Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach

Optimizing the Time and Dose of Melatonin as a Sleep-Promoting Drug: A Systematic Review of Randomized Controlled Trials and Dose-Response Meta-Analysis

Previous studies have reported inconsistent results about exogenous melatonin's sleep-promoting effects. A possible explanation relies on the heterogeneity in administration schedule and dose, which might be accountable for differences in treatment efficacy. In this paper, we undertook a systematic review and meta-analysis of double-blind, randomized controlled trials performed on patients with insomnia and healthy volunteers, evaluating the effect of melatonin administration on sleep-related parameters. The standardized mean difference between treatment and placebo groups in terms of sleep onset latency and total sleep time were used as outcomes. Dose-response and meta-regression models were estimated to explore how time of administration, dose, and other treatment-related parameters might affect exogenous melatonin's efficacy. We included 26 randomized controlled trials published between 1987 and 2020, for a total of 1689 observations. Dose-response meta-analysis showed that melatonin gradually reduces sleep onset latency and increases total sleep time, peaking at 4 mg/day. Meta-regression models showed that insomnia status (β = 0.50, p < 0.001) and time between treatment administration and the sleep episode (β = -0.16, p = 0.023) were significant predictors of sleep onset latency, while the time of day (β = -0.086, p < 0.01) was the only significant predictor of total sleep time. Our results suggest that advancing the timing of administration (3 h before the desired bedtime) and increasing the administered dose (4 mg/day), as compared to the exogenous melatonin schedule most used in clinical practice (2 mg 30 min before the desired bedtime), might optimize the efficacy of exogenous melatonin in promoting sleep.

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

Background

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

Methods

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

Results

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

Conclusion

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

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review

BACKGROUND

The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use).

METHODS

We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted.

RESULTS

From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy.

CONCLUSION

Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

An Analysis of Benzodiazepine Prescribing to Primary Care Patients in a Large Healthcare System from 2019-2020

We sought to quantify benzodiazepine prescribing by primary care providers from 2019 to 2020 and identify correlates of prescribing. We hypothesized prescribing would increase post-COVID-19 lockdown. We conducted a retrospective cohort study of adult patients with primary care visits in 2019 or 2020 in a large Ohio healthcare system. Demographics, diagnosis codes, and receipt of benzodiazepine prescriptions were collected. Using multivariable logistic regression, we examined factors associated with benzodiazepine prescription receipt during the whole study period and post-lockdown. 455,537 adult patients had 1,643,473 visits. Benzodiazepines were prescribed in 3.2% (53,049/1,643,473) of visits. Effect sizes for positive associations with benzodiazepine prescription were largest for anxiety disorders. For negative associations, they were largest for Black patients and patients with cocaine use disorder. Benzodiazepine prescribing was positively associated with multiple groups having contraindications, though effect sizes were small. Contrary to our hypothesis, odds of receiving a prescription were 8.8% lower post-lockdown. Benzodiazepine prescribing rates in our system compared favorably to national rates. Year over year odds of receiving a prescription were slightly lower post-lockdown. Racial disparities were present and deserve further study. Strategies to reduce benzodiazepine prescribing to patients with anxiety may yield the largest reductions for benzodiazepine prescribing in primary care settings.

Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper

Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.

TANGO: Development of Consumer Information Leaflets to Support TAperiNG of Opioids in Older Adults with Low Back Pain and Hip and Knee Osteoarthritis

INTRODUCTION

Globally, the rate of opioid prescription is high for chronic musculoskeletal conditions despite guidelines recommending against their use as their adverse effects outweigh their modest benefit. Deprescribing opioids is a complex process that can be hindered by multiple prescriber- and patient-related barriers. These include fear of the process of, or outcomes from, weaning medications, or a lack of ongoing support. Thus, involving patients, their carers, and healthcare professionals (HCPs) in the development of consumer materials that can educate and provide support for patients and HCPs over the deprescribing process is critical to ensure that the resources have high readability, usability, and acceptability to the population of interest.

OBJECTIVE

This study aimed to (1) develop two educational consumer leaflets to support opioid tapering in older people with low back pain (LBP) and hip or knee osteoarthritis (HoKOA), and (2) evaluate the perceived usability, acceptability, and credibility of the consumer leaflets from the perspective of consumers and HCPs.

DESIGN

This was an observational survey involving a consumer review panel and an HCP review panel.

PARTICIPANTS

30 consumers (and/or their carers) and 20 HCPs were included in the study. Consumers were people older than 65 years of age who were currently experiencing LBP or HoKOA, and with no HCP background. Carers were people who provided unpaid care, support, or assistance to an individual meeting the inclusion criteria for consumers. HCPs included physiotherapists (n = 9), pharmacists (n = 7), an orthopaedic surgeon (n = 1), a rheumatologist (n = 1), nurse practitioner (n = 1) and a general practitioner (n = 1), all with at least three years of clinical experience and who reported working closely with this target patient population within the last 12 months.

METHODS

Prototypes of two educational consumer leaflets (a brochure and a personal plan) were developed by a team of LBP, OA, and geriatric pharmacotherapy researchers and clinicians. The leaflet prototypes were evaluated by two separate chronological review panels involving (1) consumers and/or their carers, and (2) HCPs. Data collection for both panels occurred via an online survey. Outcomes were the perceived usability, acceptability, and credibility of the consumer leaflets. Feedback received from the consumer panel was used to refine the leaflets, before circulating the leaflets for further review by the HCP panel. Additional feedback from the HCP review panel was then used to refine the final versions of the consumer leaflets.

RESULTS

Both consumers and HCPs perceived the leaflets and personal plan to be usable, acceptable, and credible. Consumers rated the brochure against several categories, which scored between 53 and 97% positive responses. Similarly, the overall feedback provided by HCPs was 85-100% positive. The modified System Usability Scale scores obtained from HCPs was 55-95% positive, indicating excellent usability. Feedback for the personal plan from both HCPs and consumers was largely positive, with consumers providing the highest positive ratings (80-93%). While feedback for HCPs was also high, we did identify that prescribers were hesitant to provide the plan to patients frequently (no positive responses).

CONCLUSIONS

This study led to the development of a leaflet and personal plan to support the reduction of opioid use in older people with LBP or HoKOA. The development of the consumer leaflets incorporated feedback provided by HCPs and consumers to maximise clinical effectiveness and future intervention implementation.

Effectiveness and utility of an electronic intervention for appropriate benzodiazepine and Z-drugs prescription in psychiatric clinics: protocol for a multicentric, real-world randomised controlled trial in China

INTRODUCTION

Benzodiazepine receptor agonists (BZRAs), which include benzodiazepines and Z-drugs, are the most commonly prescribed psychotropic drugs worldwide, and their inappropriate use places a significant burden on public health. Given the widespread use of BZRAs in psychiatric settings, this condition may result from doctors' improper prescribing. Researchers have developed an electronic intervention system to assist psychiatrists in prescribing BZRAs appropriately. This study aims to determine the efficacy and utility of electronic intervention in reducing improper BZRAs prescriptions in real-world psychiatric outpatient settings.

METHODS AND ANALYSIS

A multicentre randomised controlled research study will be conducted in real-world settings with licensed psychiatrists with prescription qualifications from five of Chinese most significant regional hospitals that provide high-quality mental healthcare. Participants will be 1:1 randomly assigned to receive a 3-month electronic intervention (11 related information pushing and 3 online lectures) or be placed on a waiting list. The primary outcome is the change in the proportion of inappropriate BZRAs prescriptions between the baseline period (3 months before the intervention) and 3 months after the intervention. Secondary outcomes will be examined at baseline, the third month and the sixth month. The secondary outcomes include psychiatrists' knowledge and attitudes about appropriate BZRAs prescription, the associated side effects of BZRAs among patients and self-efficacy. To measure the utility, intervention assessment and system utilisation data from the intervention group were collected.

ETHICS AND DISSEMINATION

The institutional review board and ethics committees of Shanghai Mental Health Center, Second Xiangya Hospital, West China Hospital, Guangji Hospital and Wuhan Mental Health Center approved the study. After the study is completed, the results will be published in peer-reviewed journals or presented at conferences. If the educational materials are effective, they are available to the general public.

TRIAL REGISTRATION NUMBER

NCT03724669; Pre-results.

Depression, Anxiety, and Patterns of Mental Health Care Among Men With Prostate Cancer Receiving Androgen Deprivation Therapy

BACKGROUND

Androgen deprivation therapy (ADT) use is associated with an increased risk of developing depression and anxiety. Little is known about how the mental health of these men is treated.

MATERIALS AND METHODS

We identified men with prostate cancer who received ADT between 2001 and 2015 using Optum's de-identified Clinformatics Data Mart Database. We determined the incidence of depression or anxiety diagnoses, mental health treatments, and the specialty of providers initiating psychotropic medications, after the start of ADT. Outcomes were compared with those of men with prostate cancer not receiving ADT and men without prostate cancer.

RESULTS

Of 37 388 men with prostate cancer treated with ADT, 3964 (10.6%) received a new diagnosis of depression or anxiety. Of those 3964 men, 1892 (47.7%) did not receive a documented treatment, 10 (0.3%) received psychotherapy, 1321 (33.3%) a selective serotonin reuptake inhibitor, and 744 (18.8%) a benzodiazepine. The median time from initiation of ADT to a depression or anxiety diagnosis was 9.3 months. Primary care physicians were the most common prescribers of psychotropic medications (72.2%). The proportion of men not receiving mental health treatments of interest (47.7%) was similar compared to men without prostate cancer (49.1%), but statistically significantly lower compared to men with prostate cancer not receiving ADT (52.7%).

CONCLUSIONS

In men with prostate cancer receiving ADT with a new diagnosis of depression or anxiety, nearly half are not receiving mental health care while one in five is introduced to a benzodiazepine. Further investigation toward improving the mental health care for men on ADT is needed.

Applying action research in pharmacy practice

Medication errors are closely associated with patient safety, as they affect quality of health care. Pharmacists play a key role in preventing such errors to ensure patient safety and enhance pharmacy service quality. Quality improvement has been suggested to be incorporated into daily practice, providing practitioners an opportunity to identify service delivery gaps and configure solutions fitting the context. This paradigm is similar to the concept of action research (AR); therefore, this research approach is deemed appropriate for improving the quality of pharmacy practice. AR is context-specific, dynamic, and systematic and is driven by a spiral process to identify problems, design solutions, and evaluate the impacts of the solution. Since AR uses multiple methods, including a spiral process, confusion may arise among practicing pharmacists and novice researchers interested in using it. This paper aims to describe key information regarding AR, including its brief history and definition, spiral process, and research methods used for data collection, key characteristics, and common limitations to help readers understand the AR protocol.

Benzodiazepine Use among Medicare, Commercially Insured, and Veteran Older Adults, 2013-2017

BACKGROUND/OBJECTIVES

Benzodiazepines (BZDs) are widely prescribed to older adults. Although prescribing has declined in the U.S. Department of Veterans Affairs (VA), Medicare introduced BZD coverage in 2013. It is unknown whether declines in the VA have been widespread among older adults in the United States.

DESIGN

Observational study in traditional fee-for-service Medicare, commercial insurance, and the VA.

SETTING

United States, 2013-2017.

PARTICIPANTS

Adults aged 55 and older in traditional Medicare (234,290,693 person-months), commercial insurance (337,827,125 person-months), and the VA (256,590,369 person-months).

MEASUREMENTS

(1) Change in BZD and BZD-opioid co-prescribing modeled by Poisson regression over time; and (2) standardized ratios of BZD and BZD-opioid co-prescribing, using Medicare as the reference.

RESULTS

From April 2013 to December 2017, the monthly percentage of adults aged 55 and older who received BZDs fell from 10.4% to 9.3% in Medicare, 6.6% to 6.5% in commercial insurance, and 5.7% to 3.0% in the VA. Monthly BZD-opioid co-prescribing over the same time fell from 4.0% to 3.0% in Medicare, 2.3% to 2.0% in commercial, and 2.2% to .6% for the VA. Age- and sex-adjusted rates of decline for BZD and BZD-opioid co-prescribing were statistically significant for all systems. Annual BZD rate reductions were .98 (Medicare), .99 (commercial), and .87 (VA; P < .001 for all); co-prescribing rate reductions were .95, .99, and .75 (P < .001 for all). Using standardized ratios accounting for demographic and clinical characteristics, both prescribing and co-prescribing were lowest for the VA relative to Medicare (standardized BZD ratio = .40; 95% confidence interval [CI] = .39-.40; standardized BZD-opioid co-prescribing ratio = .35; 95% CI = .35-.35). Prescribing in commercial insurance was also lower (BZD = .65; 95% CI = .65-.65; BZD-opioid co-prescribing = .65; 95% CI = .65-.65).

CONCLUSION

BZD prescribing has declined much more to older adults receiving care through the VA than Medicare or commercial insurance. Other systems may learn from strategies implemented in the VA.

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

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

The pharmacotherapy team: A novel strategy to improve appropriate in-hospital prescribing using a participatory intervention action method

AIMS

Prescribing medication is a complex process that, when done inappropriately, can lead to adverse drug events, resulting in patient harm and hospital admissions. Worldwide cost is estimated at 42 billion USD each year. Despite several efforts in the past years, medication-related harm has not declined. The aim was to determine whether a prescriber-focussed participatory action intervention, initiated by a multidisciplinary pharmacotherapy team, is able to reduce the number of in-hospital prescriptions containing ≥1 prescribing error (PE), by identifying and reducing challenges in appropriate prescribing.

METHODS

A prospective single-centre before- and after study was conducted in an academic hospital in the Netherlands. Twelve clinical wards (medical, surgical, mixed and paediatric) were recruited.

RESULTS

Overall, 321 patients with a total of 2978 prescriptions at baseline were compared with 201 patients with 2438 prescriptions postintervention. Of these, m456 prescriptions contained ≥1 PE (15.3%) at baseline and 357 prescriptions contained ≥1 PEs (14.6%) postintervention. PEs were determined in multidisciplinary consensus. On some study wards, a trend toward a decreasing number of PEs was observed. The intervention was associated with a nonsignificant difference in PEs (incidence rate ratio 0.96, 95% confidence interval 0.83-1.10), which was unaltered after correction. The most important identified challenges were insufficient knowledge beyond own expertise, unawareness of guidelines and a heavy workload.

CONCLUSION

The tailored interventions developed with and implemented by stakeholders led to a statistically nonsignificant reduction in inappropriate in-hospital prescribing after a 6-month intervention period. Our prescriber-focussed participatory action intervention identified challenges in appropriate in-hospital prescribing on prescriber- and organizational level.

Leveraging policy to reduce chronic opioid use by educating and empowering community dwelling adults: a study protocol for the TAPERING randomized controlled trial

Background

Opioid use has risen to epidemic proportions across Canada, with increasing evidence of harms including accidental overdose and death. Policy-makers have called for effective approaches to promote opioid reduction. One promising method from deprescribing randomized trials is to empower patients through direct-to-patient education. The current trial will evaluate the effectiveness of a government-led mail-out of educational information to adult community-dwelling, chronic opioid users on the reduction of opioids compared to usual care.

Methods

This is a pragmatic, prospective, cluster randomized, parallel-arm controlled trial, comparing mailed distribution of a direct-to-patient educational brochure for chronic opioid use (intervention arm) to usual care (control arm). Eligible participants from across Manitoba, Canada, will be identified by the Provincial Drug Programs Branch within the Manitoba Health, Seniors and Active Living Department of the Manitoba Government, allocated to primary care providers, and the latter will be randomized in clusters of family medicine practices to achieve a 1:1 ratio. The primary outcome is complete cessation of opioids after 6 months assessed using Drug Program Information Network data. Secondary outcomes include ≥ 25% dose reduction in the mean morphine milligram equivalent (MME) daily dose, reduction of daily dose to < 90 mg MME, or therapeutic switch to another opioid or non-opioid medication. Data will be analyzed using intent-to-treat generalized estimating equations.

Discussion

This trial will test the efficacy of a population-based, wide-scale, government-led direct-to-patient educational initiative to drive reductions in chronic opioid use by community-dwelling adults across Manitoba.

Trial Registration

ClinicalTrials.gov, ID: NCT03400384. Registered on 18 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3508-z) contains supplementary material, which is available to authorized users.

Long-term use of benzodiazepines and Z drugs: a qualitative study of patients' and healthcare professionals' perceptions and possible levers for change

BACKGROUND

Although long-term use of benzodiazepines (BZDs) and Z drugs is associated with various side effects, they remain popular among the older population. Possible reasons for this phenomenon could be ineffective ways of transmitting information on the health risks associated with long-term use, and communication gaps between patients and healthcare professionals.

AIM

The aim was to investigate the views of patients, physicians, nurses, and pharmacists regarding long-term BZD and Z drug use.

DESIGN & SETTING

The qualitative study design used focus group interviews with physicians, pharmacists, and nurses in Hamburg. Patient interviews were conducted in Lippstadt, Germany.

METHOD

The interviews were audiotaped with each participant's permission, transcribed, and thematically analysed using a software program for qualitative research (MAXQDA).

RESULTS

The data from the four focus groups consisting of 28 participants were analysed. Patients indicated lack of knowledge about risks and side effects, difficult access to alternatives, and fears of ceasing drug use without professional support. Although the physicians were reported to be cautious about prescribing BZDs and Z drugs, the psychosocial problems of older patients are often considered to be complex and treatment knowledge, experience, and resources are frequently unsatisfactory. Nurses described that when BZDs were prescribed, they did not feel it was their responsibility to evaluate their effects. Pharmacists were reported to be strongly ambivalent in informing patients about the risks, which may contradict the prescription advice provided by the physician.

CONCLUSION

Patients, physicians, nurses, and pharmacists reported differences in the perception of long-term BZD and Z drug use. Nevertheless, all of the participants described lack of information and expressed the need for greater communication exchange.

Strategies to promote public engagement around deprescribing

Many seniors remain unaware that certain medications may be harmful, despite high rates of polypharmacy and inappropriate medication use among community-dwelling older adults. Patient education is an effective method for reducing the use of inappropriate medications. Increasing public awareness and engagement is essential for promoting shared decision-making to deprescribe. The Canadian Deprescribing Network was created to address the lack of a systematic pan-Canadian initiative to implement deprescribing among older Canadians. The Canadian Deprescribing Network deliberately included patient advocates in its organization from the outset, in order to ensure a key strategic focus on public awareness and education. In this paper, we present the processes and activities rolled out by the Canadian Deprescribing Network as a blueprint model for engaging the public on deprescribing. Embedded within the structure of the network, the subcommittee on public awareness and engagement implements an action plan that includes needs assessments, population surveys, focus groups, deprescribing fairs, national stakeholders' meetings, public lectures and monthly exchanges with community champions and seniors' organizations. Educational materials and online media have been developed based on the answers to the questions: what information do seniors need about deprescribing? who should this information be delivered to? who needs to deliver the message? and how should seniors be engaged in deprescribing? In conjunction with seniors' organizations, members of the Network have iteratively refined key deprescribing messages, disseminated information about deprescribing, engaged the press and created a grass roots-driven public awareness and education campaign across Canada. Over 3000 seniors and seniors' organizations are involved, with over 25,000 educational tools being distributed across the country.

Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.

Benzodiazepine Use: The Underbelly of the Opioid Epidemic

In the United States, benzodiazepine medication use is the secondary epidemic to opioid drug use and carries serious consequences as well, even though its use is enabled by well-intended clinicians. Benzodiazepine drugs are intended for short-term use, not to exceed 2 to 4 weeks; yet, it is common for clients to be taking benzodiazepine medications for up to 10 years. In addition to dependence or addiction, adverse effects include depression, emotional blunting, ataxia, aggression, irritability, nervousness, and cognitive impairment. These medications also contribute to increased risk for falls, suicide, overdose fatality, and vehicle crashes. The current article describes the epidemiology of benzodiazepine medication use, patient and prescriber factors that contribute to overuse and misuse, and recommendations for prescribing and deprescribing. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 11-15.].

A systematic review of regulatory and educational interventions to reduce the burden associated with the prescriptions of sedative-hypnotics in adults treated for sleep disorders

BACKGROUND

The burden of Sedative-Hypnotics (SHs) has been known since the 1980s. Yet, their consumption remains high. A systematic review of the literature should help to assess efficient interventions to improve the appropriate use of SHs in sleep disorders.

OBJECTIVES

To identify and assess regulatory and educational interventions designed to improve the appropriate use of SHs for insomnia treatment.

METHODS

We conducted a systematic review of the literature according to PRISMA guidelines. A systematic search covering the period 1980-2015 was carried out in Medline, Web of Science, Embase and PsycInfo. We included studies reporting the implementation of regulatory or educational strategies directed towards patients and/or healthcare professionals to improve the appropriate use of SHs to treat insomnia in the community, hospitals and nursing homes.

RESULTS

Thirty-one studies were included: 23 assessed educational interventions (recommendations by mail/email, computer alerts, meetings, mass media campaigns, prescription profile), 8 assessed regulatory interventions (prescription rule restriction, end of reimbursement). The most recent was implemented in 2009. Restrictive prescription rules were effective to reduce the consumption of targeted SHs but led to a switch to other non-recommended SHs. Among educational interventions, only 3 studies out of 7 reported positive results of mono-faceted interventions; whereas, 13 out of the 16 multi-faceted interventions were reported as efficient: particularly, the active involvement of healthcare professionals and patients and the spread of information through mass media were successful. The risk of bias was high for 24 studies (mainly due to the design), moderate for 3 studies and weak for 4 studies.

CONCLUSION

Educational multifaceted studies are presented as the most efficient. But further better designed studies are needed to make evidence-based results more generalizable.

Medication management policy, practice and research in Australian residential aged care: Current and future directions

Eight percent of Australians aged 65 years and over receive residential aged care each year. Residents are increasingly older, frailer and have complex care needs on entry to residential aged care. Up to 63% of Australian residents of aged care facilities take nine or more medications regularly. Together, these factors place residents at high risk of adverse drug events. This paper reviews medication-related policies, practices and research in Australian residential aged care. Complex processes underpin prescribing, supply and administration of medications in aged care facilities. A broad range of policies and resources are available to assist health professionals, aged care facilities and residents to optimise medication management. These include national guiding principles, a standardised national medication chart, clinical medication reviews and facility accreditation standards. Recent Australian interventions have improved medication use in residential aged care facilities. Generating evidence for prescribing and deprescribing that is specific to residential aged care, health workforce reform, medication-related quality indicators and inter-professional education in aged care are important steps toward optimising medication use in this setting.

People with insomnia: experiences with sedative hypnotics and risk perception

Background

Sedative hypnotics form an important part of managing insomnia and are recommended for short‐term use. It is standard practice for clinicians to inform the patient to use medications only ‘when required’, but the use of these medications is often chronic. Little is known about the impact of standard labelling/instructions on promoting appropriate medication use for managing insomnia.

Objective

To explore patient medication‐taking beliefs, experiences and behavioural practices relating to the use of pharmacological/complementary sleep aids for insomnia.

Setting and Participants

Specialist sleep/psychology clinics and the general community in Sydney, Australia.

Method

Semi‐structured interviews were conducted with 51 people with insomnia using a schedule of questions to gauge their experiences, beliefs and current practices relating to insomnia medication use. Interviews were audio‐recorded, transcribed verbatim and subjected to Framework Analysis to identify emergent themes.

Results

Participants held distinctive views about the safety and efficacy of complementary and pharmacological agents but do not intuitively turn to medications to resolve their sleep complaint. Medication use was affirmed through tangible medication‐taking cues due to the ambivalence in current instructions and labelling. Practices such as dosage modification, medication substitution and delaying medication use might be important drivers for psychological dependence.

Conclusion

Current labelling and instructions do not necessarily promote the quality use of sedative hypnotics due to the variability in patient interpretations. Clarifying the timing, quantity and frequency of medication administration as well as insomnia symptom recognition would play a significant role in optimizing the role of pharmacotherapy in the management of insomnia.

Uncovering the source of new benzodiazepine prescriptions in community-dwelling older adults'

OBJECTIVE

Initiatives to reduce benzodiazepine use have been largely unsuccessful despite strong associations with adverse outcomes. Curtailing incident use of benzodizepines is an alternate strategy that has yet to be explored. This study aims to determine the source of incident benzodiazepine prescriptions by comparing the risk of receiving a new prescription upon hospital discharge versus after an ambulatory care clinic visit.

METHODS

Data were derived from 1189 community-dwelling adults aged 65 years naive to benzodiazepine consumption, enrolled in the Étude sur la Santé des Ainés, a prospective 3-year cohort study conducted in Québec, Canada. Health survey questionnaires were linked with provincial administrative databases of prescription and health service claims. Analysis with multivariate Poisson regression models compared the risk of incident benzodiazepine use post-hospitalization versus after an ambulatory care visit. Models were adjusted for sex, age, antidepressant use, and concomitant drugs. Sub-analyses were conducted for chronic prescriptions.

RESULTS

Incident benzodiazepine use was 11% over a 2-year period, with 18.3% of prescriptions leading to chronic use (> 90 days). Hospitalization conferred a 2.7-fold greater risk of incident use than an outpatient visit (OR 2.66, 95% CI 1.78-3.98) and a 4.7-fold (OR 4.74, 95% CI 1.63-13.78) increased risk of chronic use, after adjusting for potential confounders. Despite the increased risk, only 13% of new prescriptions originated post-hospital discharge, with the remainder prescribed during outpatient visits.

CONCLUSION

Interventions are required to curb incident benzodiazepine prescriptions at their source both in hospitals and in ambulatory care settings.

Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem

Falls are a common health problem for older people, and psychotropic medications have been identified as an important independent fall risk factor. The objective of this paper was to review the literature relating to the effect of psychotropic medications on falls in older people, with a particular focus on evidence supporting minimization of their use to reduce risk of falls. A literature search identified 18 randomized trials meeting the inclusion criteria for the review of effectiveness of psychotropic medication withdrawal studies, including four with falls outcomes. One of these, which targeted reduced psychotropic medication use in the community, reported a 66% reduction in falls, while the other studies demonstrated some success in reducing psychotropic medication use but with mixed effects on falls. Other randomized trials evaluated various approaches to reducing psychotropic medications generally or specific classes of psychotropic medications (e.g. benzodiazepines), but did not report fall-related outcomes. Overall, these studies reported moderate success in reducing psychotropic medication use, and a number reported no or limited worsening of key outcomes such as sleep quality or behavioural difficulties associated with withdrawal of psychotropic medication use. Reduced prescription of psychotropic medications (e.g. seeking non-pharmacological alternatives to their use in place of prescription in the first place or, for those patients for whom these medications are deemed necessary, regular monitoring and efforts to cease use or wean off use over time) needs to be a strong focus in clinical practice for three reasons. Firstly, psychotropic medications are commonly prescribed for older people, both in the community and especially in the residential care setting, and their effectiveness in a number of clinical groups has been questioned. Secondly, there is strong evidence of an association between substantially increased risk of falls and use of a number of psychotropic medications, including benzodiazepines (particularly, the long-acting agents), antidepressants and antipsychotic drugs. Finally, the largest effect of any randomized trial of falls prevention to date was achieved with a single intervention consisting of weaning psychotropic drug users off their medications.

How is medication prescribing ceased? A systematic review

BACKGROUND

Medication prescribing is a complex process where the focus tends to be on starting new medication, changing a drug regimen, and continuing a drug regimen. On occasion, a prudent approach to prescribing may necessitate ending an ongoing course of medication, either because it should not have been started in the first place; because its continued use would cause harm; or because the medication is no longer effective.

OBJECTIVE

To identify effective strategies for stopping pre-existing prescribing in situations where continued prescribing may no longer be clinically warranted.

RESEARCH DESIGN

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed (1951-November 2009), EMBASE (1966-September 2008), and International Pharmaceutical Abstract b (1970-September 2008). A manual search for relevant review articles and a keyword search of a local database produced by a previous systematic search for prescribing influence and intervention research were also conducted.

STUDY SELECTION AND DATA EXTRACTION

Following initial title screening for relevance 2 reviewers, using formal assessment and data extraction tools, independently assessed abstracts for relevance and full studies for quality before extracting data from studies selected for inclusion.

RESULTS

Of 1306 articles reviewed, 12 were assessed to be of relevant, high-quality research. A variety of drugs were examined in the included studies with benzodiazepines the most common. Studies included in the review tested 9 different types of interventions. Effective interventions included patient-mediated interventions, manual reminders to prescribers, educational materials given to patients, a face-to-face intervention with prescribers, and a case of regulatory intervention. Partially effective interventions included audit and feedback, electronic reminders, educational materials alone sent to prescribers, and distance communication combined with educational materials sent to prescribers.

CONCLUSIONS

It appears possible to stop the prescribing of a variety of medications with a range of interventions. A common theme in effective interventions is the involvement of patients in the stopping process. However, prescribing at the level of individual patients was rarely reported, with data often aggregated to number of doses or number of drugs per unit population, attributing any reduction to cessation. Such studies are not measuring the actual required outcome (stopping prescribing), and this may reflect the broader ambiguity about when or why it might be important to end a prescription. Much more research is required into the process of stopping pre-existing prescribing, paying particular attention to improving the outcomes that are measured.

Improving the use of benzodiazepines--is it possible? A non-systematic review of interventions tried in the last 20 years

Background

Benzodiazepines are often used on a long term basis in the elderly to treat various psychological disorders including sleep disorders, some neurological disorders and anxiety. This is despite the risk of dependence, cognitive impairment, and falls and fractures. Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide. The objective of this paper is to explore interventions aimed at improving the prescribing and use of benzodiazepines in the last 20 years.

Methods

Medline, EMBASE, PsychINFO, IPA were searched for the period 1987 to June 2007.

Results

Thirty-two articles met the study eligibility criteria (interventions solely focusing on increasing appropriate prescribing and reducing long term use of benzodiazepines) and were appraised. Insufficient data were presented in these studies for systematic data aggregation and synthesis, hence critical appraisal was used to tabulate the studies and draw empirical conclusions. Three major intervention approaches were identified; education, audit and feedback, and alerts.

Conclusions

Studies which used a multi-faceted approach had the largest and most sustained reductions in benzodiazepines use. It appears that support groups for patients, non-voluntary recruitment of GPs, and oral delivery of alerts or feedback may all improve the outcomes of interventions. The choice of outcome measures, delivery style of educational messages, and requests by GPs to stop benzodiazepines, either in a letter or face to face, showed no differences on the success rates of the intervention.

An intervention to improve benzodiazepine use--a new approach

OBJECTIVE

To design, implement and evaluate a novel intervention, utilizing electronic media, to improve benzodiazepine use in specific geographical areas in Australia.

METHODS

An educational intervention about benzodiazepine use, using email, a website and bookmarks, targeted consumers, GPs, nurses (in aged care facilities) and pharmacists in two areas in Australia over a 6-month period. Two control areas, which received no aspect of the intervention, were used to compare and contrast. A drug use evaluation was conducted in aged care facilities before and after the study (in the intervention areas) and after the intervention (in the control areas) to assess quality of benzodiazepine use. Benzodiazepine dispensing data were obtained for each area before, during and after the intervention to quantitate use. Interviews were conducted with nurses and pharmacists involved in the intervention and website statistics were recorded.

RESULTS

A significantly smaller number of aged care residents were on benzodiazepines for 6 months or more (P < 0.05) after the intervention compared with before. However, other indices, such as number of residents taking benzodiazepines or taking them for a long time, did not change significantly before compared to after the intervention and there were no significant differences between the control and intervention areas after the intervention. Quantitative use of benzodiazepines did not change after the intervention. Many health care professionals in the intervention areas remembered seeing the electronic educational material for benzodiazepines. The website was viewed 115 times during the study.

CONCLUSIONS

The study was easy and inexpensive to administer and attracted high participation rates by health care professionals. There was a change in the use of benzodiazepines in aged care facilities (less long-term benzodiazepine use) in the intervention areas. The electronic educational materials (emails and website) were read and informations (especially the key messages) were able to be recalled after the intervention. However, no large changes in benzodiazepine overall use (either between control and intervention areas or before and after the intervention) were recorded.

How do different age groups use benzodiazepines and antidepressants? Analysis of an Australian administrative database, 2003-6

BACKGROUND

The use of antidepressants and benzodiazepines is increasing in Australia and worldwide, and it is thought that some of the prescribing of these classes of drugs may be inappropriate. However, the demographic characteristics of the subgroups of the population responsible for this increase remain unexplored.

OBJECTIVE

The aim of this study was to examine changes in the utilization of antidepressants and benzodiazepines between different age groups within Australia from 2003 to 2006.

METHODS

The Australian Pharmaceutical Benefits Scheme administrative database was used to obtain dispensing data for all antidepressants and publicly subsidized benzodiazepines. Changes in utilization (amounts and patterns of use of different compounds) were compared between different age groups from 2003 to 2006. The WHO Anatomic Therapeutic Chemical/Defined Daily Dose system was used.

RESULTS

Use of antidepressants increased from 2003 to 2006, and in each year increased with age, with those > or = 65 years having the greatest use. Differences were seen in the antidepressant most utilized, with the elderly using more tricyclic antidepressants than those who are younger. The utilization of benzodiazepines decreased from 2003 to 2006 in elderly individuals and those receiving social welfare benefits. Individuals aged > or = 85 years had the highest use of benzodiazepines and used more long-acting benzodiazepines compared with those aged 35-44 years.

CONCLUSION

The elderly still account for most use per capita of benzodiazepines. Some of this use may be inappropriate (e.g. use of long-acting benzodiazepines) and, hence, may represent a useful target for future educational intervention. The elderly also still account for the largest per capita use of antidepressants.

Withdrawing benzodiazepines in primary care

The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addiction have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescribers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discontinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescribers.This review sets out the stratagems that have been evaluated, concentrating on those of a pharmacological nature. Simple interventions include basic monitoring of repeat prescriptions and assessment by the doctor. Even a letter from the primary-care practitioner pointing out the continuing usage of benzodiazepines and questioning their need can result in reduction or cessation of use. Pharmacists also have a role to play in monitoring the use of benzodiazepines, although mobilizing their assistance is not yet routine. Such stratagems can avoid the use of specialist back-up services such as psychiatrists, home care, and addiction and alcohol misuse treatment facilities.Pharmacological interventions for benzodiazepine dependence have been reviewed in detail in a recent Cochrane review, but only eight studies proved adequate for analysis. Carbamazepine was the only drug that appeared to have any useful adjunctive properties for assisting in the discontinuation of benzodiazepines but the available data are insufficient for recommendations to be made regarding its use. Antidepressants can help if the patient is depressed before withdrawal or develops a depressive syndrome during withdrawal. The clearest strategy was to taper the medication; abrupt cessation can only be justified if a very serious adverse effect supervenes during treatment. No clear evidence suggests the optimum rate of tapering, and schedules vary from 4 weeks to several years. Our recommendation is to aim for withdrawal in <6 months, otherwise the withdrawal process can become the morbid focus of the patient's existence. Substitution of diazepam for another benzodiazepine can be helpful, at least logistically, as diazepam is available in a liquid formulation.Psychological interventions range from simple support through counselling to expert cognitive-behavioural therapy (CBT). Group therapy may be helpful as it at least provides support from other patients. The value of counselling is not established and it can be quite time consuming. CBT needs to be administered by fully trained and experienced personnel but seems effective, particularly in obviating relapse.The outcome of successful withdrawal is gratifying, both in terms of improved functioning and abstinence from the benzodiazepine usage. Economic benefits also ensue.Some of the principles of withdrawing benzodiazepines are listed. Antidepressants may be helpful, as may some symptomatic remedies. Care must be taken not to substitute one drug dependence problem for the original one.

A comparison of benzodiazepine and related drug use in Nova Scotia and Australia

OBJECTIVE

Benzodiazepines can be a problem if used for long periods, or in at-risk populations, such as the elderly. We compared the use of benzodiazepine and related prescription medicines in Nova Scotia and Australia.

METHODS

The Nova Scotia Pharmacare Program and the Pharmaceutical Benefits Scheme in Australia were used to obtain dispensing data in comparable populations for all publicly subsidized benzodiazepines and related compounds. Usage was compared from 2000 to 2003, using the World Health Organization anatomical therapeutic chemical and defined daily dosage (DDD) system. We also determined differences in the types of benzodiazepines prescribed.

RESULTS

The use of benzodiazepines increased at a steady but comparable rate in both areas. However, the use of benzodiazepines in Nova Scotia was more than double that of Australia in 2000 (123 and 48 DDD/1000 beneficiaries per day, respectively) through 2003 (138 and 57 DDD/1000 beneficiaries per day, respectively). Eight different benzodiazepines made up 90% of the drug use in Nova Scotia by contrast to only 4 different benzodiazepines in Australia.

CONCLUSIONS

Large differences exist between the type and rate of benzodiazepine prescribing in Nova Scotia and Australia, with Nova Scotia reporting more than twice as much use. Benzodiazepine use in both jurisdictions is increasing. The Canadian findings are especially concerning as benzodiazepine use in the Atlantic provinces has been reported to be less than other provinces. The variations between the 2 jurisdictions may be due to factors such as fewer benzodiazepines available in Australia, differences in prescriber, patient attitudes and behaviours, or different initiatives to influence benzodiazepine use.

Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial

OBJECTIVES

To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing.

DESIGN

Randomized, controlled trial, with the patient as unit of randomization.

SETTING

Acute GEM unit.

PARTICIPANTS

Two hundred three patients aged 70 and older.

INTERVENTION

Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients.

MEASUREMENTS

Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge.

RESULTS

Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR)=9.1, 95% confidence interval (CI)=4.2-21.6 and OR=6.1, 95% CI=2.2-17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria.

CONCLUSION

Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes.

Antidepressants in children and adolescents—changes in utilisation after safety warnings

BACKGROUND

Antidepressants, in particular selective serotonin reuptake inhibitors, are one of the most commonly used classes of psychotropic drug in children and adolescents. Beginning in June 2003, evidence emerged suggesting that antidepressants may increase risk of suicidal behaviour in young people. This evidence was accompanied by national and international guidelines cautioning against use of many antidepressants in young people. This study aimed to assess whether these safety warnings have impacted upon antidepressant utilisation rates.

METHOD

This study was based at a metropolitan health service incorporating children's and adult hospitals. Total service utilisation of antidepressants was extracted from pharmacy software for the period January 2002 to December 2005. Monthly utilisation rates were computed for adults and children's services as defined daily doses (DDD) per occupied bed days. Changes in utilisation over time were examined for children and adults.

RESULTS

There was a significant relationship between time and antidepressant utilisation in children and adolescents, where antidepressant use decreased over time (R = 0.474; t = -3.66; p < 0.01), and in particular, use of SSRIs (R = 0.461; t = -3.52; p < 0.01). In contrast, use of SSRIs (R = 0.587; t = 4.91; p < 0.001) and all antidepressants (R = 0.327; t = 2.35; p < 0.05) increased over time in adults.

CONCLUSIONS

National and international warnings about safety of antidepressants in children and adolescents appear to have influenced local utilisation of these medications in young people but not in adults. Further research is required to determine optimal utilisation rates.

A community-based intervention to reduce antibiotic use for upper respiratory tract infections in regional South Australia

OBJECTIVE

To evaluate the effectiveness of a community-based and GP-based intervention in reducing unnecessary antibiotic prescribing for upper respiratory tract infections (URTIs) including sore throats, sinusitis and otitis media.

DESIGN

Analysis of pharmacy dispensing data in June to October before (2000) and after (2001) the intervention, which commenced on 25 June 2001.

SETTING AND PARTICIPANTS

Local consumers, health professionals, the Adelaide Southern Division of General Practice, the South Australian Government, and the local media in a rural region of South Australia, covering about 2000 square kilometres, with a population of over 20 000.

INTERVENTION

Community dissemination of consumer information on antibiotic use for URTIs (including a local media campaign) and education of health professionals (including sessions with general practitioners at the four practices in the study area) on current Australian therapeutic guidelines for antibiotics, and a validated clinical scoring system for decision making in managing sore throat.

MAIN OUTCOME MEASURES

Total dispensing data from local pharmacies for the months of June to October in 2000 and 2001, covering the six antibiotics considered most likely to be used for URTIs (amoxycillin, amoxycillin/clavulanic acid, cefaclor, doxycycline, erythromycin and roxithromycin).

RESULTS

The dispensing of the six antibiotics reduced by 32% overall, from 77.1 to 52.9 defined daily doses per 1000 population per day, with statistically significant reductions in the range of 31%-70% for individual antibiotics; there was no reduction for amoxycillin with or without clavulanic acid.

CONCLUSION

The intervention was associated with reduced dispensing of unnecessary antibiotics for URTIs.