visits included patient demographics, diagnoses, and prescribed medications; (3) Results: Neurotic disorders were the most prevalent diagnoses (43.1%, n = 5714). Hypnotics-sedatives and anxiolytics were prescribed in 51.7% (n = 6850) and 39.1% (n = 5181) of psychiatric visits, respectively, with zolpidem being the most commonly prescribed drug (22.6%, n = 2998); and (4) Conclusion: Hypnotics and sedatives were widely prescribed for the outpatient population, and zolpidem had the highest annual prevalence of use. These findings deserve the attention of clinicians and policy makers for monitoring the abuse and dependence of these agents and subsequent adverse events.