Evidence of clonazepam abuse liability: results of the tools developed by the French Centers for Evaluation and Information on Pharmacodependence (CEIP) network

Characteristics of high-dose benzodiazepine use: nationwide cohort study on new benzodiazepine users with 5-year follow-up

BACKGROUND

A nationwide register-based cohort study from Finland including 48 124 incident benzodiazepines and related drug (BZDR) users aged 18-65 years who initiated use in 2006 and were not dispensed BZDRs during 2004-2005. The follow-up was 5 years or until death, whichever occurred first.

AIMS

To investigate sociodemographic and clinical factors associated with high-dose use of BZDRs (i.e. Z-drugs) among new BZDR users.

METHOD

The temporal BZDR dose was calculated as a point estimate every 6 months after initiation as defined daily doses (DDDs) per day, based on the PRE2DUP method (an approach based on mathematical modelling of personal drug purchasing behaviours). Sociodemographic and clinical factors associated with dose categories were studied using multinomial logistic regression.

RESULTS

During the 5-year follow-up, very high-dose BZDR use was observed in 7.4% (n = 3557) and medium high-dose use in 25.5% (n = 12 266) of the users (corresponding to ≥30 mg and 10-29 mg in diazepam equivalents, respectively). Very high-dose use was more common among men compared with women (10.9% versus 4.6%). Very high-dose use patterns were especially observed in younger age groups (18- to 25-year-olds). Compared with oxazepam, initiating BZDR use with clonazepam (adjusted odds ratio 3.86, 95% CI 3.24-4.60), diazepam (2.05, 1.78-2.36) or alprazolam (1.76, 1.52-2.03) was associated with increased odds for very high-dose use. Both medium high-dose and very high-dose BZDR use were associated with a lower level of education. In all, 58% of very high-dose use occurred in BZDR users who received their first prescription from general practitioners.

CONCLUSIONS

Clinicians should be aware of the dose escalation risk especially when prescribing diazepam, alprazolam or clonazepam for psychiatric indications. If BZDRs are needed, our findings suggest favouring oxazepam.

Use and misuse of psychoactive medicines: a descriptive cross-sectional study in a densely populated region of Portugal

Introduction

Although psychoactive medicines (PMed) are needed in several psychiatric conditions, their use and misuse bear risks. We aimed at estimating the prevalence of PMed use and misuse.

Methods

Data on all PMed prescribed in 2017 and dispensed in community pharmacies of the Lisbon and Tagus Valley region of Portugal (ARSLVT) were extracted from ARSLVT medicines' dispensing database. For 21 PMed among prescription opioids, benzodiazepines and z-drugs (BZDR), antidepressants (AD) and anticonvulsants (AC), we estimated the number of users of each PMed, and assessed PMed misuse by a set of proxy indicators for studying this practice: chronic use (use of ≥180 DDD during the study period) of PMed intended for short-term treatments, concomitant use of several PMed, in particular if involving long-term (≥ 30 days) opioid analgesic (OA) use, and doctor shopping (patients consulting several physicians in order to have access to a quantity higher than intended by each prescriber). Data were analysed using descriptive statistics and hypothesis testing, and multivariate logistic regression was used to explore potential factors affecting long-term concomitant treatment of chronic OA with other PMed.

Results

PMed use prevalence was 21.7%: 6.6% for OA, 12.7% for benzodiazepines (BZD), 5.3% for AD and 2.8% for AC. BZDR were mainly prescribed in primary care and OA in hospital outpatients. Chronic use of PMed was observed in 25%, especially with sertraline and buprenorphine for opioid use disorder (long-term treatment), and lorazepam (short-term treatment). About 56.6% of OA chronic users were long-term concurrent users with other PMed, mainly BZDR. Risk of abuse was low for BZDR, whilst four opioids had meaningful doctor shopping indicators - fentanyl, opioid use disorder buprenorphine, morphine and hydromorphone.

Conclusions

BZD are the main PMed used in ARSLVT, often chronically, especially lorazepam. Prevalence of OA use is low, although with higher risk of misuse than BZDR. Concomitant use of several PMed is frequent.

Addictovigilance in women, the hidden part of the iceberg?

Epidemiology of substance use disorders and their complications is driven by a male predominance, and women, even if they are more and more prevalent, are never specifically represented in studies in the field. Apart from the time of pregnancy, which in itself requires specific prevention, treatment and follow-up, the importance of the sex of women in the complications of substance abuse is neglected. To illustrate, we described some characteristics of women identified in the addictovigilance information system in France and Europe, related to drug use disorders (both for illicit substances and medications). Even if the exposure to some psychoactive substances remains more prevalent in men, women, and particularly young women, seem to be more vulnerable to the adverse effects of these substances, as observed for opioid analgesics, benzodiazepines, cannabis and even nitrous oxide. It is now imperative that the female sex/gender be taken into consideration in addictovigilance expertise and in drug safety in general, even for substances for which use is predominantly male. In addition, the adequate management of the women requires the development of specific prevention and care strategies.

Did the pattern of use of zolpidem change since the enforcement of a new prescription rule? A latent class analysis using the French health insurance database

BACKGROUND

In recent years, zolpidem has been the subject of numerous reports of misuse, abuse and dependence. In view of these risks, the French drug agency decreed the implementation of secure prescription pads in April, 2017. The objective of this study was to characterize the impact of this regulatory change on the patterns of zolpidem use.

RESEARCH DESIGN AND METHODS

We included patients with at least one reimbursement for zolpidem before and/or after the regulatory change using a sample of the French health insurance database. For each period, we identified profiles of users using a latent class analysis (LCA).

RESULTS

In total, 15,550 zolpidem users were identified before the measure and 8,301 after the measure. We identified the same three profiles of zolpidem users before and after the measure: non-problematic users (the most prevalent), users whose drug prescriptions suggest psychiatric disorder and potential problematic users. The profile of potential problematic users was similar after the regulatory change but represented a lower absolute number of patients.

CONCLUSION

In conclusion, the regulatory change had a positive impact on the patterns of zolpidem use, but the impact should be reevaluated, because withdrawal can take a long time, especially in long-term users.

TRIAL REGISTRATION

The study was registered at www.clinicaltrials.gov under the reference number NCT03584542.

Evolution of doctor shopping for oxycodone in the 67 million inhabitants in France as a proxy for potential misuse or abuse

ABSTRACT

This nationwide study aimed to compare use of oxycodone and doctor shopping for oxycodone in 2010 and 2016, and to quantify doctor shopping for oxycodone by sex, age, formulation, and dosage in 2010 and 2016. This study is a cross-sectional comparative analysis of doctor shopping based on all dispensings of oxycodone in France, in 2010 and 2016. Dispensings of oxycodone were extracted from the Système national des données de santé, which covers the 67 million inhabitants in France. Quantification of doctor shopping relies on an algorithm accounting for overlapping prescriptions, which is a proxy for potential misuse or abuse. The number of subjects who received oxycodone increased by 214% from 67,838 subjects in 2010 to 212,753 subjects in 2016, and the number of subjects with doctor-shopping behavior increased by 197%, from 1066 subjects in 2010 to 3163 subjects in 2016. For 30- to 44-year-old men, the total quantity of oxycodone obtained by doctor shopping increased by 391%, from 4582 defined daily doses in 2010 to 22,517 defined daily doses in 2016. By formulation and dosage, the total quantity of oxycodone obtained by doctor shopping increased with the dosage for both immediate-release and extended-release tablets in 2010 and 2016. The widespread extent of doctor shopping and its 3-fold increase in line with population exposure is a strong signal in the French context. These results are another argument to avoid trivializing oxycodone to prevent misuse, potential abuse, and potential oxycodone-related deaths, but it requires caution to prevent compromising effective treatment of pain.

Doctor shopping for methylphenidate as a proxy for misuse and potential abuse in the 67 million inhabitants in France

Doctor shopping enables subjects to receive more than the prescribed dose out of any medical management, which suggests a search for high doses and makes doctor shopping a relevant proxy for misuse and potential abuse. Therefore, this study aimed to identify and characterize profiles of subjects with doctor-shopping behavior for methylphenidate in the entire French population. This study is a cross-sectional study of doctor-shopping behavior for methylphenidate in France, in 2016, using the Système national des données de santé, and accounting for overlapping prescriptions. Subjects who obtained >840 mg by doctor shopping were defined as subjects with heavy doctor-shopping behavior, and subjects who obtained >0 mg and ≤840 mg by doctor shopping were defined as subjects with light doctor-shopping behavior. A total of 63 739 subjects were included, and received 339.6 kg of methylphenidate. Among them, 216 (0.3%) subjects had heavy doctor-shopping behavior, and 313 (0.5%) subjects had light doctor-shopping behavior. Compared with subjects with light doctor-shopping behavior, subjects with heavy doctor-shopping behavior were older (64% of 30- to 49-year-old subjects vs. 77% of ≤17-year-old subjects; P < 0.001), received more concomitant dispensings of antipsychotics (37% vs. 26%; P = 0.008) and opioid maintenance treatments (50% vs. 6%; P < 0.001), and had more prescribers (4 [IQR = 2-5] vs. 2 [IQR = 2-3]; P < 0.001). In the French context where prescription and dispensing of methylphenidate are highly regulated and methylphenidate is much less used than in other countries, these results are a warning signal to avoid trivializing methylphenidate in adults.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Health Information Technology and Doctor Shopping: A Systematic Review

Doctor shopping is the practice of visiting multiple physicians to obtain multiple prescriptions. Health information technology (HIT) allows healthcare providers and patients to leverage records or shared information to improve effective care. Our research objective was to determine how HIT is being leveraged to control for doctor shopping. We analyzed articles that covered a 10-year time period from four databases and reported using preferred reporting items for systematic reviews and meta-analysis (PRISMA). We compared intervention, study design, and bias, in addition to showing intervention interactions with facilitators, barriers, and medical outcomes. From 42 articles published from six countries, we identified seven interventions, five facilitator themes with two individual observations, three barrier themes with six individual observations, and two medical outcome themes with four individual observations. Multiple HIT mechanisms exist to control for doctor shopping. Some are associated with a decrease in overdose mortality, but access is not universal or compulsory, and data sharing is sporadic. Because shoppers travel hundreds of miles in pursuit of prescription drugs, data sharing should be an imperative. Research supports leveraging HIT to control doctor shopping, yet without robust data sharing agreements, the efforts of the system are limited to the efforts of the entity with the least number of barriers to their goal. Shoppers will seek out and exploit that organization that does not require participation or checking of prescription drug monitoring programs (PDMP), and the research shows that they will drive great distances to exploit this weakest link.

Addictovigilance contribution during COVID-19 epidemic and lockdown in France

Addictovigilance is a safety monitoring targeted at substances with potential for abuse and dependence. This vigilance was involved during the period of COVID-19 epidemic due to the significant changes in access to drugs and psychological disruption caused by the pandemic and lockdown. This article aims to present the different steps implemented by the French Addictovigilance network in collaboration with the French Health authorities from March to May 2020, including monitoring of potential harmful events, and scientific communication. The first events were identified through the continuity of the networking between the French addictovigilance centres and their partners: community pharmacies, general practitioners, specialized structures and emergency wards. As soon as the lockdown began, first cases of overdoses (lethal or not) were reported with opioids, mainly with methadone, and other opioids (heroin, oxycodone, tramadol or antitussive codeine). Lockdown-related noteworthy events consisted in clinical cases or other relevant information for which lockdown clearly played an important role: among the many substances identified at least once, pregabalin, benzodiazepines, cannabis, cocaine and nitrous oxide were the most significant in terms of prevalence, seriousness or particularly specific to the lockdown context. Despite significant decrease in the activity and travel limited to vital needs, community pharmacies continued to identify falsified prescriptions in this period, highlighting an increase in suspicious requests for pregabalin, codeine and tramadol. In parallel, the French addictovigilance network continued its communications efforts in the period, issuing a newsletter on tramadol, a press release on methadone and naloxone, and participating in the COVID-19 frequently asked questions (FAQs) of the French Society of Pharmacology and Therapeutic website (https://sfpt-fr.org/covid19). COVID-19 epidemic has been an important challenge for addictovigilance, and has proved that this monitoring is highly essential for alerting health professionals and health authorities to points of vigilance in the field of psychoactive substances.

Consequences of the new zolpidem prescription regulations: a cohort study from the French national healthcare database

PURPOSE

To determine changes in the prevalence of zolpidem consumption since the change in the regulations of prescription. Formulations containing zolpidem were subject to the regulations of narcotics by the French decree of April 7, 2017.

METHODS

Longitudinal cohort study using data from the representative French healthcare database. The main outcome was the prevalence of oral hypnotic drug reimbursement before and after April 2017. The secondary outcome was the change in prescription habits for zolpidem since the decree in long-term users and excessive users.

RESULTS

A total of 81,174 individuals had at least one hypnotic drug reimbursement; among, whom 2143 had at least one reimbursement of zolpidem. Before the decree, 26% had at least one reimbursement of zolpidem, whereas it dropped to 18.4% after the decree. Among the 545 long-term users, the reimbursement of zolpidem was discontinued after the decree for 60.4% and 24.2% retained zolpidem as a treatment. The main replacement drug was zopiclone for 6.4% of them. Among the 1598 excessive users, the reimbursement of zolpidem was stopped after the decree for 16.5% and 56.3% retained zolpidem as a treatment. The main replacement drug was zopiclone for 12.1% of them.

CONCLUSIONS

The French decree had a major impact on the reimbursement of oral zolpidem. Indeed, prescription of the hypnotic was discontinued for half of the long-term users of zolpidem, and just over one-sixth of the excessive users discontinued the prescription of zolpidem after the decree.

Consumo do benzodiazepínico clonazepam (Rivotril®) no estado do Rio de Janeiro, Brasil, 2009-2013: estudo ecológico

Resumo O objetivo do estudo é estimar a prevalência do uso de clonazepam no Estado do Rio de Janeiro (RJ). Estudo ecológico e descritivo do consumo de clonazepam (2009-2013), com dados do Sistema Nacional de Gerenciamento de Produtos Controlados da Anvisa. O consumo foi medido pela Dose Diária Definida, com indicadores por população total e com 18 anos e mais utilizando a DDD padronizada de 8mg (anticonvulsivante) e a de 1mg (hipnosedativo). Os Municípios da Região Metropolitana foram agrupados segundo os Índices de Desenvolvimento Humano (IDH) e de GINI, submetidos à análise de conglomerados e apresentados segundo o consumo de clonazepam. No Estado do RJ, o consumo entre 2009 e 2013 aumentou de 0,35 para 1,97 DDD/1000 habitantes. Os valores são maiores para os indivíduos acima de 18 anos. Empregando-se 1mg ao invés de 8mg, chega-se a 21 DDD/1000 habitantes acima de 18 anos, em 2013. Rio de Janeiro e Niterói, com os maiores IDH, apresentaram em 2013 os maiores consumos, 3,38 e 4,52 DDD, respectivamente. Os dados sugerem que até 2% da população adulta é usuária de clonazepam, possivelmente como hipnosedativo. Deve-se atentar para o uso ampliado e fora de indicações terapêuticas, dados o potencial de abuso e as reações adversas ao clonazepam.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patterns of gabapentin and pregabalin use and misuse: Results of a population-based cohort study in France

AIMS

The aim of this study was to assess the use and factors associated with the misuse of gabapentin and pregabalin in the general French population, through a cohort study in the EGB (General Sample of Beneficiaries), a national representative sample of the French general population.

METHODS

New users of gabapentin and pregabalin were identified from June 2006 to December 2014, and new users of duloxetine served as control group. Misuse was defined as a use of higher daily doses than recommended. Cox proportional hazard regression models were performed to identify associated factors of misuse.

RESULTS

Misuse was more frequent in the 8692 new users of pregabalin (12.8%) than in the 1963 gabapentin (6.6%) or the 3214 duloxetine new users (9.7%) (P < 0.001). Factors associated with misuse were pregabalin (hazard ratio [HR] 1.48; 95% confidence interval [CI] [1.29-1.69]), age (HR_{[18-45] versus > 70 years} 1.98 [1.70-2.31] and HR_{[58-70] versus > 70 years} 1.25 [1.06-1.47]), multiple prescribers (HR_{2 or 3 versus 1 prescriber} 1.29 [1.15-1.45]; HR_{4 or more versus 1 prescriber} 1.54 [1.30-1.83]), cancer (1.28 [1.11-1.47]), multiple sclerosis (1.53 [1.07-2.18]), neuropathy (1.85 [1.19-2.89]), depression (1.26 [1.07-1.49]) and methadone (2.61 [1.16-5.84]). After this first episode of drug misuse, 11.6% of gabapentin and 10.7% of pregabalin misusers developed a primary addiction.

CONCLUSION

In a cohort of new users, misuse is more likely to occur in new users of pregabalin, with different associated factors of misuse compared to gabapentin and duloxetine. Health professionals and prescribers must be aware of this misuse potential, which could lead to abuse and dependence.

Initiation and long-term use of benzodiazepines and Z-drugs in bipolar disorder

OBJECTIVES

Increasing evidence points to the harmful effects of long-term benzodiazepine treatment. Our objective was to study the incidence of, and predictors for, long-term use of benzodiazepines and Z-drugs in bipolar disorder.

METHODS

We conducted a population-based cohort study, using data from Swedish national registers. Swedish residents aged 18-75 years with a recorded diagnosis of bipolar disorder or mania between July 2006 and December 2012, and no history of benzodiazepine/Z-drug use in the past year, were included. Patients were followed for 1 year with regard to prescription fills of benzodiazepines/Z-drugs. Initiators were followed for another year during which continuous use for >6 months was defined as "long-term". Patient and prescription characteristics were investigated as potential predictors for long-term use in multivariate logistic regression models.

RESULTS

Out of the 21 883 patients included, 29% started benzodiazepine/Z-drug treatment, of whom one in five became long-term users. Patients who were prescribed clonazepam or alprazolam had high odds for subsequent long-term use (adjusted odds ratios [aORs] 3.78 [95% confidence interval (CI) 2.24-6.38] and 2.03 [95% CI 1.30-3.18], respectively), compared to those prescribed diazepam. Polytherapy with benzodiazepines/Z-drugs also predicted long-term use (aOR 2.46, 95% CI 1.79-3.38), as did age ≥60 years (aOR 1.93, 95% CI 1.46-2.53, compared to age <30 years), and concomitant treatment with psychostimulants (aOR 1.78, 95% CI 1.33-2.39).

CONCLUSIONS

The incidence of subsequent long-term use among bipolar benzodiazepine initiators is high. Patients on clonazepam, alprazolam or benzodiazepine/Z-drug polytherapy have the highest risk of becoming long-term users, suggesting that these treatments should be used restrictively.

Identification and tracking of Addictovigilance signals in general practice: which interactions between the general practitioners and the French Addictovigilance Network?

Addictovigilance is a health vigilance dedicated to the survey of medicinal or illicit psychoactive substance use disorders (SUDs). France is the only European country to have a vigilance system specifically dedicated to substances with an abuse/addiction potential. The French Addictovigilance system is organized in a network of regional tertiary centres (called Abuse and Dependence Monitoring Centres, CEIP-Addictovigilance) and works in close collaboration with Regional and National health authorities. Because of the essential and unavoidable nature of their practice in the French Healthcare system, general practitioners (GPs) are key actors to identify and track Addictovigilance signals. They have been involved in several of the pharmacoepidemiological surveys implemented by the French Addictovigilance Network (FAN). Now, they increasingly participate in clinical research projects and studies. In this article, interactions between GPs and the FAN are illustrated with two examples: patients on opioid substitution treatment and patients on opioid analgesics. Collaborations between GPs and the FAN could be further potentiated. In particular, more effective communication on psychoactive SUDs including abuse/addiction is necessary to optimize the implementation of preventive measures for patients on psychoactive substances medications, and to improve the attitudes of GPs and more widely health professionals in the management of any psychoactive user suffering from SUDs. In addition, both adapted training and improved collaborative research could contribute to the optimization (safety, quality) of professional practices.

Concurrent Use of Benzodiazepine by Heroin Users-What Are the Prevalence and the Risks Associated with This Pattern of Use?

INTRODUCTION

Polydrug use involving heroin and benzodiazepines is common. The potential risk of additive pharmacological effects may be associated with poorer outcomes in patients who use benzodiazepines together with heroin. The aim of this study was to determine the clinical picture of patients presenting to the emergency department following acute drug toxicity involving heroin and benzodiazepines.

METHODS

Exposure information, clinical data and outcome of acute drug toxicity presentations were collected between 1 October 2013 and 30 September 2014 as part of the European Drug Emergencies Network (Euro-DEN) project. The database was interrogated to identify patients who had taken heroin with or without benzodiazepine(s).

RESULTS

A total of 1345 presentations involving acute heroin toxicity were identified: 492 had used one or more non-heroin/benzodiazepine drug and were not further considered in this study; 662 were lone heroin users and 191 had co-used heroin with one or more benzodiazepines. Co-users were more likely than lone heroin users to have reduced respiratory rate at presentation 12.7 ± 4.9 vs 13.6 ± 4.4 (p = 0.02) and require admission to hospital 18.3 vs 9.8% (p < 0.01). There were no differences in critical care admission rates 3.1 vs 3.9% (p = 0.83) or length of stay 4 h 59 min vs 5 h 32 min (p = 0.23). The 3 most common benzodiazepines were clonazepam, diazepam, and alprazolam. No differences were observed for clinical features between the three benzodiazepines.

CONCLUSION

This study shows that co-use of heroin and benzodiazepines is common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.

Doctor shopping of opioid analgesics relative to benzodiazepines: A pharmacoepidemiological study among 11.7 million inhabitants in the French countries

BACKGROUND

The abuse of prescription opioids and its subsequent consequences is an important public concern particularly in the USA. The literature on opioid analgesic abuse is scarce.

OBJECTIVE

We assess the extent and risk of opioid analgesics abuse relative to benzodiazepines (BZD) using the doctor shopping method, taken into account the pharmacological characteristics (dosage, route of administration, extended or immediate release).

METHODS

We used SNIIRAM database covering 11.7 million inhabitants. All individuals with at least one reimbursement for non-injectable opioid analgesic or BZD in 2013 were included. Opioids for mild to moderate pain and for moderately severe to severe pain were studied. The Doctor Shopping Quantity (DSQ) is the quantity obtained by overlapping prescriptions from several prescribers. The Doctor Shopping Indicator (DSI) is the DSQ divided by the total dispensed quantity.

RESULTS

The strong opioid analgesics have the highest DSI (2.79%) versus 2.06% for BZD hypnotics. Flunitrazepam ranked first according to its DSI (13.2%), followed by morphine (4%), and zolpidem (2.2%). The three-strong opioids having the highest DSI were morphine, oxycodone and fentanyl (respectively 4%, 1.7% and 1.5%). The highest DSI was observed for the highest dosages of morphine (DSI = 8.4% for 200 mg) and oxycodone (DSI = 2.8% for 80 mg). The highest DSI for fentanyl was described with nasal and transmucosal forms (4.1% and 3.3% respectively). The highest DSI for morphine was described for extended-release (4.1%).

CONCLUSION

There is a need to reinforce surveillance systems to track opioid misuse and to increase awareness of healthcare professionals.

Tamper-resistant prescription forms for narcotics in France: Should we generalize them?

In France, prescription of narcotics must be written on a tamper-resistant prescription form with specific technical particularities. Dosage and daily dose of medicines shall be written out entirely in letters. These prescription forms are also mandatory for buprenorphine, clorazepate, clonazepam, tianeptine, buccal midazolam and zolpidem owing to traffic, abuse or diversion. In 2012, to assess the use of standard and tamper-resistant prescription forms and the acceptability of the generalization of the latter to all medicines, a national opinion survey was performed, with a postal questionnaire, within three randomized samples of 1500 prescribers (physicians, dentists and midwives). Of the 403 participating prescribers (participation rate of 26.8%), 373 were physicians, 14 dentists and 16 midwives. Tamper-resistant prescription forms were used by 76.2% of prescribers, but only by 5.1% in a computerized version, whereas for standard prescription forms, 61% used computer assisted prescription software. The main reason was the inability of the prescription software to print these forms or to respect the mandatory prescription rules for narcotics. Theft and falsification of prescriptions had ever occurred (working life). Most prescribers (62.5%) were against the generalization of tamper-resistant prescription forms. Those in favour were for a generalization to all medicines (65%) and not only to psychotropic agents. Generalization of tamper-resistant prescription forms is not a consensual solution to prevent medicines' diversion. Some prescribers alluded to the possibility of dematerialization and electronic transmission of prescription forms, which could avoid theft, forgery or falsification.

Medical prescriptions falsified by the patients: a 12-year national monitoring to assess prescription drug diversion

Diversion of prescription drugs is difficult to assess in quality and quantity. This study aimed to characterize diversion of prescription drugs in France through a comparative analysis of falsified prescriptions collected during three periods from 2001 to 2012. The data recorded in a national program which records all falsified prescriptions presented to community pharmacies were studied. Included data regarded: subjects, prescription forms, and drugs. Description of the dataset in three periods (2001-2004, 2005-2008, and 2009-2012) was completed with clustering analyses to characterize profiles of prescriptions and subjects associated with the most reported drugs. The 4469 falsified prescriptions concerned most often females (51.6%). Average age was 46.5 years. Zolpidem, bromazepam, and buprenorphine were the most frequent drugs. Alone, 13 drugs (1.7%, 13/772) represented more than 40% of the total reports (3055/7272). They were associated with three diversion profiles: (i) buprenorphine, flunitrazepam, and morphine were mentioned on overlapping secure prescription forms presented by young men; (ii) alprazolam, bromazepam, zolpidem, codeine/acetaminophen were mentioned on simple prescription forms presented by experienced women; and (iii) acetaminophen and lorazepam were mentioned on modified prescription forms presented by elderly subjects. Clonazepam, clorazepate, dextropropoxyphene, zopiclone moved between those profiles. The patterns of falsified prescriptions provided in this study contribute to enhance the scientific knowledge on the most diverted prescription drugs. The latter follow distinct trajectories across time depending on their pharmacology (including their abuse/addiction potential) and on their regulation's history. The close and continuous analysis of falsified prescriptions is an excellent way to monitor prescription drug diversion.

Burning mouth syndrome

Objective

To review the clinical entity of primary burning mouth syndrome (BMS), its pathophysiological mechanisms, accurate new diagnostic methods and evidence-based treatment options, and to describe novel lines for future research regarding aetiology, pathophysiology, and new therapeutic strategies.

Description

Primary BMS is a chronic neuropathic intraoral pain condition that despite typical symptoms lacks clear clinical signs of neuropathic involvement. With advanced diagnostic methods, such as quantitative sensory testing of small somatosensory and taste afferents, neurophysiological recordings of the trigeminal system, and peripheral nerve blocks, most BMS patients can be classified into the peripheral or central type of neuropathic pain. These two types differ regarding pathophysiological mechanisms, efficacy of available treatments, and psychiatric comorbidity. The two types may overlap in individual patients. BMS is most frequent in postmenopausal women, with general population prevalence of around 1%. Treatment of BMS is difficult; best evidence exists for efficacy of topical and systemic clonazepam. Hormonal substitution, dopaminergic medications, and therapeutic non-invasive neuromodulation may provide efficient mechanism-based treatments for BMS in the future.

Conclusion

We present a novel comprehensive hypothesis of primary BMS, gathering the hormonal, neuropathic, and genetic factors presumably required in the genesis of the condition. This will aid in future research on pathophysiology and risk factors of BMS, and boost treatment trials taking into account individual mechanism profiles and subgroup-clusters.

A Case Report of Clonazepam Dependence: Utilization of Therapeutic Drug Monitoring During Withdrawal Period

Clonazepam is long-acting benzodiazepine agonist used in short-acting benzodiazepine withdrawal; however, recent observations suggest the existence of its abuse. We demonstrate a 40-year-old man with a 20-year history of psychiatric care with recently benzodiazepine dependence (daily intake of ∼60 mg of clonazepam and 10 mg of alprazolam). High serum levels of both drugs were analyzed 3 weeks before admission to hospitalization (clonazepam 543.9 ng/mL, alprazolam 110 ng/mL) and at the time of admission (clonazepam 286.2 ng/mL, alprazolam 140 ng/mL) without any signs of benzodiazepine intoxication. Gradual withdrawal of clonazepam with monitoring of its serum levels and increase of gabapentin dose were used to minimize physical signs and symptoms of clonazepam withdrawal. Alprazolam was discontinued promptly. Clinical consequences of the treatment were controllable tension, intermittent headache, and rarely insomia. It is the first case report showing utilization of therapeutic drug monitoring during withdrawal period in the patient with extreme toleration to severe benzodiazepine dependence.

Prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines: A 2-year cohort study

BACKGROUND

Little is known about the use of multiple prescribers for benzodiazepines, which might reflect fragmented patient care and increases the risk of hospital admission for drug dependence or poisoning. Therefore, we aimed to identify the prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines.

METHODS

We conducted a 2-year cohort study of 1178,361 recipients aged 0-74 years using a large health insurance claims database in Japan. We quantified multiple prescriber episodes for benzodiazepines occurring in ambulatory care settings in a baseline and subsequent year by (1) counting the number of unique providers within a 12-month period, (2) calculating the maximum number of unique providers within a single month, and (3) identifying consecutive overlapping prescriptions of over 30 days duration.

RESULTS

Among 58,314 patients with a benzodiazepine prescription during the baseline year, 282 (0.5%) filled prescriptions from four or more providers within a 12-month period, 439 (0.8%) filled prescriptions from three or more providers within a single month, and 757 (1.3%) filled consecutive overlapping prescriptions. The odds for multiple prescriber episodes were significantly higher among patients with multiple chronic conditions. Consecutive overlapping prescriptions had the best accuracy to detect patients with potentially questionable prescribed quantities as well as to predict those with multiple prescriber episodes in the subsequent year.

CONCLUSIONS

These results highlight the need for pharmacists to increase their involvement in prescription oversight and for health insurance agencies to implement a prescription monitoring program to screen for patients with multiple prescriber episodes for benzodiazepines.

Drug abuse monitoring: which pharmacoepidemiological resources at the European level?

Monitoring the potential for abuse and dependence of psychoactive substances falls within the scope of international conventions on narcotic drugs. At the European level, this monitoring is based on activities controlled by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) for substance abuse in general and by the European Medicines Agency (EMA) for marketed drugs, in the context of pharmacovigilance. If France has set up in the early 1990s an original system to assess potential for abuse of psychoactive substances, with specific tools combining both the evaluation of the use of these substances (illicit substances or diverted drugs), and the consequences of that use in terms of morbidity and mortality, there is no equivalent in other European countries. Indeed, unlike the USA, who, for several decades, organized this type of surveillance, with a multisource approach (sentinel systems, databases, medical and administrative data, databases for seeking care in relation abuse), we have not found in other European countries integrated system for identifying a signal of drug abuse, or to assess the impact of measures for minimizing the risk of abuse. However, some recent examples show a growing concern about drug addiction, based on a pharmacoepidemiological approach using pharmacovigilance databases or medical administrative data. These examples illustrate the interest of these approaches in the field of drug of abuse.

Has Previous Abuse of Flunitrazepam Been Replaced by Clonazepam?

BACKGROUND AND AIMS

For many years, flunitrazepam was the benzodiazepine of choice among users of illegal drugs. The aim of this study was to investigate to which extent clonazepam use has increased in this population, and whether this was related to increased prescription or because of illegal availability.

METHODS

We used data from three sources to study the changes in the use of clonazepam: (1) Presence and concentrations of clonazepam and flunitrazepam in blood samples collected from Norwegian drugged drivers; (2) Sales numbers (legal market) for clonazepam, extracted from the Norwegian prescription database (NorPD), and (3) Specific seizures (illegal market) for clonazepam in Norway.

RESULTS

In 2004, 13.0% of the analysed blood samples from drugged drivers contained clonazepam, whereas this proportion had increased to 27.7% in 2013. In the same period, the frequency of flunitrazepam in drugged drivers decreased from 16.6% in 2004 to 3.2% in 2013. The number of clonazepam prescriptions decreased, while the number of seized tablets containing clonazepam increased considerably from 2004 to 2013.

CONCLUSIONS

For the last 10 years, a significant increase in the illegal use of clonazepam has been seen, now replacing flunitrazepam as the most used illegal benzodiazepine in Norway.

Baclofen for alcohol dependence in France: incidence of treated patients and prescription patterns--a cohort study

Recently, baclofen has been widely promoted for treatment of alcohol dependence in France. Our aim was firstly to describe the incidence of patients newly treated with baclofen for alcohol dependence in France from 2007 to 2011, and secondly to describe baclofen prescription patterns and prescribers. A retrospective cohort study of patients newly treated with baclofen was conducted using the "Echantillon Généraliste des Bénéficiaires" database (EGB). Patients with a first dispensation of baclofen between 01/01/2007 and 31/12/2011, followed by a second in the next 120 days, were included. Patients were considered treated with baclofen for neurological conditions if at least one of the following conditions was found to be true: (1) presence of a neurological condition for which baclofen could be prescribed, (2) dispensation of dantrolene, another anti-spastic drug, or (3) hospitalization for a neurological condition for which baclofen could be prescribed. We assumed that all the remaining patients were treated for alcohol dependence. During the 5-year period, 676 patients were incident users. While the annual incidence rate of patients newly treated with baclofen for neurological conditions remained stable, the annual incidence rate of patients newly treated with baclofen for alcohol dependence increased by a factor of 2.9 between 2007 (0.09/1000 person-years) and 2011 (0.26/1000 person-years). In the alcohol dependence group, median duration of baclofen treatment was 143.5 [74.0; 377.0] days; median daily dose was 24.4 [14.8; 39.5] mg. This study demonstrated the rapidly increasing use of baclofen in France for treatment of alcohol dependence.

A European community pharmacy-based survey to investigate patterns of prescription fraud through identification of falsified prescriptions

AIM

To identify prescription drugs involved in falsified prescriptions in community pharmacies in 6 European countries.

METHODS

A cross-sectional survey among 2,105 community pharmacies in Belgium, France, Italy, the Netherlands, Spain and Sweden was carried out to collect all suspect prescription forms. For each reported drug, the number of reported falsified prescriptions per thousand inhabitants was estimated. A falsification ratio was calculated by dividing the number of reports by the number of defined daily doses per 1,000 inhabitants per day for this drug, computed from national sale or reimbursement data.

RESULTS

On 862 prescription forms, benzodiazepines (zolpidem, bromazepam, alprazolam), buprenorphine (as an opioid maintenance drug) and tramadol were the most frequently reported. Depending on their level of use in each country, methylphenidate, morphine and flunitrazepam presented the highest falsification ratios, particularly in Spain, Belgium and France.

CONCLUSIONS

Stimulants, opioids and some benzodiazepines were the most frequently reported drugs in this survey on falsified prescriptions, but differences between countries were observed.

OPPIDUM surveillance program: 20 years of information on drug abuse in France

It is important to assess drug abuse liability in 'real life' using different surveillance systems. Some are based on specific population surveys, such as individuals with drug abuse or dependence, or under opiate maintenance treatment, because this population is very familiar with drugs and is more likely to divert or abuse them. In France, an original surveillance system based on this specific population and called 'Observation of illegal drugs and misuse of psychotropic medications (OPPIDUM) survey' was set up in 1990 as the first of its kind. The aim of this article is to describe this precursor of French drug abuse surveillance using different examples, to demonstrate its ability to effectively give health authorities and physicians interesting data on drug abuse. OPPIDUM is an annual, cross-sectional survey that anonymously collects information on abuse and dependence observed in patients recruited in specialized care centers dedicated to drug dependence. From 1990 to 2010, a total of 50,734 patients were included with descriptions of 102,631 psychoactive substance consumptions. These data have outlined emergent behaviors such as the misuse of buprenorphine by intravenous or nasal administration. It has contributed to assess abuse liability of emergent drugs such as clonazepam or methylphenidate. This surveillance system was also able to detect the decrease of flunitrazepam abuse following implementation of regulatory measures. OPPIDUM's twenty years of experience clearly demonstrate that collection of valid and useful data on drug abuse is possible and can provide helpful information for physicians and health authorities.

Slow-release oral morphine sulfate abuse: results of the postmarketing surveillance systems for psychoactive prescription drug abuse in France

BACKGROUND

Few data are available concerning the diversion and abuse of morphine sulfate. In France, morphine sulfate abuse is currently investigated by the health authorities. The aim of our study was to provide data on morphine sulfate abuse in France, collected during the period 1996-2011.

METHODS

The French monitoring system for psychoactive medication abuse collected data from several sources: spontaneous reporting of cases of abuse or dependence (NotS; 'Notifications Spontanées'), specific periodic surveys from specialized care centers (OPPIDUM; 'Observation des Produits Psychotropes Illicites ou Détournés de leur Utilisation Médicamenteuse'), and community pharmacists (OSIAP; 'Ordonnances Suspectes Indicateur d'Abus Possible').

RESULTS

A total of 649 cases (75% men, median age: 34 years) were spontaneously reported: 578 cases of abuse and 71 cases of use as opiate maintenance treatment. The medication formulation was Skenan(®) (614 cases), and Moscontin(®) (35 cases). All surveys (NotS, OPPIDUM, and OSIAP) showed an overrepresentation of Skenan(®) (87.9-94.6% of cases) that was intravenously injected in 60.4-61.2% of the cases. Data analysis showed that patients abusing morphine sulfate have a long history of drug abuse and a history of polydrug use.

CONCLUSION

All the data presented in this study highlight the level of morphine sulfate abuse, specify the modalities of use (intravenous route), and show the risks associated with abuse (infectious diseases). This study outlines the usefulness of our epidemiological tools, and provides evidence supporting intensive surveillance.