Factors associated with benzodiazepine prescribing in community mental health settings

The RECAPACITA PROJECT: comparative study of the clinical, neuropsychological, and functional profile of people with severe mental disorder and partial and total capacity modification

BACKGROUND

Evaluating the decision-making capacity of individuals with Severe Mental Disorder (SMD) is essential for compliance with the 2006 Convention on the Rights of People with Disabilities. In Spain, capacity was historically determined through judicial procedures, resulting in partial or total capacity modification (CM). The abolition of this procedure in 2021 has left a gap in addressing the needs of this population, creating challenges under the new legal framework.

AIM

The RECAPACITA project studied the clinical, neuropsychological, and functional profiles of individuals with SMD and CM, focusing on differences between partial (pCM) and total (tCM) modifications.

METHODS

A cross-sectional study was conducted with 77 adult patients with SMD and CM (47 tCM, 30 pCM) from the Parc Sanitari Sant Joan de Déu mental health network (Spain). Sociodemographic, clinical, functional, and neuropsychological data were collected, along with an independent assessment of mental capacity.

RESULTS

Around 87% of sample had a schizophrenia spectrum disorder; pCM patients presented more substance-related and personality disorders as a secondary diagnosis. While no statistically significant differences were observed between groups, clinically, tCM group presents greater clinical alteration, lower insight, sustained attention, coding capacity, processing speed and resistance to interference compared to pCM group. tCM group had worse social functioning, and lower scores in reasoning and appreciation when assessing mental capacity.

CONCLUSIONS

Individuals with tCM show greater clinical impairment and higher support needs compared to those with pCM. With the practical and legal abolition of tCM, it is essential to ensure that these individuals' persistent challenges are adequately addressed, as their needs remain significant despite the disappearance of this legal category.

Psychiatric and racial/ethnic differences in incident and long-term benzodiazepine use: A commercial healthcare claims study

OBJECTIVES

This study evaluated psychiatric diagnoses and race/ethnicity as predictors of both incident and long-term benzodiazepine use.

METHODS

We implemented two designs using commercial healthcare claims from Optum's de-identified Clinformatics® Data Mart Database. We first conducted a case-control study and examined 1,904,608 individuals with a new benzodiazepine prescription (ages 13-64 from 2010 to 2019) and matched controls. We used conditional logistic regression to examine 21 potential indications and other psychiatric diagnoses and race/ethnicity as predictors of filling a benzodiazepine prescription. We then used Cox proportional hazards regression in a cohort study among those with a new benzodiazepine to examine the degree to which psychiatric diagnoses and race/ethnicity predicted transitioning to long-term treatment, defined as six months or more of continuous prescription fills.

RESULTS

All included psychiatric diagnoses were associated with incident benzodiazepine use, and most subsequently predicted long-term treatment. Among the most common and strongest predictors for incident use was having any anxiety disorder (Odds Ratio = 5.71; 95% Confidence Interval [CI], 5.67-5.76). Two years after the initial prescription, 8.0% of BZD recipients had met criteria for long-term treatment at least once. Among the strongest predictors of long-term treatment was severe mental illness [e.g., schizophrenia; (Hazard Ratio = 2.36; 95% CI, 2.27-2.47)]. Individuals from all racial/ethnic minoritized groups were less likely to have both incident and long-term benzodiazepine use compared with White individuals.

CONCLUSIONS

These findings highlight that transition to long-term treatment is occasionally occurring and notable among BZD recipients, particularly among those with severe mental illness.

Demographic Characteristics and Prescription Drug Histories of Unintentional Overdose Decedents in Philadelphia, PA

BACKGROUND

Philadelphia's opioid overdose crisis has reached unprecedented levels. However, overdose deaths involving non-opioids have also increased in recent years. As overdose deaths continue to increase, this study describes and compares the demographic characteristics, prescription drug histories, and exposure to potentially inappropriate prescribing practices (PIPPs), in the year before death of three groups of overdose decedents: (1) only opioid(s) detected in postmortem toxicology, (2) only non-opioid(s) detected, (3) both opioids and non-opioids co-detected [i.e. concomitant detections].

METHODS

Philadelphia Medical Examiner's Office data on unintentional overdose deaths from July 1, 2017 to June 30, 2022, were matched to Pennsylvania Prescription Drug Monitoring Program data. Differences were assessed using chi-square analyses, z-tests of proportions, and a multinomial logistic regression.

RESULTS

During the study period, 5,440 overdose deaths occurred in Philadelphia. Compared to the other two toxicology groups, a substantially larger proportion of non-opioid only decedents were Non-Hispanic Black (all z-tests p-values <0.001). In the year before death, a larger proportion of decedents with concomitant detections filled benzodiazepine and/or buprenorphine prescriptions and were exposed to PIPPs (all z-tests p-values <0.05). Differences by demographic characteristics, time period of death, and history of buprenorphine and benzodiazepine prescriptions remained statistically significant in the multinomial logistic regression (all p-values < 0.05).

CONCLUSIONS

To ensure that equitable policies and prevention programs are developed, more research is needed on (1) the intersectionality of demographic characteristics and the perceived risks, preferences, and access of non-opioids (including controlled drug prescriptions), and (2) the implications of current prescribing guidelines on people who may use multiple substances.

Differential effects of healthcare worker burnout on psychotropic medication use and misuse by occupational level

PURPOSE

Burnout has been well examined among physicians and other high-wage, high-autonomy healthcare positions. However, lower-wage healthcare workers with less workplace autonomy (e.g., medical assistants, nurses' aides) represent a substantial proportion of the workforce, but remain understudied. We aimed to examine the effects of burnout on psychotropic medication use and misuse and whether these effects differed by occupational level.

METHODS

In March 2022, we collected data from a diverse sample of US healthcare workers (N = 200) and examined the cross-sectional relationship between burnout and changes in prescribed psychotropic medication (i.e., starting, stopping, and/or having a change in the dose/frequency) during the COVID-19 pandemic. We also separately examined the relationship between burnout and psychotropic medication misuse (i.e., without a prescription, in greater amounts, more often, longer than prescribed, and/or for a reason other than prescribed). We stratified models by occupational level (prescribers/healthcare administrators vs. other healthcare workers).

RESULTS

Greater burnout was associated with higher odds of changes in prescribed psychotropic medication among prescribers/healthcare administrators (aOR = 1.23, 95% CI 1.01, 1.48), but not among other healthcare workers (aOR = 1.04, 95% CI 0.98, 1.10). Greater burnout was not associated with psychotropic medication misuse among prescribers/healthcare administrators (aOR = 0.96, 95% CI 0.82, 1.12) but was associated with increased odds of psychotropic medication misuse among other healthcare workers (aOR = 1.07, 95% CI 1.01, 1.14).

CONCLUSIONS

Potential disparities in help-seeking and healthcare access might manifest in non-medical use of prescription drugs among some healthcare workers, which has implications for worker safety and well-being.

Racial-Ethnic Disparities in Benzodiazepine Prescriptions for Anxiety in US Emergency Departments

BACKGROUND/OBJECTIVES

Benzodiazepines are commonly used to treat anxiety and panic disorders. White patients are more likely to receive a benzodiazepine prescription than non-White patients in different medical settings. Racial-ethnic disparities have also been found in prescription of opioids from the emergency room. It is not known whether racial disparities in benzodiazepine prescriptions exist at the emergency department level. This study aims to analyze the relationship between benzodiazepine prescriptions for anxiety in an emergency department setting.

DESIGN

Data for this cross-sectional study was obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) Years 2009-2018. Patients ≥ 18 years of age presenting to the emergency department with anxiety were identified. Adjusted survey logistic regression was conducted to evaluate the patient characteristics and receipt of benzodiazepines.

RESULTS

This study analyzed 1,174,556,119 emergency department (ED) visits out of which 2.8% had a diagnosis of anxiety disorder. Prevalence of anxiety was higher in the following groups: females, younger age range (18-34 years old), and non-Hispanic (NH) White. Rates of benzodiazepine prescription for patients with anxiety were higher for NH-White and Hispanic patients at 29% and 28% respectively than for NH-Black and NH-Other (24% and 21% respectively). Compared to NH-White patients, NH-Black patients were 36% less likely to be prescribed a benzodiazepine (prevalence ratio (PR) = 0.64; 95% confidence interval (CI) = 0.54-0.76) and Hispanic patients were 19% less likely to be prescribed a benzodiazepine (PR = 0.81; 95% CI = 0.68-0.96). Age, sex, or type of insurance did not show a statistically significant influence in the prescription of benzodiazepines.

CONCLUSIONS

These findings reveal that NH-Black and Hispanic patients with anxiety are significantly less likely to be prescribed benzodiazepines than their NH-White counterparts in the ED. Further studies are needed to determine the root causes of these health disparities and strategies to combat them.

The influence of prescriber and patient gender on the prescription of benzodiazepines: results from the Florida Medicaid Dataset

BACKGROUND

Benzodiazepine (BZD) prescription rates have increased over the past decade in the United States. Available literature indicates that sociodemographic factors may influence diagnostic patterns and/or prescription behaviour. Herein, the aim of this study is to determine whether the gender of the prescriber and/or patient influences BZD prescription.

METHODS

Cross-sectional study using data from the Florida Medicaid Managed Medical Assistance Program from January 1, 2018 to December 31, 2018. Eligible recipients ages 18 to 64, inclusive, enrolled in the Florida Medicaid plan for at least 1 day, and were dually eligible. Recipients either had a serious mental illness (SMI), or non-SMI and anxiety.

RESULTS

Total 125 463 cases were identified (i.e., received BZD or non-BZD prescription). Main effect of patient and prescriber gender was significant F(1, 125 459) = 0.105, P = 0 .745, partial η2 < 0.001. Relative risk (RR) of male prescribers prescribing a BZD compared to female prescribers was 1.540, 95% confidence intervals (CI) [1.513, 1.567], whereas the RR of male patients being prescribed a BZD compared to female patients was 1.16, 95% CI [1.14, 1.18]. Main effects of patient and prescriber gender were statistically significant F(1, 125 459) = 188.232, P < 0.001, partial η2 = 0.001 and F(1, 125 459) = 349.704, P < 0.001, partial η2 = 0.013, respectively.

CONCLUSIONS

Male prescribers are more likely to prescribe BZDs, and male patients are more likely to receive BZDs. Further studies are required to characterize factors that influence this gender-by-gender interaction.