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

Long-Term Use of Benzodiazepines and Benzodiazepine-Related Drugs: A Register-Based Danish Cohort Study on Determinants and Risk of Dose Escalation

OBJECTIVE

The authors investigated the frequency and determinants of long-term use and risk of dose escalation of benzodiazepines and benzodiazepine-related drugs (benzodiazepine receptor agonists, or BZRAs).

METHODS

All adults ages 20-80 years living in Denmark on January 1, 2000 (N=4,297,045) were followed for redeemed prescriptions of BZRAs in the Danish National Prescription Registry from January 1, 2000, to December 31, 2020. For each drug class, we calculated long-term use for more than 1 or 7 years, and dose escalation measured as increase in dose to a level above the recommended level. Associations were examined using logistic regression.

RESULTS

The authors identified 950,767 incident BZRA users, of whom 15% and 3% became long-term users for more than 1 or 7 years, respectively. These percentages were highest for individuals who initiated Z-drugs (17.8% and 4%). Among the 5% of BZRA users who had at least 3 years of continuous use, there was no indication of dose escalation, as the median dose remained relatively stable. However, 7% (N=3,545) of BZRA users escalated to doses above the recommended level. Psychiatric comorbidity, especially substance use disorder, was associated with higher risk of long-term use and dose escalation.

CONCLUSIONS

A limited portion of the population that received BZRA prescriptions were classified as continuous users, and only a small proportion of this group escalated to doses higher than those recommended in clinical guidelines. Thus, this study does not, under the current regulations, support the belief that BZRA use frequently results in long-term use or dose escalation.

And they slept happily ever after: Online interpretive repertoires on the use of benzodiazepines and z-drugs

Drawing on a critical social-psychological framework for discourse analysis, data from a popular forum for people over 50 were analysed to study how the habitual use of benzodiazepines and Z-drugs (BZD/Z) is discursively negotiated by Flemish older adults. We present five different repertoires (risk and addiction; alternative pathways; suffering; rationalisation; cessation) that illustrate how a pharmaceutical imaginary of these medications is constructed online and how posters act as reflexive users taking on a health role. Most repertoires emerge from a tacit norm on the undesirability of medication use for sleeping problems. In the alternative pathways and cessation repertoires this norm is implicitly accepted by focussing on how to either prevent or overcome chronic use with various alternative solutions or through tapering off, while the risk and addiction repertoire is used to more openly defend and discursively magnify the idea that medication has to be avoided at all cost. We discuss how this reflects a prevailing imperative of health and ethos of healthicisation of sleep. The rationalisation and suffering repertoires on the other hand challenge this norm by defending medication use. We further explore how these repertoires are used to self-position as either 'noble non-user', 'deserving and/or compliant patient' or 'rational user', reflecting previously found moral positions in offline settings. Our data add another position that has thus far not been discussed extensively with regard to prescription medication use, namely that of a 'recovered user'. As such, this study shows how this particular online community is a site for contestation of health promotion and medical/pharmaceuticalised discourses on sleep by users and non-users alike and offers a unique insight into how people in the age group that is known to use most BZD/Z discursively negotiate the use of these medications in pseudonymised online interactions.

The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review

Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.

Long-term use of hypnotics: Analysis of trends and risk factors

OBJECTIVE

Patients with chronic insomnia are prone to long-term use of hypnotics. Reported risk factors include aging, female sex, and comorbid psychiatric disorders. However, most previous studies have been cross-sectional cohort studies.

METHOD

We conducted a retrospective cohort study using medical service payment data for 330,000 people to determine the duration of prescription of hypnotics and the risk factors for long-term use. We followed up 3981 patients (2382 M, 1599 F, age 40.3 ± 12.4 years) who were prescribed hypnotics for the first time between April 2005 and March 2008.

RESULTS

Of these 3981 patients, 59.6% were prescribed hypnotics for only 1 month, 11.3% were prescribed hypnotics for 2 consecutive months, and 10.1% of patients continued receiving prescriptions for the entire 12-month observation period. In multiple logistic time-dependent Cox analyses, use of antidepressants, mean dose of hypnotics, and advanced age were significantly associated with long-term use of hypnotics (p < 0.01). In an analysis of the association between long-term use of hypnotics and prescribed dosage, high monthly dose, advanced age, and department of first visit were significantly associated with long-term use (p < 0.01).

CONCLUSION

These clinical indicators may be effective for early identification of patients with insomnia who are at high risk of developing physical dependence on hypnotics.

Factors associated with long-term prescription of benzodiazepine: a retrospective cohort study using a health insurance database in Japan

OBJECTIVES

Current clinical guidelines discourage long-term prescription of benzodiazepines and Z-drugs (BZD); however, the practice continues to exist. The aim of this study was to investigate the proportion of long-term BZD prescriptions and its risk factors.

DESIGN

Retrospective cohort study using a health insurance database.

SETTING

Japan.

PARTICIPANTS

A total of 86 909 patients were identified as outpatients aged 18 to 65 years who started BZD between 1 October 2012 and 1 April 2015. After excluding patients who underwent surgery on the day of first BZD prescription (n=762) and patients without 8 months follow-up (n=12 103), 74 044 outpatients were analysed.

MAIN OUTCOME MEASURES

We investigated the proportion of long-term prescriptions for ≥8 months among new BZD users. We assessed patient demographics, diagnoses, characteristics of the initial BZD prescription and prescribers as potential predictors of the long-term BZD prescription. Multivariable logistic regression was performed to assess the association between long-term prescription and potential predictors.

RESULTS

Of the new BZD users, 6687 (9.0%) were consecutively prescribed BZD for ≥8 months. The long-term prescription was significantly associated with mood and neurotic disorder, cancer, prescription by psychiatrists, multiple prescriptions, hypnotics and medium half-life BZD in the initial prescription.

CONCLUSION

Despite the recent clinical guidelines, 9% of new BZD users were given prescriptions for more than 8 months. Physicians should be aware of risk factors when prescribing BZDs for the first time.

The impact of in hospital patient-education intervention on older people's attitudes and intention to have their benzodiazepines deprescribed: a feasibility study

Background

Long-term benzodiazepine use in the older population is common and is associated with significant harm. The provision of a patient-educational booklet during hospitalization may encourage patients to discuss review and possible deprescribing of benzodiazepine therapy with their health professionals. The aim of this study was to assess the feasibility and effect of a patient empowerment intervention in hospital inpatients on patient initiation of a discussion about deprescribing benzodiazepines versus usual care.

Methods

A feasibility interventional study using a patient-empowerment education intervention was conducted at a Sydney teaching hospital. Patients aged ⩾ 65 years, prescribed a benzodiazepine, and able to provide consent were invited to participate in the study. Participants were randomly allocated to intervention or control group (1:1). Intervention participants received the patient-empowerment booklet and control received usual care. All participants received 1-month follow-up phone interviews to assess medication and attitudinal changes.

Results

A total of 42 participants were recruited (20 intervention and 22 control). The average age was 71.5 (interquartile range: 69.0-80.3) and 54.8% were females. There was no difference in baseline characteristics between intervention and control groups (p > 0.05). At baseline, 65.0% of participants (53.0% intervention, 86.0% control) were not concerned about the potential benzodiazepine side effects. Twenty-nine participants (15 intervention and 14 control) completed 1-month follow up; 22 participants (11 intervention and 11 control) were discharged on the benzodiazepine. Among these, 13 (59.1%) had ceased benzodiazepine at 1-month follow up [46.2% (n = 6) intervention; 53.8% (n = 7) control]. In the intervention group, 33.3% (n = 5) of participants had initiated a discussion with their doctor or pharmacist about stopping the benzodiazepine compared with 35.7% (n = 5) in the control group.

Conclusion

Cessation of benzodiazepines 1 month following discharge was common. Future larger studies are required to confirm the effectiveness of providing a patient-empowerment booklet on reducing benzodiazepine use and other potentially inappropriate medications.

Attitudes and behaviour towards psychotropic drug prescribing in Swedish primary care: a questionnaire study

Background

The prescribing of psychotropic drugs, i.e. antidepressants, sedatives (anxiolytics, hypnotics), and antipsychotics is considerable and a large proportion is prescribed by general practitioners (GPs). There are concerns about dependency and medicalisation, and treatment decisions in psychiatry may appear arbitrary. Increased knowledge of GPs’ opinions on the prescribing of psychotropics may lead to more rational use of these drugs. We aimed to quantify GPs’ attitudes, beliefs and behaviour towards various aspects of psychotropic drug prescribing.

Methods

A questionnaire was distributed to physicians in all 199 GP practices in Region Västra Götaland, Sweden. The questions concerned determinants of psychotropic drug prescribing that had been identified in a previous, qualitative study.

Results

Questionnaires from 516 physicians (64% of whom were specialists in family medicine, 21% interns in family medicine, 15% others) at 152 GP practices (59% of which were state owned, 72% in an urban area, with a median of 7808 registered patients) were returned (estimated response rate: 48%). A majority – 62% – of GPs found it easier to start prescribing psychotropic drugs than to stop (95% confidence interval, 57%, 66%) vs. 8% (6%, 10%). Most GPs considered psychotherapy more suitable than psychotropic drugs in cases of mild psychiatric disease: 81% (77%, 84%) vs. 4% (3%, 6%). The problems treated with psychotropic drugs were considered to be mostly socioeconomic, or mostly medical, by similar proportions of physicians: 38% (34%, 42%) vs. 40% (36%, 45%). GPs were on average satisfied with their levels of antidepressant and sedative prescribing in relation to medical needs. More GPs regarded their prescribing of antipsychotics as being too low rather than too high: 33% (28%, 39%) vs. 7% (4%, 10%).

Conclusions

This study illustrates the complexities of psychiatric drug treatment in primary care and identifies potential drivers of increased prescribing of psychotropics. The manifold factors, medical and non-medical, that affect prescribing decisions may explain a sense of arbitrariness surrounding psychotropic drug treatment. This notwithstanding, GPs seem mostly content with their prescribing.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0885-4) contains supplementary material, which is available to authorized users.

Patterns, predictors and persistence of chronic sedative use: a population-based observational study of older adults in British Columbia, Canada

BACKGROUND

Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada.

METHODS

This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years.

RESULTS

Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013.

INTERPRETATION

Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.

Continuation and discontinuation of benzodiazepine prescriptions: A cohort study based on a large claims database in Japan

Although benzodiazepines (BZDs) are often prescribed to treat a wide range of psychiatric and neurological conditions, they are also associated with various harms and risks including dependence. However the frequency of its continued use in the real world has not been well studied, especially at longer follow-ups. The aim of this study was to clarify the frequency of long-term BZD use among new BZD users over longer follow-ups and to identify its predictors. We conducted a cohort study to examine how frequently new BZD users became chronic users, based on a large claims database in Japan from January 2005 to June 2014. We used Cox proportional hazards models to identify potential predictors. A total 84,412 patients with new BZD prescriptions were included in our cohort. Among them, 35.8% continued to use BZD for three months, 15.2% for one year and 4.9% for eight years without ever attaining three months of no BZD prescription. The confirmed predictors for long-term BZD use were older age, psychiatrist-prescriber, regular use, high dose of BZD, and concomitant prescription of psychotropic drugs. When we consider BZD use, we have to keep in mind these figures and avoid these predictors as much as possible.

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

Background

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

Methods

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

Results

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

Conclusions

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

Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

BACKGROUND

Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected.

RESULTS

Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53%) articles were original research, predominantly randomized controlled trials (n = 52 [37%]), whereas 58 (42%) were narrative reviews and seven (5%) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57%]). Additional deprescribing strategies included psychological therapies (n = 10 [14%]), mixed interventions (n = 12 [16%]), and others (n = 10 [14%]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76%]), education (n = 36 [47%]), and training (n = 29 [39%]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely.

CONCLUSIONS

Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.

Pregabalin is increasingly prescribed for neuropathic pain, generalised anxiety disorder and epilepsy but many patients discontinue treatment

AIM

To assess prescribing patterns, sociodemographic characteristics and previous disease history in patients receiving pregabalin.

METHODS

An observational study using register data on dispensed drugs and recorded diagnoses for all patients in Stockholm, Sweden, who filled at least one prescription of pregabalin between July 2005 and December 2009. Analyses focused on prevalence, incidence, diagnosis patterns, prior dispensing of other analgesics/psychotropics and persistence to treatment over time.

RESULT

A total of 18,626 patients (mean age 55 years, 63% women) were initiated on treatment between July 2006 and December 2009. Approved indications were recorded in hospital and/or primary care within 1 year prior to the first dispensing for 40% of the patients (epilepsy 1.3%, neuropathic pain 35.5% and generalised anxiety disorder (GAD) 3.6%). Antidepressants were used by 55%, opioids by 49% and sedatives by 48% prior to initiation of pregabalin. One-third (34%) only purchased one prescription and the proportion purchasing pregabalin 1 year after initiation was 42.1% for epilepsy, 36.3% for GAD, 21.5% for neuropathic pain and 25.6% for those without any of the included diagnoses.

CONCLUSION

Pregabalin was mainly used as a second-line drug for the treatment of GAD or neuropathic pain and to a lesser extent as add-on therapy in epilepsy. However, a large proportion of all patients only purchased one prescription and the persistence declined rapidly over time. The issue of potential off-label prescribing or poor registration of diagnoses should also be noted as a high proportion had been prescribed the drug without a record of any of the approved indications.

Assessing the effect of a guideline change on drug use prevalence by including the birth cohort dimension: the case of benzodiazepines

PURPOSE

The aim of this study was to investigate whether including the birth cohort dimension in time series analysis leads to a more accurate estimation of the (long-term) effect of a guideline change on the trend of benzodiazepine use.

METHODS

We calculated age-specific (20-84 years) and sex-specific prevalence of benzodiazepine use per 1000 population per quarter year (1998 to 2008) using a prescription database set in the Netherlands. We studied the prevalence over time by age group and within birth cohorts through interrupted time series analyses to estimate the effect of the guideline change in 2001.

RESULTS

From 1998 to 2008, the overall age-standardized prevalence of benzodiazepine use per 1000 population declined from ~54 for men and ~107 for women to ~45 for men and ~85 for women. The relative change increased significantly after 2001 for both sexes and for the majority of age groups. Within birth cohorts, the prevalence increased with age until the year 2001 and leveled thereafter. The age-period approach overall had worse model fit indicators than the within-cohort approach and predicted larger long-term effects than the within-cohort approach. The age-period projection estimated 36% decline in benzodiazepine use relative to 2008, whereas the birth-cohort projection estimated 8% decline.

CONCLUSION

Explicitly following birth cohort trajectories led to models with better fit; the conventional approach estimated a stronger long-term guideline effect. This has important implications for professional practice.

Reimbursement restriction and moderate decrease in benzodiazepine use in general practice

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Benzodiazepines revisited--will we ever learn?

AIMS

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

METHODS

A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

RESULTS

Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.

CONCLUSIONS

The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.

Use of addictive anxiolytics and hypnotics in a national cohort of incident users in Norway

PURPOSE

To examine (1) incidence rates for treatment with addictive anxiolytics and hypnotics in Norway, (2) the proportions initiated by general practitioners (GPs), psychiatrists, and other physicians, and (3) the course of the treatment among incident users during a 3.5 year follow-up period.

METHOD

Data on all prescriptions of anxiolytics (ATC code N05B) and hypnotics (N05C) dispensed to the general population from 1 January 2004 to 31 August 2009 were extracted from the Norwegian Prescription Database and merged with data about GPs from the Norwegian Regular General Practitioner Scheme.

RESULTS

One-year incidence rates per 1,000 inhabitants were 18.2 for anxiolytics, 24.5 for hypnotics, and 35.4 for anxiolytics and hypnotics combined. GPs and psychiatrists initiated the treatment to 75.4 and 2.4%, respectively. Only 30.8% received short-term treatment as recommended. Long-term use (11.8%) and heavy use (1.4%) were most common for treatments initiated by a GP, but the risk both of long-term and of heavy use was highest for patients initially treated by a psychiatrist. The amount redeemed during the first quarter was the strongest predictor of long-term use and of heavy use. However, even during the quarter with highest drug consumption, 81.5% of the patients received <1 DDD/day.

CONCLUSIONS

This study indicates that physicians' prescribing strategy towards initial users is crucial in order to prevent inappropriate drug use. There is a need to implement relevant guidelines and systems for structured clinical audits in general practice.

Benzodiazepines predict use of opioids--a follow-up study of 17,074 men and women

OBJECTIVE

To evaluate the effect of the use of benzodiazepines on prescription of opioids 4-7 years later in patients with noncancer pain.

DESIGN

A cohort of 7,991 men and 9,083 women aged 40, 45 and 60 years who reported no use of opioids in health surveys in 2000-2001 was linked to the nationwide Norwegian Prescription Database, and their prescriptions of opioids during 2004-2007 were analyzed. Moderate-high prescription frequency of opioids was defined as at least 12 prescriptions during the period January 2004-December 2007.

RESULTS

The unadjusted odds ratio for moderate-high prescription frequency of opioids for individuals who had previously used benzodiazepines was 7.7 (95% confidence interval 5.6-10.5) as compared with previous nonusers. After adjustment for musculoskeletal pain, alcohol, smoking habits, and socioeconomic variables, the odds ratio was lowered to 3.1 (2.1-4.6). The analysis of the effect of benzodiazepines and chronic pain individually and in combination suggest that use of benzodiazepines is an even stronger predictor of later opioid use than self-reported chronic pain.

CONCLUSIONS

Our study suggests that earlier use of benzodiazepines may predict repeated use of opioids. Before starting pain treatment with opioids, clinicians should take into consideration the possibility of substance abuse and mental health disorders. A central issue when prescribing opioids for chronic noncancer pain is to balance the risk of problematic use of these drugs with the benefits of pain relief.

Assessment of abuse potential of benzodiazepines from a prescription database using 'doctor shopping' as an indicator

BACKGROUND

Benzodiazepines are widely used for different purposes because of their pharmacological properties, but their abuse potential may represent a limitation to their use. Data suggest that this abuse potential may vary between products and available dosages. Doctor shopping (the simultaneous use of several physicians by a patient) is one of the most important ways in which prescription drugs, in particular benzodiazepines, are diverted.

OBJECTIVE

To assess the potential for abuse of several benzodiazepines using doctor shopping in a French administrative area as a proxy for abuse.

METHODS

All prescriptions reimbursed during the year 2003 in Haute-Garonne, France (one million inhabitants) for benzodiazepines that were available in ambulatory care through community pharmacies as solid oral forms were extracted from a reimbursement database. The benzodiazepines were alprazolam (0.25 mg, 0.50 mg), bromazepam 6 mg, clonazepam 2 mg, clorazepate (5 mg, 10 mg, 50 mg), diazepam (1 mg, 5 mg, 10 mg), flunitrazepam 1 mg, lorazepam (1 mg, 2.5 mg) and tetrazepam 50 mg. For each patient, the quantities prescribed, dispensed and obtained by doctor shopping (i.e. overlap between prescriptions from different prescribers) were computed. Benzodiazepines were compared using their 'doctor shopping indicator' (DSI, the percentage of each drug obtained through doctor shopping among the total reimbursed quantity).

RESULTS

About 128 000 patients received at least one benzodiazepine during the year. Four groups of benzodiazepines were identified according to their abuse potential: very high abuse potential (flunitrazepam, DSI = 42.8%); high abuse potential (diazepam 10 mg, DSI = 3.2%; clorazepate 50 mg, DSI = 2.7%); intermediate abuse potential (alprazolam 0.50 mg, bromazepam, clonazepam, DSI ranging from 1.8% to 1.9%); and low abuse potential (other benzodiazepines and dosages, DSI ranging from 0.3% to 1.1%).

CONCLUSION

The DSI can be used to assess the relative abuse liability of benzodiazepines and to detect signals of new patterns of abuse in settings where centralized records of prescription or deliveries are available for the great majority of patients.

Usage of benzodiazepines: A review

Abstract Purpose. The use of benzodiazepines remains a source of controversy. Some prescribers believe that they are beneficial and espouse their use; others regard their risk:benefit ratio as too adverse for any but occasional use. This review considers these viewpoints based on the appropriate literature. Survey. The recent English-language literature relating to this topic was surveyed. The publications proved too heterogeneous for a formal meta-analysis, so a descriptive review is provided. Overview. Surveys of benzodiazepine use provide data mainly from the UK, Europe and North America. Prescribing patterns varied widely but long-term usage is common and sometimes the norm. Conclusions. Long-term prescription of benzodiazepines still takes place despite general warnings from the medical and other professions and drug regulatory bodies that long-term use is unjustified both from the lack of a systemic database establishing such efficacy and a large literature documenting the risks of long-term usage, such as dependence. The young and the old are particularly at risk. Continued monitoring is essential, but the regulatory authorities may need to take a more active role in curbing such undesirable practice.

Dispensing of psychotropic drugs to adults in community pharmacies in Latvia

OBJECTIVE

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

SETTING

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

METHOD

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Identifying how age and gender influence prescription drug use in a primary health care environment in Catalonia, Spain

What is already known about this subject. Knowledge of prescription patterns in primary health care is an important tool in rational drug therapy. Age and gender are the principal determining factors of cost variability between medical practices, due to drug prescriptions. Age and gender are the principal determining factors of cost variability in relation to the therapeutic group. What this study adds. This study provides specific information on the use of drugs in the primary health care environment of the Catalan Health System, and the differences observed are analyzed with respect to age and gender of the population receiving care. The study shows that there is a high prevalence of drugs in the under 5 year old age group, and also in persons over 54 years of age. The variability found in the cost per patient suggests that adjustment should be made for age in practitioners' prescription evaluation procedures in primary health care in Catalonia.

AIMS

To determine the prevalence and usage patterns of prescription drugs according to patients' age and gender, and to identify their relative importance in the prescription costs, in primary health care within the Catalan Health Institute.

METHODS

This was a cross-sectional study using computerized pharmacy dispensing records for 5 474 274 members registered, during 2002. Twenty age-gender categories were established. Use of a drug group was defined as filling at least one prescription. The variables studied were age, gender, number of prescriptions and net cost. The prevalence of use, the number of prescriptions and cost issued to each age category were reported.

RESULTS

The overall prevalence of drug use was 74.53% (women 80.93%, men 67.84%). This was higher in the group of 0-4 year-olds, and in the >or= 55 year-olds. Age (P < 0.001) produced a statistically more significant effect than gender (P < 0.05). The most used therapeutic groups were analgesics, nonsteroidal anti-inflammatory drugs, antiulcer drugs, anxiolytics, expectorants and mucolytics. The number of prescriptions and costs per patient rose with age and showed great variation in the use of these groups for patients in different age groups. The risk of prescription in women was 23% higher than in men (RR 1.23, 95% CI 1.11, 1.37, P < 0.001).

CONCLUSIONS

The majority of subjects were exposed to one or more drugs. The variability in the number of prescriptions and in the prescribing cost per patient between the different age groups suggests that adjustments should be made for age in practitioners' prescription evaluation processes in primary health care in Catalonia.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prospective cohort study into post-disaster benzodiazepine use demonstrated only short-term increase

OBJECTIVES

Benzodiazepines are typically prescribed for anxiety and insomnia, two complaints often reported after disasters. Benzodiazepines can cause mental or physical dependence, especially when taken for a long time. This study aims at evaluating benzodiazepine use in a disaster-stricken community with the help of computer-based records.

STUDY DESIGN AND SETTING

This prospective cohort study covers a period of 4 years. For every patient, predisaster baseline data are available. Multilevel regression is applied to study differences in benzodiazepine use in 496 patients whose children were involved in the Volendam café fire on January 1, 2001 compared with 1,709 community controls, and 4,530 patients from an unaffected cohort.

RESULTS

In community controls and patients from the unaffected cohort, benzodiazepine use remained stable in the course of the years. In the first year postfire, parents of disaster victims were 1.58 times more likely to use benzodiazepines than community controls (95% confidence interval 1.13-2.23). With regard to long-term use, differences between community controls and parents were statistically nonsignificant.

CONCLUSIONS

In the studied community, benzodiazepines were predominantly prescribed as a short-term intervention. Clinical guidelines that advocate a conservative prescription policy were well adhered to.

Use of Health Care Databases in Pharmacoepidemiology

Pharmacoepidemiology is the study of the use and effects of medications in populations. Large health care databases are often used to address research questions within pharmacoepidemiology. This paper briefly describes the kinds of research questions that can be addressed using pharmacoepidemiology databases, provides an overview of pharmacoepidemiologic databases, describes some differences between medical records and administrative databases, discusses factors that should be considered when choosing a database for a particular study, and considers what the future holds.

Patterns and correlates of benzodiazepine use in the French general population

OBJECTIVE

To investigate the prevalence of current use of benzodiazepines (BZDs) and related drugs in the French general population and factors associated with this use.

METHODS

National cross-sectional telephone survey conducted between 25 April 2001 and 8 May 2001 in a representative sample of non-institutionalized adults of BZD use and duration, prescriber specialty, socio-demographic data and mood and anxiety disorders, using a structured diagnostic interview.

RESULTS

The prevalence of current use of BZD was 7.5%. It was higher among women (9.7%) than men (5.2%). It increased with age and was higher in the jobless (10.9). Duration of BZD use was more than 6 months in 75.9% of users and increased with age. Of the 711 (17.7%) subjects with at least one mood or anxiety disorder, 122 (17%) used BZD compared with 180 (5.5%) of the 3296 subjects without mood or anxiety disorders. In multivariate analysis, factors associated with BZD use were age [odds ratio (OR): 3.6; 95% confidence interval (CI) 2.0-5.6], 6.5 (4.1-10.3) and 10.9 (6.9-17.1), respectively, for ages 35-44 years, 45-59 years and over 60 years compared with below 34 years, female gender (OR: 1.7; 95% CI 1.3-2.1), anxiety only (OR: 2.2; 95% CI 1.5-3.2), mood disorder only (OR: 4.4; 95% CI 2.7-7.1) or both mood and anxiety disorders (OR: 8.8; 95% CI 5.9-12.6).

CONCLUSION

Despite precautions, warnings and attempts to limit use, there remains a high proportion of long-term BZD users in the general French population, especially in the elderly. Our findings add to the weight of opinion that messages concerning proper use of BZDs certainly need to be clarified and amplified.