Risk of benzodiazepine dependence resulting from hospital admission

Postoperative use of hypnotics is associated with increased length of stay after uncomplicated surgery for colorectal cancer

Background/Aims:

Hypnotics are used to treat perioperative sleep disorders. These drugs are associated with a higher risk of adverse effects among patients undergoing surgery. This study aims to quantify the use of hypnotics and factors influencing the administration of hypnotics in relation to colorectal cancer surgery.

Method:

A retrospective cohort study of 1979 patients undergoing colorectal cancer surgery.

Results:

In all, 381 patients (19%) received new treatment with hypnotics. Two of the six surgical centres used hypnotics less often (odds ratio (95% confidence interval), 0.24 (0.16–0.38) and 0.20 (0.12–0.35)). Active smokers (odds ratio (95% confidence interval), 1.57 (1.11–2.24)) and patients receiving perioperative blood transfusion (odds ratio (95% confidence interval), 1.58 (1.10–2.26)) had increased likelihood of receiving hypnotics. In the uncomplicated cases, a multivariable linear regression analysis showed that consumption of hypnotics postoperatively was significantly associated with increased length of stay (1.5 (0.9–2.2) days).

Conclusion:

One in five patients began treatment with hypnotics after colorectal cancer surgery. Postoperative use of hypnotics was associated with an increased length of stay for uncomplicated cases of colorectal cancer surgery.

Why is your patient sedated?

PURPOSE

The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital.

DESIGN/METHODOLOGY/APPROACH

All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications.

FINDINGS

SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent.

PRACTICAL IMPLICATIONS

Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers.

ORIGINALITY/VALUE

For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback

BACKGROUND

Benzodiazepines are commonly prescribed for older people. Inappropriate benzodiazepine prescribing may result in serious adverse effects, including confusion and falls.

AIMS

To determine the prevalence and appropriateness of benzodiazepine prescribing for elderly inpatients at nine public hospitals in Victoria, Australia, and to assess the impact of multidisciplinary feedback on quality of benzodiazepine prescribing.

METHODS

Clearance for the study was obtained from ethics committees of participating hospitals. Medication charts for 1301 patients aged 65 years and over were reviewed to identify patients prescribed a benzodiazepine. Using an evidence-based indicator of prescribing appropriateness, cross-sectional notes-based audits were conducted at three time points (baseline, 4-8 weeks and 6 months). Feedback of baseline audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in benzodiazepine prescribing over the following 6 months were assessed.

RESULTS

At baseline, benzodiazepines were prescribed for 36% of patients, and 20% of prescriptions were appropriate. Four to six weeks after feedback, the proportion of patients prescribed a benzodiazepine had not changed significantly (31%, P = 0.125); however, more prescriptions were appropriate (44%, P < 0.0001). For patients who were using a benzodiazepine prior to admission and had a contraindication, there were more attempts to withdraw or reduce the dose (47% vs 21%, P = 0.002) and more prescriptions were for acceptable indications (7.4% vs 2.6%, P = 0.024). Six months after feedback, appropriateness of prescribing remained improved compared with baseline (50%, P = 0.002).

CONCLUSIONS

Benzodiazepines were prescribed for approximately one in three elderly hospital inpatients and a large proportion was inappropriate. A multidisciplinary intervention based on audit and feedback improved prescribing and the impact of the intervention was still evident after 6 months.

Benzodiazepine prescribing in a Sydney teaching hospital

OBJECTIVES

To determine the pattern of benzodiazepine prescribing in hospital and at discharge in relation to prior benzodiazepine therapy.

DESIGN

Patient interview within 48 hours of admission to determine benzodiazepine, alcohol and other psychotropic drug use before admission and review of medical records after discharge to document drugs prescribed in hospital and at discharge.

SETTING

Tertiary teaching hospital, January to August 1995.

RESULTS

1453 patients (mean age, 60 [SD, 19] years; 52.7% female) were interviewed; 277 patients (19.1%) were taking benzodiazepines regularly (one or more doses per week) before admission. Of these, 28.5% did not have benzodiazepine therapy continued while in hospital and 63.9% did not receive benzodiazepines at the time of discharge. Of the remaining 1176 patients (those not previously taking benzodiazepines), 277 (23.6%) were prescribed them for the first time in hospital and 5.3% received benzodiazepines at the time of discharge. Older age, female sex, marital status (single, divorced or widowed) and the use of antidepressants and Schedule 8 narcotic analgesics were all statistically significant predictors of benzodiazepine use before admission, but alcohol consumption was not.

CONCLUSIONS

A substantial number of patients do not have their benzodiazepine therapy continued in hospital and at the time of discharge, and are thus at risk of developing benzodiazepine withdrawal syndromes, including delirium. A small but clinically significant number of patients who do not usually take benzodiazepines receive them at the time of discharge and may be at risk of becoming long term users.

Sedatives and hypnotics in Stockholm: social factors and kinds of use

OBJECTIVES

The aims of the study were (1) to estimate prevalence rates of current, regular, and long-term use of sedatives and hypnotics and the incidence of regular use in an urban population and (2) to study the association between such use of drugs and sociodemographic factors, symptoms of disease, and alcohol consumption.

METHODS

Data on drug use in a random sample of 6217 adults in Stockholm County were analyzed with logistic regression.

RESULTS

The prevalence rate for current use of sedatives or hypnotics was 12.8% among men and 18.6% among women; the rate for regular use was 3.7% among males and 4.7% among females. The odds ratio for current use increased with age and was higher among unemployed persons and disability pensioners, high consumers of alcohol, persons with an increased level of symptoms, and widows. More than 25% of the persons who had used sedatives or hypnotics during the previous 2 weeks were regular users 6 months later. For persons aged 25 through 64 years, the annual incidence rate was 1.8% among men and 2.7% among women.

CONCLUSIONS

The comparatively low incidence and high prevalence of regular use implies that long-term use of sedatives and hypnotics is common.