Utilization, Spending, and Price Trends for Benzodiazepines in the US Medicaid Program: 1991-2009

The rising cost of rhinologic medications

BACKGROUND

The high prescription drug cost in the United States may negatively affect patient prognosis and treatment compliance.

OBJECTIVE

To fill the knowledge gap and inform clinicians regarding rhinology medications price changes by evaluating trends in price changes of highly used nasal sprays and allergy medications.

METHODS

The 2014-2020 Medicaid National Average Drug Acquisition Cost database was queried for drug pricing information for the following classes of medications: intranasal corticosteroids, oral antihistamines, antileukotrienes, intranasal antihistamines, and intranasal anticholinergics. Individual medications were identified by Food and Drug Administration-assigned National Drug Codes. Per unit, drug prices were analyzed for average annual prices, average annual percentage price changes, and inflation-adjusted annual and composite percentage price changes.

RESULTS

Beclometasone (Beconase AQ, 56.7%, QNASL, 77.5%), flunisolide (Nasalide, -14.6%), budesonide (Rhinocort Aqua, -1.2%), fluticasone (Flonase, -6.8%, Xhance, 11.7%), mometasone (Nasonex, 38.2%), ciclesonide (Omnaris, 73.8%), combination azelastine and fluticasone (Dymista, 27.3%), loratadine (Claritin, -20.5%), montelukast (Singulair, 14.5%), azelastine (Astepro, 21.9%), olopatadine (Patanase, 27.3%), and ipratropium bromide (Atrovent, 56.6%) had an overall change in inflation-adjusted per unit cost between 2014 and 2020 (% change). Of 14 drugs evaluated, 10 had an increase in inflation-adjusted prices, for an average increase of 42.06% ± 22.27%; 4 of 14 drugs had a decrease in inflation-adjusted prices, for an average decrease of 10.78% ± 7.36%.

CONCLUSION

The rising cost of highly used medications contributes to increased patient acquisition costs and may pose barriers of drug adherence to particularly vulnerable populations.

Association Between Benzodiazepine or Z-Drug Prescriptions and Drug-Related Poisonings Among Patients Receiving Buprenorphine Maintenance: A Case-Crossover Analysis

OBJECTIVE

Persons with opioid use disorder who take benzodiazepines are at high risk for overdose. The objective of this study was to evaluate the association of benzodiazepine and Z-drug use with drug-related poisonings among patients receiving buprenorphine maintenance treatment.

METHODS

A case-crossover study design was used to analyze prescription claims among persons ages 12-64 with opioid use disorder who had buprenorphine prescriptions and had claims data in the IBM MarketScan databases (2006-2016), encompassing 14,213,075 person-days of observation time for 23,036 individuals who experienced drug-related poisoning. The exposures were buprenorphine prescriptions and benzodiazepine or Z-drug prescriptions, standardized as daily diazepam-equivalent milligram doses and separated by pharmacologic properties (short-acting or long-acting benzodiazepines, Z-drugs). The outcome of interest was nonfatal drug-related poisoning. Conditional logistic regression was used to evaluate variation in benzodiazepine or Z-drug and buprenorphine use between poisoning and nonpoisoning days.

RESULTS

Buprenorphine treatment days were associated with a nearly 40% reduction in the risk of poisoning events (odds ratio=0.63, 95% CI=0.60, 0.66) compared with nontreatment days, whereas benzodiazepine or Z-drug treatment days were associated with an 88% increase in the risk of such events (95% CI=1.78, 1.98). In stratified analyses by dose, we observed a 78% (95% CI=1.67, 1.88) and 122% (95% CI=2.03, 2.43) increase in poisonings associated with low-dose and high-dose benzodiazepine or Z-drug treatment days, respectively. High-dose, but not low-dose, benzodiazepine or Z-drug treatment was associated with increased poisonings in combination with buprenorphine cotreatment (odds ratio=1.64, 95% CI=1.39, 1.93), but this was lower than the odds risk associated with benzodiazepine or Z-drug treatment in the absence of buprenorphine (low-dose: odds ratio=1.69, 95% CI=1.60, 1.79; high-dose: odds ratio=2.23, 95% CI=2.04, 2.45).

CONCLUSIONS

Increased risk of nonfatal drug-related poisoning is associated with benzodiazepine or Z-drug treatment in patients with opioid use disorder, but this risk is partially mitigated by buprenorphine treatment. Dose reduction of benzodiazepines or Z-drugs while maintaining buprenorphine treatment may provide the advantage of lowering drug-related poisoning risk.

Medical use, non-medical use and use disorders of benzodiazepines and prescription opioids in adults: Differences by insurance status

OBJECTIVES

To report and analyze prevalence's of Benzodiazepines (BZDs) and Prescription Opioids (POs) use by insurance status and to investigate associations between insurance status and BZDs, POs and concurrent medical/non-medical use and use disorders.

METHODS

This study included 81,133 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported past- year medical use, non-medical use and use disorders of BZDs and POs were assessed, along with their insurance status (Private/Military, Medicare, Medicaid, and Uninsured) and demographic characteristics.

RESULTS

In 2015-2016, 12.6% of adults reported using BZDs and 36.9% reported using POs in the past year. Among adults, 8.3% reported past-year use of both BZDs and POs; also, 1.9% and 3.8% reported non-medical use of BZDs and POs, respectively, and 0.9% reported non-medical use of both BZDs and POs. Medicaid-covered respondents had higher risk of BZDs (aRRR = 1.59, 95%CI = [1.45, 1.74]), POs (aRRR = 1.66, 95%CI = [1.54, 1.79]) and concurrent past-year medical use (aRRR = 2.11, 95%CI = [1.87, 2.38]), higher risk of BZDs non-medical use (aRRR = 1.40, 95%CI = [1.17, 1.68]) and BZD Use Disorders (aRRR = 2.60, 95%CI = [1.82, 3.72]), POs non-medical use (aRRR = 1.67, 95%CI = [1.45, 1.92]), PO use Disorders (aRRR = 4.12, 95%CI = [3.33, 5.11]) and concurrent non-medical use (aRRR = 1.52, 95%CI = [1.20, 1.92]) and Use Disorders (aRRR = 3.68, 95%CI = [1.93, 6.78]), compared to those with private insurance.

CONCLUSIONS

Future health policies should focus on reducing individual and co-prescription of BZDs and POs and providing different strategies of pain management.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α₂δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H₁ antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Landslide susceptibility mapping in an area of underground mining using the multicriteria decision analysis method

Landslides are geomorphological phenomena that affect anthropogenic and natural features on the Earth's surface. Many previous studies have identified several factors that have contributed to landslides. Among these factors are physical characteristics, such as slope, aspect, and land cover, of Earth's surface. Moreover, landslides can be triggered by human activities such as underground mining. This study aims to identify landslide susceptibility areas by analyzing landslide-related factors, including land subsidence triggered by underground mining. The area of interest was Kozlu, Turkey, where underground mining has been in progress for the past 100 years. Thus, to identify landslide risk zones, the multicriteria decision analysis method, together with the analytical hierarchy method, was used. The datasets included were topography, land cover, geological settings, and mining-induced land subsidence. The spatial extent of land subsidence was estimated using a previously published model. A landslide susceptibility map (LSM) was developed using a purposely developed GIS-based software. The results were compared with a terrain deformation map, which was developed in a separate study using the differential synthetic aperture radar interferometry (DInSAR) technique. The results showed a substantial correlation between the LSM and DInSAR map. Furthermore, it was found that ~ 88% of the very high and high landslide risk areas coincided with location of the past landslide events. These facts suggest that the algorithm and data sources used were sufficient to produce a sufficiently accurate LSM, which may be used for various purposes such as urban planning.

The Medicaid Rebate: Changes in Oncology Drug Prices After the Affordable Care Act

BACKGROUND

Prescription drug spending is a significant component of Medicaid total expenditures. The Affordable Care Act (ACA) includes a provision that increases the Medicaid rebate for both brand-name and generic drugs. This study examines the extent to which oncology drug prices changed after the increase in the Medicaid rebate in 2010.

METHODS

A pre-post study design was used to evaluate the correlation between the Medicaid rebate increase and oncology drug prices after 2010 using 2006-2013 State Drug Utilization Data.

RESULTS

The results show that the average annual price of top-selling cancer drugs in 2006, adjusted for inflation and secular changes in drug prices, have increased by US$154 and US$235 for branded and competitive brand drugs, respectively, following the 2010 ACA; however, generic oncology drug prices showed no significant changes.

CONCLUSIONS

The findings from this study indicate that oncology drug prices have increased after the 2010 ACA, and suggest that pharmaceutical companies may have increased their drug prices to offset increases in Medicaid rebates.

Simultaneous Antidepressant and Benzodiazepine New Use and Subsequent Long-term Benzodiazepine Use in Adults With Depression, United States, 2001-2014

IMPORTANCE

Benzodiazepines have been prescribed for short periods to patients with depression who are beginning antidepressant therapy to improve depressive symptoms more quickly, mitigate concomitant anxiety, and improve antidepressant treatment continuation. However, benzodiazepine therapy is associated with risks, including dependency, which may take only a few weeks to develop.

OBJECTIVES

To examine trends in simultaneous benzodiazepine and antidepressant new use among adults with depression initiating an antidepressant, assess antidepressant treatment length by simultaneous new use status, estimate subsequent long-term benzodiazepine use in those with simultaneous antidepressant and benzodiazepine new use, and identify determinants of simultaneous new use and long-term benzodiazepine use.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study using a US commercial claims database included commercially insured adults (aged 18-64 years) from January 1, 2001, through December 31, 2014, with a recent depression diagnosis who began antidepressant therapy but had not used antidepressants or benzodiazepines in the prior year.

EXPOSURES

Simultaneous new use, defined as a new benzodiazepine prescription dispensed on the same day as a new antidepressant prescription.

MAIN OUTCOMES AND MEASURES

The proportion of antidepressant initiators with simultaneous new use and continuing antidepressant treatment for 6 months and the proportion of simultaneous new users receiving long-term (6-months) benzodiazepine therapy.

RESULTS

Of the 765 130 adults (median age, 39 years; interquartile range, 29-49 years; 507 451 women [66.3%]) who initiated antidepressant treatment, 81 020 (10.6%) also initiated benzodiazepine treatment. The mean annual increase in the proportion simultaneously starting use of both agents from 2001 to 2014 was 0.49% (95% CI, 0.47%-0.51%), increasing from 6.1% (95% CI, 5.5%-6.6%) in 2001 to 12.5% (95% CI, 12.3%-12.7%) in 2012 and stabilizing through 2014 (11.3%; 95% CI, 11.1%-11.5%). Similar findings were apparent by age group and physician type. Antidepressant treatment length was similar in simultaneous new users and non-simultaneous new users. Among simultaneous new users, 12.3% (95% CI, 12.0%-12.5%) exhibited long-term benzodiazepine use (64.0% discontinued taking benzodiazepines after the initial fill). Determinants of long-term benzodiazepine use after simultaneous new use were longer initial benzodiazepine days' supply, first prescription for a long-acting benzodiazepine, and recent prescription opioid fills.

CONCLUSIONS AND RELEVANCE

One-tenth of antidepressant initiators with depression simultaneously initiated benzodiazepine therapy. No meaningful difference in antidepressant treatment at 6 months was observed by simultaneous new use status. Because of the risks associated with benzodiazepines, simultaneous new use at antidepressant initiation and the benzodiazepine regimen itself require careful consideration.

Utilization, Spending, and Price Trends for Quinolones in the US Medicaid Programs: 25 Years' Experience 1991-2015

BACKGROUND

Given that the quinolones is one of the antibacterial classes most frequently used to treat patients with bacterial infections in the United States, any change in prescribing patterns of quinolones will impact Medicaid medical expenditures.

OBJECTIVES

This study was undertaken to examine trends in utilization, reimbursement, and prices of quinolone antibacterials for the US Medicaid population.

METHODS

The publicly available Medicaid State Drug Utilization outpatient pharmacy files were used for this study. Quarterly and annual prescription counts and reimbursement amounts were calculated for each of the quinolones reimbursed by Medicaid from quarter 1, 1991 through quarter 2, 2015. Average per-prescription reimbursement, as a proxy for drug price, was calculated as the drug reimbursement divided by the number of prescriptions.

RESULTS

The total annual number of quinolone prescriptions increased 402%, from 247,395 in the first quarter of 1991 to 1.2 million in the second quarter of 2015, peaking at 1.3 million in the first quarter of 2005. Similarly, the total reimbursement for quinolone agents increased by 245.5% over the same period. More than 80% of quinolone prescriptions reimbursed by Medicaid were for the second-generation agent, ciprofloxacin, and the third-generation agent, levofloxacin. The average payment per prescription for quinolones increased from US$43.8 in the first quarter of 1991 to US$87.6 in the second quarter of 2015.

CONCLUSIONS

A substantial rise in Medicaid expenditures on quinolones was observed during the 25-year study period, which was mainly because of rising utilization. Therefore, there is a need for additional research that has access to clinically relevant data with which to measure the rate of inappropriate quinolone use among the Medicaid population and associated clinical outcomes and healthcare costs.

Financial Impact of Direct-Acting Oral Anticoagulants in Medicaid: Budgetary Assessment Based on Number Needed to Treat

BACKGROUND

Faced with rising healthcare costs, state Medicaid programs need short-term, easily calculated budgetary estimates for new drugs, accounting for medical cost offsets due to clinical advantages.

OBJECTIVE

To estimate the budgetary impact of direct-acting oral anticoagulants (DOACs) compared with warfarin, an older, lower-cost vitamin K antagonist, on 12-month Medicaid expenditures for nonvalvular atrial fibrillation (NVAF) using number needed to treat (NNT).

METHOD

Medicaid utilization files, 2009 through second quarter 2015, were used to estimate OAC cost accounting for generic/brand statutory minimum (13/23%) and assumed maximum (13/50%) manufacturer rebates. NNTs were calculated from clinical trial reports to estimate avoided medical events for a hypothetical population of 500,000 enrollees (approximate NVAF prevalence × Medicaid enrollment) under two DOAC market share scenarios: 2015 actual and 50% increase. Medical service costs were based on published sources. Costs were inflation-adjusted (2015 US$).

RESULTS

From 2009-2015, OAC reimbursement per claim increased by 173 and 279% under maximum and minimum rebate scenarios, respectively, while DOAC market share increased from 0 to 21%. Compared with a warfarin-only counterfactual, counts of ischemic strokes, intracranial hemorrhages, and systemic embolisms declined by 36, 280, and 111, respectively; counts of gastrointestinal hemorrhages increased by 794. Avoided events and reduced monitoring, respectively, offset 3-5% and 15-24% of increased drug cost. Net of offsets, DOAC-related cost increases were US$258-US$464 per patient per year (PPPY) in 2015 and US$309-US$579 PPPY after market share increase.

CONCLUSIONS

Avoided medical events offset a small portion of DOAC-related drug cost increase. NNT-based calculations provide a transparent source of budgetary-impact information for new medications.

Benzodiazepine, psychotropic medication, and dementia: A population-based cohort study

INTRODUCTION

Benzodiazepine use has been associated with increased risk of dementia. However, it remains unclear whether the risk relates to short or long half-life benzodiazepines and whether it extends to other psychotropic drugs.

METHODS

Prospective cohort study among 8240 individuals ≥65, interviewed on medication use. Incident dementia confirmed by an end point committee after a multistep procedure.

RESULTS

During a mean of 8 years of follow-up, 830 incident dementia cases were observed. Users of benzodiazepines at baseline had a 10% increased risk of dementia (adjusted hazard ratio [HR], 1.10; 95% confidence interval, 0.90-1.34). However, long half-life (>20 hours) benzodiazepine users had a marked increased risk of dementia (HR = 1.62; 1.11-2.37) compared with short half-life users (HR = 1.05; 0.85-1.30). Users of psychotropics had an increased risk of dementia (HR = 1.47; 1.16-1.86).

DISCUSSION

Results of this large, prospective study show increased risk of dementia for long half-life benzodiazepine and psychotropic use.

Emergency Department Visits and Overdose Deaths From Combined Use of Opioids and Benzodiazepines

INTRODUCTION

Opioid analgesics and benzodiazepines are the prescription drugs most commonly associated with drug overdose deaths. This study was conducted to assess trends in nonmedical use-related emergency department (ED) visits and drug overdose deaths that involved both opioid analgesics and benzodiazepines in the U.S. from 2004 to 2011.

METHODS

Opioid analgesic and benzodiazepine nonmedical use-related ED visits from the Drug Abuse Warning Network and drug overdose deaths from the National Vital Statistics System were analyzed for 2004-2011 to determine trends and demographic-specific rates. Data were analyzed from March 2014 to June 2014.

RESULTS

From 2004 to 2011, the rate of nonmedical use-related ED visits involving both opioid analgesics and benzodiazepines increased from 11.0 to 34.2 per 100,000 population (p-trend<0.0001). During the same period, drug overdose deaths involving both drugs increased from 0.6 to 1.7 per 100,000 (p-trend<0.0001). Statistically significant increases in ED visits occurred among males and females, non-Hispanic whites, non-Hispanic blacks, and Hispanics, and all age groups except 12- to 17-year-olds. For overdose deaths, statistically significant increases were seen in males and females, all three race/ethnicity groups, and all age groups except 12- to 17-year-olds. Benzodiazepine involvement in opioid analgesic overdose deaths increased each year, increasing from 18% of opioid analgesic overdose deaths in 2004 to 31% in 2011 (p-trend<0.0001).

CONCLUSIONS

ED visits and drug overdose deaths involving both opioid analgesics and benzodiazepines increased significantly between 2004 and 2011. Interventions to improve the appropriate prescribing and use of these medications are needed.

[Trends in the consumption of anxiolytic and hypnotic drugs in a Colombian population]

INTRODUCTION

In Latin America, psychotropic medications are the third most marketed drug group, especially antidepressants (35%) and anxiolytics (5%). The objective of this study was to determine the trends in the consumption and the costs of anxiolytic and hypnotic drugs in a population of patients enrolled in the Health System of Colombia.

MATERIAL AND METHODS

A descriptive, observational study was performed using the data recorded inprescriptions for any anxiolytic or hypnotic drug prescribed to outpatients in the period between January 2008 and December 2013 in a population of 3.5 million people. Sociodemographic, pharmacological variables, overall costs, and cost per thousand inhabitants per day (CHD), were also recorded.

RESULTS

The number of patients who received the drugs studied varied from 11,097 to 19,231 between 2008 and 2013. The most used drugs were clonazepam (44.1% of formulations), alprazolam (31.2%), and lorazepam (13.2%). The invoiced value of anxiolytics increased from US$ 207,673.63 in 2008 to US$ 488,977 in 2013, an increase of 135.4%. The CHD was US$ 0.31 for benzodiazepines, and US$ 0.02 for zaleplon, zolpidem and zopiclone (Z drugs) for 2008, and US$ 0.36 and US$ 0.02 in 2013 respectively. The CHD declined after 2010 following the introduction of generic drugs.

CONCLUSIONS

Patients receiving benzodiazepines in Colombia are mostly women, average age 55 years, with very low frequency in defined daily doses per thousand inhabitants when compared with other countries.

Use of benzodiazepines and related drugs in Manitoba: a population-based study

BACKGROUND

Despite their favourable toxicology profile, benzodiazepines and the related Z-drugs (zopiclone, zolpidem and zaleplon) have been associated with physiological tolerance, dependence and addiction. Evidence of harm (e.g., falls, motor vehicle collisions and cognitive disturbances) has been reported in older populations. The aim of this study was to determine the relation between users' characteristics and the use of benzodiazepines and Z-drugs in Manitoba over a 16-year period.

METHODS

This time-series analysis was based on prescription data from Apr. 1, 1996, to Mar. 31, 2012, obtained from the Drug Product Information Network database of Manitoba. We obtained sociodemographic information on benzodiazepine and Z-drug users from the Population Registry and determined changes in utilization rates over time using generalized estimating equations.

RESULTS

Overall, the prevalence of benzodiazepine use remained stable at about 61.0 per 1000 population between 1996/97 and 2011/12; however, the prevalence of Z-drug use increased steadily from 10.9 to 37.0 per 1000 over the same period. In older people (≥ 65 years), the incidence of benzodiazepine use decreased from 55.5 to 30.3 users per 1000, whereas the incidence of Z-drug use increased from 7.3 to 20.3 users per 1000 over the study period. Among those 18-64 years of age, the incidence of benzodiazepine use decreased from 30.1 to 27.6 users per 1000, but the increase in incidence of Z-drug use was more than 2-fold. The youngest population (≤ 17 years) showed the lowest rates of use of these drugs. The highest rates of use were observed among older women and the low-income population.

INTERPRETATION

Over the study period, benzodiazepines have been prescribed less frequently to older patients in Manitoba; however, zopiclone prescribing has continued to increase for all age groups. The reasons for this increase remain to be determined.

Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States

Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Benzodiazepines

The misuse and abuse of prescription medications in the United States continues to increase despite interventions by health care professionals, regulatory, and law enforcement agencies. Opioid analgesics are the leading class of prescription drugs that have caused unintentional overdose deaths. Benzodiazepines when taken alone are relatively safe agents in overdose. However, a 5-fold increase in deaths attributed to benzodiazepines occurred from 1999 to 2009. Emergency department visits related to opioid analgesics increased by 111% followed by benzodiazepines 89%. During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression. Physician and pharmacy shopping by patients occurs, and prescription drug-monitoring programs can provide important information on benzodiazepine and opioid analgesic prescribing patterns and patient usage. Health care professionals need to inform patients and work closely with regulatory agencies and legislatures to stem the increasing fatalities from prescription drug unintentional overdoses.