Usage patterns of benzodiazepines in a Dutch community: a 10-year follow-up

Trends in the consumption rates of benzodiazepines and benzodiazepine-related drugs in the health region of Lleida from 2002 to 2015

Background

The high prevalence and long-term use of benzodiazepines (BZDs) treatment are debated topics because of the risk they can cause to the patients. Despite the current information on the risk-benefit balance of these drugs, their consumption remains particularly high. We determined the trend in the consumption prevalence of benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs) in the population of the Health Region of Lleida to explore patterns of use and the associated characteristics associated between 2002 and 2015.

Methods

An analysis of secular trends was carried out between 2002 and 2015; the databased included all individuals from the Health Region of Lleida, which had 358,157 inhabitants in 2015, that consumed BZDs. The consumption of BZDs was evaluated using prescription billing data from the Public Health System. All types of BZDs and BZD analogues that had been approved by the drug agency were included. Trends by age and sex were investigated.

Results

Over the whole study period, a total of 161,125 individuals accounted for 338,148 dispensations. Overall, 59% were women, and the mean age was 56 years. The dispensing prevalence of BZDs use in 2015 was 14.2% overall —18.8% in women and 9.6% in men—and was 36% in those over 65 years. According to the half-life of BZDs, the prevalence of short-intermediate BZD use, intermediate-long BZD use, and Z-drugs use was 9.7, 5.5 and 0.8%, respectively. The evolution of the annual prevalence of BZD dispensing showed a progressive decline, from 15.3% in 2002 to 14.2% in 2015, which was attributed to a decrease in the consumption of intermediate-long half-life BZDs (8.0% vs. 5.5%) and Z-drugs (1.4% vs. 0.8%).

Conclusion

The dispensing prevalence of BZDs and Z-drugs was high, although a small reduction was observed during this time period. The dispensing prevalence was especially high in the population over 65, despite the risk of cognitive decline and falls. Integral actions are required to lower the BZD prescription rate.

Socio-demographic and clinical characteristics of benzodiazepine long-term users: Results from a tertiary care center

OBJECTIVE

The use of benzodiazepines (BDZs) represents a critical issue since a long-term treatment may lead to dependence. This study aimed at evaluating socio-demographic and clinical characteristics of BZD long-term users who followed a detoxification program at a tertiary care center.

METHOD

Two hundred-five inpatients were evaluated. Socio-demographic (e.g., gender, age, education) and clinical information (e.g., BZD used, dose, reason of prescription) was collected. BZDs dose was standardized as diazepam dose equivalents and was compared via the Defined Daily Dose (DDD). Chi-square, Fisher test, ANOVA and Bonferroni analyses were performed.

RESULTS

Females were more frequently BDZ long-term users than males. Hypnotic BZDs were frequently prescribed for problems different from sleep disturbances. Lorazepam, alprazolam, and lormetazepam were the most prescribed drugs. Lorazepam was more frequently used by males, consumed for a long period, in pills, and prescribed for anxiety. Lormetazepam was more frequently consumed by females with a high school education, having a psychiatric disorder, taken in drops and prescribed for insomnia. Lormetazepam had the highest DDD.

CONCLUSION

A specific profile of BZD long-term user seems to exist and presents different socio-demographic and clinical characteristics according to the benzodiazepine taken into account.

Long-term use of benzodiazepines: Definitions, prevalence and usage patterns – a systematic review of register-based studies

Background

Numerous treatment guidelines recommend that long-term use of benzodiazepines (BZD) should be avoided primarily due to development of tolerance and a risk for BZD dependence. Despite this, long-term BZD use remains a controversial subject in clinical patient care with “for and against” debates. However, there is no explicit understanding of what is meant by long-term BZD use in real world. The aim of this study was to assess different definitions, usage patterns, prevalence and other characteristics of long-term BZD use based on published register-based studies. Synthesis of these characteristics is essential to derive a meaningful definition of long-term BZD.

Methods

Systematic review of register-based studies on long-term BZD use published in 1994–2014.

Results

Fourty-one studies met our predetermined inclusion criteria. The length of BZD use defined as “long-term” varied in these studies ranging from one month to several years. The most common definition was six months or longer during a year. The prevalence of long-term BZD use in the general population was estimated to be about 3%. The relative proportion of long-term BZD users (all definitions) in adult BZD users ranged from 6% to 76% (mean 24%; 95% CL 13–36%). The estimates were higher in studies only on the elderly (47%; 95% CL 31–64%). Long-term use involved typically steady treatment with low BZD doses. However, in elderly patients long-term BZD use and exceeding recommended doses was relatively common. Several characteristics associated with long-term use were found.

Conclusions

Long-term BZD use is common and a clinical reality. Uniform definitions for “long-term”, which is in line with population-based evidence, is needed to have more comparable results between studies. Our systematic review suggests that duration of BZD treatment over six months, the most common definition for long-term BZD use in the included studies. As also recommended previously, it is a useful starting point for further analyses on disadvantages but also potential advantages associated with long-term BZD use.

Assessing the cumulative effects of exposure to selected benzodiazepines on the risk of fall-related injuries in the elderly

BACKGROUND

The use of benzodiazepines is associated with increased risk of fall-related injuries in the elderly. However, it is unclear if the risks vary across the products and how they depend on the pattern of use and dosage. Specifically, the possibility of cumulative effects of past benzodiazepine use has not been thoroughly investigated.

METHODS

We used the administrative database for a cohort of 23,765 new users of benzodiazepines, aged 65 years and older, in Quebec, Canada, between 1990 and 1994. The associations between the use of seven benzodiazepines and the risk of fall-related injuries were assessed using several statistical models, including a novel weighted cumulative exposure model. That model assigns to each dose taken in the past a weight that represents the importance of that dose in explaining the current risk of fall.

RESULTS

For flurazepam, the best-fitting model indicated a cumulative effect of doses taken in the last two weeks. Uninterrupted use of flurazepam in the past months was associated with a highly significant increase in the risk of fall-related injuries (HR = 2.83, 95% CI: 1.45-4.34). The cumulative effect of a 30-day exposure to alprazolam was 1.27 (1.13-1.42). For temazepam, the results suggested a potential withdrawal effect.

CONCLUSIONS

Mechanisms affecting the risk of falls differ across benzodiazepines, and may include cumulative effects of use in the previous few weeks. Thus, benzodiazepine-specific analyses that account for individual patterns of use should be preferred over simpler analyses that group different benzodiazepines together and limit exposure to current use or current dose.

Prevalence and correlates of psychotropic medication use among older adults in Israel: cross-sectional and longitudinal findings from two cohorts a decade apart

OBJECTIVES

To assess: (1) changes in use of psychotropic medications across two cohorts, 10 years apart, of community-dwelling elderly and the socio-demographic, physical and mental health correlates of their use; and (2) changes in psychotropic medication use over 3.5 years follow-up.

METHODS

Data were taken from two national surveys of the Israeli Jewish population aged 75–94, which, respectively, sampled two cohorts in 1989 (n=1200) and again in 1999 (n=421). Psychotropic medications were assessed from the list of all medications recorded during a face-to-face interview. The current analysis focused on two medication groups: anxiolytics and sedatives/hypnotics and antidepressants.

RESULTS

Sedatives/hypnotics and anxiolytics use increased from 22.2% in 1989 to 25.4% in 1999 and antidepressants from 3.8% to 4.8% (both nonsignificantly) corresponding to a decline in the health profile of community-dwelling older adults. Similar patterns of associations were observed for socio-demographics, physical, and mental health status indicators with the use of psychotropic medications across the two cohorts. The pooled multivariate analysis showed significantly higher use of sedative/hypnotics and anxiolytics among women and lower use among religious elderly. Additional risk factors were sleeping problems, number of other medications, depressive symptoms, and traumatic life events. Antidepressants use was related to a higher education, ADL disability, and depressive symptoms. Longitudinally, use of psychotropic medications was not significantly different among participants who were followed again after 3.5 years.

CONCLUSIONS

Sedative/hypnotics and anxiolytics use was relatively high while antidepressants use was low even among depressed elderly suggesting that some depressed elderly were treated inappropriately with benzodiazepines.

Reimbursement restriction and moderate decrease in benzodiazepine use in general practice

PURPOSE

To limit misuse and save costs, on January 1, 2009, benzodiazepines were excluded from the Dutch reimbursement list when used as anxiolytic, hypnotic, or sedative. This study aims to assess the impact of this reimbursement restriction on benzodiazepine use in patients with newly diagnosed anxiety or sleeping disorder in general practice.

METHODS

Was conducted a retrospective observational database study deriving data on diagnoses and prescriptions from the electronic health records-based Netherlands Information Network of General Practice (LINH). We looked for patients aged 18 years and older with an incident diagnosis of sleeping disturbance (International Classification of Primary Care code: P06) or anxiety (P74, P01) between January 2008 and December 2009. Incidence of these diagnoses, benzodiazepine use, and initiation of selective serotonin reuptake inhibitor (SSRI) treatment was compared between 2008 and 2009.

RESULTS

In total, we identified 13,596 patients with an incident diagnosis of anxiety (3,769 in 2008 and 3,710 in 2009) or sleeping disorder (3,254 in 2008 and 2,863 in 2009). The proportion of patients being prescribed a benzodiazepine after a diagnosis was lower in 2009 than in 2008 for both anxiety (30.1% vs. 33.7% P < .05) and sleeping disorder (59.1% vs. 67.0%, P < .05), as was the proportion of patients with more than 1 benzodiazepine prescription for both anxiety (36.4% vs. 42.6%, P < .05) and sleeping disorder (35.0% vs. 42.6%, P < .05). We found no increase in the use of alternative treatment for anxiety with SSRIs.

CONCLUSIONS

The reimbursement restriction has led to a moderate decrease in the number of incident diagnoses and initiation of benzodiazepine use in patients with newly diagnosed anxiety or sleeping disorder. This finding indicates that in settings where no such reimbursement opportunities exist, physicians have room to reduce benzodiazepine prescribing.

Gender and use of hypnotics or sedatives in old age: a nationwide register-based study

OBJECTIVE

To investigate whether gender is associated with use of hypnotics or sedatives and with different types of hypnotics or sedatives in older people after adjustment for age, socioeconomic status (i.e., education) and co-morbidity (i.e., number of other drugs).

SETTING

Sweden Method We conducted a register-based analysis of data on gender, age, dispensed drugs, and education from people aged 75-89 years registered in the Swedish Prescribed Drug Register between July and October 2005 (n = 645,429).

MAIN OUTCOME MEASURE

The hypnotic or sedative drug classes were benzodiazepines, benzodiazepine related drugs (i.e., Z-drugs) and other types of hypnotics or sedatives. The individual hypnotics or sedatives were nitrazepam, flunitrazepam, triazolam, zopiclone, zolpidem, clomethiazole and propiomazine.

RESULTS

In the total study population, 27.1% of the women and 18.1% of the men were dispensed at least one hypnotic or sedative drug. The logistic regression analyses of those who used hypnotics or sedatives (n = 151,700) revealed that women were more likely than men to use benzodiazepines (adjusted OR = 1.11; 95% CI 1.07-1.14) and benzodiazepine related drugs (adjusted OR = 1.14; 95% CI 1.12-1.17), whereas men were more likely to use other types of hypnotics or sedatives (adjusted OR = 0.69; 95% CI 0.67-0.71). Among the individual hypnotics or sedatives, the strongest associations with gender was found for nitrazepam (adjusted OR = 1.19; 95% CI 1.14-1.25 for women compared with men), zolpidem (adjusted OR = 1.18; 95% CI 1.16-1.21), clomethiazole (adjusted OR = 0.48; 95% CI 0.46-0.51) and propiomazine (adjusted OR = 0.77; 95% CI 0.75-0.79).

CONCLUSION

Use of hypnotics or sedatives in old age seems to be related to female gender. Also, among elderly users of hypnotics or sedatives, women appear to be more likely to use benzodiazepines and benzodiazepine related drugs than men. The explanation to these gender differences merits further investigation.

Discontinuation of long-term benzodiazepine use: 10-year follow-up

BACKGROUND

Several interventions aiming at discontinuation of long-term benzodiazepine use have been proven effective in the short term. However, data on the persistence of discontinuation are lacking.

OBJECTIVES

To assess 10-year follow-up status in patients who succeeded in stopping benzodiazepine use after a discontinuation letter from the patient's own GP. To identify determinants of successful discontinuation on the long term.

METHODS

Follow-up data of patients who participated in a large prospective, controlled stepped care intervention programme among long-term benzodiazepine users in primary care.

RESULTS

At 10-year follow-up, the percentage of benzodiazepine abstinence was 58.8%. Non-abstinent patients used lower doses of benzodiazepine. Being abstinent at 21 months after the intervention predicted abstinence at 10-year follow-up.

CONCLUSIONS

Ten years after a minimal intervention to decrease long-term benzodiazepine use, the majority of patients who were able to discontinue benzodiazepine use initially, does not use benzodiazepines at 10-year follow-up. Patients who did not succeed in maintaining abstinence from benzodiazepines appear to use lower or average dosages.

Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety (NESDA)

AIM

Results on determinants of benzodiazepine (BZD) use in general and inappropriate use were inconsistent and mostly univariate. The relative importance of sociodemographic, psychological and physical determinants has never been investigated in a comprehensive, multivariate model.

METHODS

We included 429 BZD users and 2423 non-users from the Netherlands Study of Depression and Anxiety (NESDA) in order to investigate sociodemographic, psychological and physical determinants of BZD use and inappropriate use by logistic and linear regression analyses.

RESULTS

BZDs were used by a considerable proportion of the 2852 NESDA participants (15.0%). BZD use was independently associated with older age, singleness, unemployment, treatment in secondary care, higher medical consumption (more severe) anxiety, depression (OR [95% CI]=1.95 [1.29, 2.93]), comorbidity, insomnia, SSRI (OR [95% CI]=2.05 [1.55, 2.70]), TCA and other antidepressant (OR [95% CI]=2.44 [1.64, 3.62]) use. Overall, BZD use was rarely in accordance with all guidelines, mainly because most users (82.5%) exceeded the recommended duration of safe use. Inappropriate use was independently associated with older age (β=0.130) and chronic illnesses (β=0.120). Higher scores on agreeableness were associated with less inappropriate use.

CONCLUSIONS

Mentally or physically vulnerable subjects were most likely to use BZDs. The most vulnerable (i.e. the old and physically ill) BZD users were at highest risk of inappropriate BZD use. Without further evidence of the effectiveness of BZDs in long-term use, caution in initiating BZD prescriptions is recommended, particularly when patients are chronically ill and old, as those are most likely to display inappropriate use.

Effects of legal and illegal use of benzodiazepines at acute admission to a psychiatric acute department

BACKGROUND

In the psychiatric acute and emergency services patients present in severe crisis often complicated by behavioral problems, substance use, and multiple axis 1 diagnoses. In these clinical settings both legal and illegal use of benzodiazepines are difficult to evaluate since benzodiazepines could in some patients be regarded as first line treatment and in other patients as the cause of the acute psychiatric condition. The aims of this study were to evaluate the frequency and clinical effects of both legal and illegal use of benzodiazepines at admittance to a psychiatric acute department.

METHODS

All patients acutely admitted to a Norwegian acute psychiatric university department serving a catchment area were asked about use of benzodiazepines, other medications and substances before admission. Patients were asked to give urine samples for analyses of benzodiazepines and substances.

RESULTS

In 227 consecutive admissions there was legal use of benzodiazepines before admission in 39%, illegal use in 13% and no use in 48%. Patients with legal use of benzodiazepines were older, used more often antidepressants and a higher number of prescribed psychotropic medications. Illegal users of benzodiazepines more often used other illegal substances, were evaluated as clinically affected by a substance at admittance and were diagnosed with a substance use disorder. Patients with psychoses or major affective disorders treated with adequate medication (antidepressants, antipsychotics or mood-stabilizers) before admission more often received benzodiazepines than patients without adequate medication.

CONCLUSIONS

The patients using benzodiazepines at admittance to psychiatric acute departments could be divided in illegal and legal users. The illegal users were young, used illegal substances and were more often regarded clinically affected by substances at admittance. The legal users were older, did not use other substances and were not regarded as clinically affected by substances at admittance. Benzodiazepines were used as adjuvant therapy to specific pharmacological treatment with antidepressants, antipsychotics or mood stabilizers for major psychiatric disorders.

TRIAL REGISTRATION

NCT 00184119/NCT 00184132.

A descriptive study of anxiolytic and hypnotic prescribing according to age and sex

Objective

Benzodiazepines are primarily indicated for the treatment of anxiety states and as hypnotics. Their inappropriate use often relates to duration and manner of use. Few studies have attempted to assess the prevalence of benzodiazepine prescribing in South Africa. The primary aim of the study was to examine the prevalence of sedative/hypnotic prescribing according to patient age and sex in a primary care setting. Setting South African private healthcare patients.

Method

An exposure cohort drug utilisation study was conducted. Prescription data were obtained from a South African private medical aid administrator. Descriptive statistics were used in the data analysis.

Key findings

Prescription records (n = 27 080) of 8084 patients in 2004 who were prescribed one or more benzodiazepines were retrospectively analysed. The average age of patients receiving benzodiazepines was 43.17 years (standard deviation (SD) 14.42 years). Benzodiazepine prescribing was more common in females (55.64% of patients were female). There was an increase in prescriptions per patient with increasing age, peaking at an older age among females. Diazepam (13.36%), zopiclone (13.19%) and oxazepam (12.03%) were the most frequently prescribed active ingredients. The majority of benzodiazepine hypnotics were prescribed in quantities of up to 14 units (tablets or capsules), while the benzodiazepine-related drugs zolpidem and zopiclone were prescribed in quantities of up to 30 units. Anxiolytics were often prescribed in quantities of 20 to 30 units.

Conclusion

Anxiolytics were prescribed in greater quantities than hypnotics. An increase in anxiolytic/hypnotic prescriptions and quantities of tablets/capsules occurred with increasing age. The trends and differences that were detected in the prescribing of benzodiazepines warrant further investigation in larger patient populations, especially with respect to the choice of agent, duration of treatment and patient age.

Prescribing antidepressants and benzodiazepines in the Netherlands: is chronic physical illness involved?

In this study we assessed differences in new and repeat prescriptions of psycho-tropics between patients receiving prescriptions for drugs to treat a common chronic disease and people without such prescriptions. The study used the databases of two Dutch health insurance companies (3 million people). We selected all Dutch men and women aged 45 and older who were registered for six consecutive years (1999-2004). Our analyses both found a consistent relation between psycho-tropics on the one hand and physical illness on the other. People with multi-morbidity were prescribed these drugs most often, especially men and those younger than 65. Epidemiological studies showed a prevalence of depression among people with multi-morbidity to be twice as high as among people without such conditions. According to recent guidelines non-drug treatment may be the first therapy option for patients with non severe depression. If prescribed for a long time, benzodiazepine prescriptions are especially known to be addictive. Our data raise the question to what extent patients with a chronic physical disease suffering from co-occurring mental problems are prescribed psycho-tropics in accord with the guidelines that also advise mental support in case of non severe mental problems. Further research can answer this important question.

Substance use at admission to an acute psychiatric department

Substance use is prevalent in patients with psychiatric disorders and may cause severe symptoms in addition to complicating the diagnosis of psychiatric disorders. The aims of the study were to find the prevalence in use of alcohol, drugs, benzodiazepines, hypnotics, opiates and stimulants, and to find the prevalence of substance use disorders at admission to an acute psychiatric department receiving all admissions from a catchment area. Patients were interviewed about use of medications and intoxicating substances during the last week before admission in 227 consecutive admissions. Urine samples were analysed with the liquid chromatography with mass spectrometry (LC-MS) method. Use of substances was determined from reported use and findings in urine samples. Diagnoses were set at discharge according to ICD-10 research criteria. In 81.9% of the admissions, the patient had used alcohol, drugs, benzodiazepines, hypnotics, opiates or stimulants prior to admission. More men used alcohol, cannabis and stimulants, whereas more women used benzodiazepines. In 31.7% of the admissions, 49.5% of men and 16.4% of women, the patients had a substance use disorder (ICD-10, F10-19). Patients with substance use disorders had a shorter stay in hospital than other patients, and patients with no psychiatric disorder other than substance use disorders had a median length of stay of 2 days. Most patients had used psychoactive substances before admission to the acute psychiatric department, and half of the men had a substance use disorder.

Dispensing of psychotropic drugs to adults in community pharmacies in Latvia

OBJECTIVE

To estimate outpatient utilization of psychotropic drugs before and after pharmaceutical reform in Latvia.

SETTING

Data concerning prescribing and dispensing of psychotropic drugs were collected in six community pharmacies in the region of Latgale of Latvia.

METHOD

An exploratory analysis of prescription data provided by six community pharmacies from 2004 to 2007. Drugs included in the study were classified according to an Anatomical-Therapeutic-Chemical (ATC) drug classification system, and ATC data were used to calculate defined daily doses (DDD) per 1,000 inhabitants. The National SSK-10 classification was used for analysis of codes of disease diagnosis.

MAIN OUTCOME MEASURES

Identification of the most often prescribed psychotropic drug and prescribing physician, patient characterization by age and gender, and analysis of codes of diseases.

RESULTS

Benzodiazepines and benzodiazepine-related drugs were mainly prescribed in outpatient practice. Diazepam was the most frequently prescribed benzodiazepine-12 DDD/1,000/day. The drugs were prescribed mainly by family physicians (in 66% of cases). Female residents bought more psychotropic drugs than males. In addition, residents of cities bought little more drugs than those living outside urban areas. Accordingly to the recorded disease codes, the codes for neurotic and behavioral disorders dominated.

CONCLUSION

The introduction of new norms neither increased nor decreased the number of psychotropic drug prescriptions filled. The most often prescribed psychotropic drugs over 4-year period were benzodiazepines and their derivates. Disease codes on the prescriptions fully justified a reason for psychotropic drug use.

Social-cognitive predictors of intended and actual benzodiazepine cessation among chronic benzodiazepine users

Long-term benzodiazepine use is associated with a variety of negative health consequences. Cessation of long-term use is therefore an important health goal. In a prospective study among chronic benzodiazepine users (N=356) social-cognitive factors of benzodiazepine cessation were examined with a nine-month follow-up. Results showed that outcome expectations, self-efficacy and disengagement beliefs predicted intention, and that intention in turn predicted benzodiazepine cessation. More specifically, benzodiazepine users reported a more positive intention to quit when they perceived more positive consequences and fewer negative consequences of cessation. In addition, a higher self-efficacy to quit and lower disengagement beliefs related to lower higher intention. Intention, in turn was the only significant psychosocial predictor of actual quitting at 9 months. The implications of these results will be discussed in terms of possible intervention strategies.

Prevalence and sociodemographic characteristics associated with benzodiazepines use among community dwelling older adults: the Bambuí Health and Aging Study (BHAS)

OBJECTIVES: To assess the prevalence and sociodemographic characteristics associated with benzodiazepine use among community-dwelling older adults. METHOD: 1606 subjects, aged > 60 years, corresponding to 92% of the residents of Bambuí city, participated in this study. The information about medication use was obtained by means of a standard interview and the review of medication packaging. Substances were classified using the Anatomical Therapeutic Chemical Index. RESULTS: The prevalence of benzodiazepine current use was 21.7% (26.7% among females and 14.0% among males). From these, 68.7% had been taking the medication for over one year, 31.3% for over five years and 53.2% were using long half-life benzodiazepines. The medication most frequently used was bromazepam (35.6%), followed by diazepam (22.5%), clonazepam (12.6%) and lorazepam (7.8%). After adjustment for confounders, female gender (RP = 1.93; CI95% = 1.51-2.46) was the only sociodemographic characteristic found to be independently associated with substance consumption. CONCLUSIONS: The prevalence of benzodiazepine use in the study population was high, but within the variation observed in developed countries. Chronic use of benzodiazepines and long half-life medications predominated.

Benzodiazepine use and mortality of incident dialysis patients in the United States

Benzodiazepines and other omega-receptor agonists are frequently used for sleep and anxiety disorders. We studied the rates, correlates, and safety of individual benzodiazepines and zolpidem use from the records of 3690 patients in a national cohort of Dialysis Morbidity and Mortality Study Wave 2 data. We assessed drug utilization and an association between drug use and all-cause mortality. Overall, 14% of incident dialysis patients used a benzodiazepine or zolpidem. Women, Caucasians, current smokers, and patients with chronic obstructive pulmonary disease were more likely to use these drugs, whereas patients with cerebrovascular disease were less likely to use these drugs. In adjusted analyses, benzodiazepine or zolpidem use was associated with a 15% higher mortality rate. Chronic obstructive pulmonary disease significantly modified this association, suggesting that these patients were at higher risk. No association was found between benzodiazepine use and greater risk for hip fracture. We conclude that benzodiazepine or zolpidem use is common in incident dialysis patients and may be associated with greater mortality. Further studies are needed to elucidate the safety of these drugs in the dialysis population, which may lead to cautious and restrictive utilization of omega-receptor agonists in dialysis patients.

Benzodiazepine use in the real world of psychiatric practice: low-dose, long-term drug taking and low rates of treatment discontinuation

OBJECTIVE

The present study was designed to (1) estimate the frequency of benzodiazepine use in psychiatric practice, (2) investigate factors associated with use, (3) establish whether a relationship exists between benzodiazepine dose and length of use, and (4) investigate factors associated with time to discontinuation.

METHODS

This study was conducted in South Verona, Italy. All individuals who were exposed to benzodiazepines during 2005 were extracted from the local Psychiatric Case Register, and the longitudinal history of benzodiazepine exposure was retrospectively described.

RESULTS

In 2005, a total of 1,771 individuals were in contact with at least one of the psychiatric facilities of the South Verona catchment area. Of these, 535 were benzodiazepine users, yielding a frequency of use of 30.2% [95% confidence intervals (CI) 28.0, 32.4]. In multivariate logistic regression analysis, lower level of education, diagnosis of affective illness, longer length of illness and higher service use were significantly associated with benzodiazepine exposure. An increase in dosages over time to maintain the drug's effectiveness was not evident from the analysis of the relationship between daily dose and length of therapy. A total of 17.3% (93/535) of patients exposed to benzodiazepines discontinued treatment. Cox regression analysis revealed that age and length of illness were negatively associated with the probability of discontinuing therapy, while the concomitant use of antipsychotics and mood stabilisers was positively associated with discontinuing therapy.

CONCLUSION

The finding that in the great majority of psychiatric patients, low doses of benzodiazepines are routinely prescribed on a long-term basis suggests that, in this specific setting of care, treatment recommendations stating that use should be short term may not be applicable.

Use of anxiolytic or hypnotic drugs and total mortality in a general middle-aged population

PURPOSE

The aim of the study was to evaluate the effect of the consumption of anxiolytic or hypnotic drugs on total mortality in a general population.

METHODS

We followed a cohort of 7225 men and 7726 women aged 40-42 years who underwent health surveys in 1985-1989 in two Norwegian counties, with respect to deaths. Mean follow-up period was 18 years. The subjects were categorised according to frequency of anxiolytic or hypnotic drug use during the last month: daily, every week, less than every week and not used during the last month.

RESULTS

The proportion of anxiolytic or hypnotic drug users was 6.6% among men and 16.2% among women. Altogether 402 men and 290 women died. There was an increase in risk of death with an increase in frequency of use. Crude hazard ratios for men and women daily using anxiolytics or hypnotics were 3.1 (95%CI 2.0, 4.8) and 2.7 (1.9, 4.0), respectively, as compared with non-users last month. After adjusting painkiller use and smoking the hazard ratios were lowered, being 2.4 (1.5-4.0) (men) and 2.1 (1.4-3.2) (women). After additional adjustments for other possible confounders the hazard ratios were further attenuated to 1.5 (0.9-2.7) for men and 1.7 (1.1-2.6) for women.

CONCLUSIONS

Daily users of anxiolytic or hypnotic drugs in our study showed higher crude mortality than non-users. However, after adjusting lifestyle and socio-economic variables the difference was markedly reduced suggesting that the remaining excess mortality is due to residual confounding.

Benzodiazepine prescribing behaviour and attitudes: a survey among general practitioners practicing in northern Thailand

BACKGROUND

Over-prescribing of benzodiazepines appears common in many countries, a better understanding of prescribing practices and attitudes may help develop strategies to reduce prescribing. This study aimed to evaluate benzodiazepine prescribing behaviour and attitudes in general practitioners practising in Chiang Mai and Lampoon, Thailand.

METHODS

Questionnaire survey of general practitioners in community hospitals, to estimate: i) use of benzodiazepines for anxiety/insomnia, panic disorder, depression, essential hypertension, and uncomplicated low back pain and ii) views on the optimal duration of benzodiazepine use.

RESULTS

Fifty-five of 100 general practitioners returned the completed questionnaires. They reported use of benzodiazepines for anxiety/insomnia (n = 51, 93%), panic disorder (n = 43, 78%), depression (n = 26, 43%), essential hypertension (n = 15, 27 %) and uncomplicated low back pain (n = 10, 18%). Twenty-eight general practitioners would prescribe benzodiazepines for non-psychiatric conditions, 17 for use as muscle relaxants. Seventy-five per cent, 62% and 29% of the general practitioners agreed or totally agreed with the use of benzodiazepines for insomnia, anxiety and depression, respectively. Practitioners agreed that prescribing should be less than one week (80%); or from 1 week to 1 month (47%); or 1 to 4 months (16%); or 4 to 6 months (5%) or more than 6 months (2%). Twenty-five general practitioners (45%) accepted that they used benzodiazepines excessively in the past year.

CONCLUSION

A considerable proportion of general practitioners in Chiang Mai and Lampoon, Thailand inappropriately use benzodiazepines for physical illnesses, especially essential hypertension and uncomplicated low back pain. However, almost half of them thought that they overused benzodiazepines. General practitioner's lack of time, knowledge and skills should be taken into account in improving prescribing behaviour and attitudes.

The impact of hospitalisation on the initiation and long-term use of benzodiazepines

BACKGROUND

Inappropriate (long-term) use of benzodiazepines (BZDs) is a reason for concern. Several studies have suggested that hospitalisation may be a determinant for initiation of BZD use as well as for long-term use. However, the available evidence is conflicting.

OBJECTIVE

To determine whether hospitalisation induces initiation of BZD use and subsequent long-term use.

METHODS

A retrospective follow-up study was conducted. Randomly, 10,000 patients who had been hospitalised were selected (index date). Non-hospitalised patients, matched on age and gender, were sampled from the same living region and assigned the same index date as the corresponding hospitalised patient. Patients were included if adequate medication data were available from 18 months before to 18 months after the index date. Initiation of BZD use was defined as a prescription for a BZD or BZD-related hypnotic without a prescription for any of these drugs during the prior 6 months. Long-term use was defined as a period of consecutive use for at least 6 months following initiation.

RESULTS

In this study, 8,681 hospitalised patients and an equal number of non-hospitalised patients were finally included. Overall, the relative risk for initiation of BZD use was almost twice as high [IDR 1.97 (95%CI 1.84-2.10)] among hospitalised patients as in non-hospitalised patients. This relative risk was most clearly elevated during the time window from 3 months before to 3 months after hospitalisation [IDR 4.81 (95%CI 4.08-5.67)]. The relative risk for long-term use during the entire 36-month observation period was not higher [IDR 1.04 (95%CI 0.95-1.13)] among hospitalised patients than among non-hospitalised patients. Within the time window of 3 months before and after hospitalisation, the relative risk for long-term use was significantly lower for the hospitalised group [RR 0.82 (CI 0.69-0.98)].

CONCLUSION

Our results confirm that hospitalisation is associated with an increased risk for initiation of BZD use; the risk is highest during the 3 months just before and after hospitalisation. However, hospitalisation appeared not to be a determinant for long-term use of BZDs.

The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).

Initial 3-month usage characteristics predict long-term use of benzodiazepines: an 8-year follow-up

OBJECTIVE

The aim of the study was to identify initial usage predictors for prolonged benzodiazepine use.

METHODS

An 8-year pharmacy data-based study (1983-1992) was carried out on a retrospective cohort of 425 initial benzodiazepine users. The setting was the only pharmacy in a community of 13,500 people.

RESULTS

Among the 425 initial users, 36% had a single initial exposure year, 50% had two to seven exposure years, and 14% had benzodiazepine use during all 8 years of follow-up. Prolonged use over more years was associated with an initial high number of prescriptions, elderly patients and initial use of hypnotics. Two patterns of irregular prolonged use were investigated: increase in use was associated with a shorter length of the first usage period and switching to another benodiazepine during the first 90 days; relapses of use were associated with a shorter length of first usage period and initial use of an anxiolytic. Gender and initial dosage were not associated with prolonged use at all.

CONCLUSION

During the first 90 days after initiation of benzodiazepine use, a number of determinants of prolonged benzodiazepine use were visible. The prescribers of these drugs and the pharmacists should advise rational use not only at the start but also at the moment of the first repeat prescription in order to prevent needless prolonged use and dependence.

Comparing patterns of long-term benzodiazepine use between a Dutch and a Swedish community

BACKGROUND

There is much concern about the widespread long-term use of benzodiazepines. Utilisation data can give a foundation for interventions for appropriate use.

OBJECTIVE

To compare long-term usage patterns of benzodiazepines in a Dutch and a Swedish community in different periods.

METHODS

Eight-year follow-up patterns of use were investigated with respect to the characteristics of those who continued use over the whole follow-up period. In the Dutch community of 13,500, the data of a cohort of 1358 benzodiazepine users were analysed during the years 1984-1991; in the Swedish community of 20,000 people, a cohort of 2038 benzodiazepine users was followed from 1976.

RESULTS

At the end of the follow-up period, 32.9% of the Dutch cohort and 33% of the Swedish cohort had continued use of benzodiazepines. The two overall survival curves showed similar patterns. Stratification for age, gender, previous versus initial use and heavy versus non-heavy use showed comparable proportions of patients continuing benzodiazepine use over time.

CONCLUSION

The parallels in the results of two cohorts in different countries and different periods are striking and give support to the idea to stimulate interventions to reduce long-term benzodiazepine use.

Do Spanish patients drink alcohol while undergoing treatment with benzodiazepines?

In this study, we analyzed patterns of combined benzodiazepines and alcohol use among the Spanish general population over the age of 16 years. The study was based on information from the 1997 Spanish National Household Health Survey. A total of 6,396 persons over 16 years of age, a representative sample of noninstitutionalized Spaniards, were surveyed. One percent of the population are consumers of benzodiazepines and daily drinkers of alcohol; fundamentally, these consumers are men, of whom 15.4% drink alcohol at a high level (>50 units/week). Findings show the frequency of concurrent use of benzodiazepines and alcohol by the Spanish population.

Progressive trends in the prevalence of benzodiazepine prescribing in older people in Ontario, Canada

OBJECTIVES

The extensive use of benzodiazepines has been a concern of healthcare providers and policy makers in Canada and around the world. The purpose of this study was to examine temporal trends in benzodiazepine prescriptions dispensed in older people from 1993-1998.

DESIGN

Retrospective population-based cross-sectional study using administrative databases.

SETTING

Ontario, Canada.

PARTICIPANTS

The over 1 million residents of Ontario age 65 and older covered by the provincial universal drug benefit program.

MEASUREMENTS

The main outcome measures were the prevalence, overall and with respect to age and gender, of benzodiazepine prescriptions dispensed and the ratio of the number of people to whom short- versus long-acting benzodiazepine prescriptions were dispensed in each study year. The annual rates of switching to other psychotropic agents were examined for those patients that discontinued filling benzodiazepine prescriptions.

RESULTS

The annual prevalence of benzodiazepine prescriptions dispensed decreased consistently over time (25.1% in 1993 to 22.5% in 1998; P < .001). Benzodiazepine dispensing prevalence increased with increasing age (approximately 20% of those age 65 to 69 to approximately 30% of those age > or =85; P < .001) and more females than males received the medication (relative risk = 1.50, 95% confidence interval = 1.49-1.51). The ratio of short- to long-acting benzodiazepine prescriptions filled increased over time (3.6 in 1993 to 5.8 in 1998; P < .001), in line with guideline recommendations. Rates of switching to antidepressants increased over time (8.5% in 1993 to 10.2% in 1998; P < .001), whereas switching to barbiturates was consistently low (0.12%; P = .403).

CONCLUSION

The prevalence of benzodiazepine therapy for older people in Ontario has steadily declined between 1993 and 1998. There is a trend of dispensing relatively more short-acting than long-acting benzodiazepines and of replacing benzodiazepines with antidepressants in older people without a remarkable increase in barbiturate consumption. These findings suggest that, without undue regulation, physicians are making progress in the prescribing of benzodiazepine therapy on the basis of current knowledge available.

Psychotropic drug use in Italy, 1984-99: the impact of a change in reimbursement status

After years of corruption surrounding drug reimbursement, in 1994, a change in drug reimbursement status was implemented in Italy according to cost-effectiveness criteria. The aim of this study was to assess the impact of these changes on the use of psychotropic drugs. National trends in antipsychotic, antidepressant and benzodiazepine prescriptions were analysed from 1984 to 1999. During the study period, prescriptions of antipsychotic drugs were stable from 1984 to 1994 but, in the subsequent 5 years, increased by 54%. Although the use of atypical compounds in 1999 accounted for only 6% of total antipsychotics sold, the cost of these new drugs accounted for almost one-half the total antipsychotic expenditure. The use of benzodiazepines increased by 53%. In 1999, the psychotropic drugs lorazepam and alprazolam were the most sold by value. From 1984 to 1999, the total antidepressants sold increased by 55%. Although the use of selective serotonin reuptake inhibitors and newer antidepressants in 1999 accounted for less than 50% of total antidepressants sold, the cost of these drugs accounted for 65% of total antidepressant expenditure. This analysis highlights specific areas of concern which should become the object of public health programs.

Sedative, hypnotic, and antianxiety medication use in an aging cohort over ten years: a racial comparison

OBJECTIVES

Prescriptions of sedatives, hypnotics, and antianxiety medications have decreased over the past 15 years. However, racial differences have not been well investigated in controlled analyses.

DESIGN

A prospective cohort study.

SETTINGS AND PARTICIPANTS

The authors analyzed data from a community-based, biracial cohort of older adults (n = 4,000 at baseline) followed for 10 years to determine sociodemographic and health characteristics associated with the use of these medications between 1986 and 1996.

MAIN OUTCOME MEASURES

Information about sedative, hypnotic, and antianxiety medication use and demographic and health characteristics was obtained from a race-stratified, probability-based sample of black and white community-dwelling older adults in the Piedmont region of North Carolina during four in-person interviews spanning 10 years. Descriptive statistics were calculated. Logistic regression was used for the final models.

RESULTS

A total of 13.3% of the subjects were taking these medications in 1986, with the frequency of use declining only to 11.8% in 1996 despite the cohort aging 10 years. Correlates of use at baseline were female gender, white race, depressive symptoms, poor self-rated health, impaired physical function, and health services use. These correlates persisted for each of the three follow-up waves of the survey. In 1996, the odds for being white and using these medications was 4.70 in controlled analyses.

CONCLUSIONS

Despite the overall decline in the use of sedative, hypnotics, and antianxiety agents in the general population in recent years, over the 10 years of this survey, an aging cohort continued to use these medications at a frequency greater than the general population and did not demonstrate a significant decline in use. Factors unrelated to health status, specifically being white, were among the strongest correlates of use throughout the years of follow-up.

Benzodiazepine pathways in the chronically ill

The association between patterns of use of benzodiazepines and chronic somatic morbidity was examined by applying the Chronic Disease Score (CDS). In the only pharmacy in a Dutch community, 6921 patients with data available covering a 10-year period (1983-1992) were included. In 1992, two-thirds of the patients had a CDS of 0, indicating no chronic morbidity. Patients with chronic morbidity showed a twofold risk of a history of benzodiazepine use. Within the group of benzodiazepine users, longer exposure to benzodiazepines as well as a history of different benzodiazepines were associated with a higher risk of chronic morbidity. Duration of episodes of use and daily dose were not found to be significantly associated with chronic disease. A pattern of increased benzodiazepine use showed a higher risk of chronic morbidity compared with benzodiazepine users with a stable use. Moreover, a history of benzodiazepine use was found to predict a sharp increase in chronic morbidity. We found a clear association between previous and actual use of benzodiazepines and chronic somatic disease. Benzodiazepine use may be induced by sleeping difficulties and anxiety problems caused by the chronic disease.

Neighbourhood characteristics and use of benzodiazepines in The Netherlands

This paper analyses the relationship between individual and neighbourhood characteristics and the use of benzodiazepines within a Dutch city. It is hypothesized that the proportion of users is lower in more socially integrated and less deprived neighbourhoods. Hypotheses have been tested by using multi-level analysis to distinguish between composition and context effects. Age and gender have a clear relation to the use of benzodiazepines and neighbourhood differences in the proportion of users are partly the effect of population composition by age and gender. The proportion of users is higher in neighbourhoods with a higher percentage of one-parent families, with a lower percentage of social rented housing and with a larger number of rooms per person. The strength of the relation between age and use is influenced by neighbourhood characteristics. Neighbourhood variation in the amount used only depends on population composition.